Pancreatic cancer is one of the most serious of cancers. It develops when cancerous cells form in the tissues of your pancreas — a large organ that lies horizontally behind the lower part of your stomach. Your pancreas secretes enzymes that aid digestion and hormones that help regulate the metabolism of carbohydrates.

Pancreatic cancer spreads rapidly and is seldom detected in its early stages, which is a major reason why it's a leading cause of cancer death. Signs and symptoms may not appear until the disease is quite advanced. By that time, the cancer is likely to have spread to other parts of the body and surgical removal is no longer possible.

For years, little was known about pancreatic cancer. But researchers are beginning to understand the genetic basis of the disease — knowledge that may eventually lead to new and better treatments. Just as important, you may be able to reduce your risk of pancreatic cancer with some lifestyle changes.

Signs and symptoms of pancreatic cancer often don't occur until the disease is advanced. When symptoms do appear, they may include:

• Upper abdominal pain that may radiate to your middle or upper back. Pain is a common symptom of advanced pancreatic cancer. Abdominal pain occurs when a tumor presses on surrounding organs and nerves. Pain may be constant or intermittent and is often worse after you eat or when you lie down. Because many conditions other than cancer can cause abdominal pain, be sure to discuss your symptoms carefully with your doctor.
• Loss of appetite and unintentional weight loss. Unintended weight loss is a common sign of pancreatic cancer. Weight loss occurs in most types of cancer because cancerous (malignant) cells deprive healthy cells of nutrients, and this is especially true in pancreatic cancer.
• Yellowing of your skin and the whites of your eyes (jaundice). About half of people with pancreatic cancer develop jaundice, which occurs when bilirubin, a breakdown product of worn-out blood cells, accumulates in your blood. Normally, bilirubin is eliminated in bile, a fluid produced in your liver. But if a pancreatic tumor blocks the flow of bile, excess pigment from bilirubin may turn your skin and the whites of your eyes yellow. In addition, your urine may be dark brown and your stools white or clay-colored. Although jaundice is a common sign of pancreatic cancer, it's more likely to result from other conditions, such as gallstones or hepatitis.
• Itching. In the later stages of pancreatic cancer, you may develop severe itching when high levels of bile acids, another component of bile, accumulate in your skin.
• Nausea and vomiting. In advanced cases of pancreatic cancer, the tumor may block a portion of your digestive tract, usually the upper portion of your small intestine (duodenum), causing nausea and vomiting.
• Digestive problems. When cancer prevents pancreatic enzymes from being released into your intestine, you're likely to have a hard time digesting foods — especially those high in fat. Eventually, this may lead to significant weight loss — as much as 25 pounds or more — and malnutrition.

Your pancreas is about 6 inches long and looks something like a pear lying on its side. The wider end (head) is located near the center of your abdomen next to the upper part of your small intestine (duodenum). The main part (body) of the pancreas stretches behind your stomach, and the narrow end (tail) is on your left side, next to your spleen.

A part of your digestive system, your pancreas performs two essential functions:

• It produces digestive juices and enzymes that help break down proteins, carbohydrates and fats so the food you eat can be digested in your small intestine.
• It secretes the hormones insulin and glucagon that regulate the way your body metabolizes sugar (glucose).

Most of your pancreas is composed of cells that produce digestive enzymes and juices. Pancreatic juices flow into the main pancreatic duct, which leads to your small intestine (duodenum). The pancreatic duct joins up with the tube leading from your gallbladder to form the common bile duct, which then empties into the small intestine. Your pancreas also contains small "islands" of cells that secrete the hormones insulin and glucagon, along with somatostatin.

Types of pancreatic cancer
Most pancreatic tumors originate in the duct cells or in the cells that produce digestive enzymes (acinar cells). Called adenocarcinomas, these tumors account for nearly 95 percent of pancreatic cancers.

Tumors that begin in the islet cells (endocrine tumors) are much less common. When they do occur, they may cause the affected cells to produce too much hormone. For example, tumors in glucagon cells (glucagonomas) might cause excess amounts of glucagon to be secreted, while tumors in insulin cells (insulinomas) may lead to an overproduction of insulin.

Tumors can also develop in the ampulla of Vater — the place where your bile and pancreatic ducts empty into your small intestine. Called ampullary cancers, these tumors often block the bile duct, leading to jaundice. Because even a small tumor can obstruct the bile duct, signs and symptoms of ampullary cancer usually appear earlier than do symptoms of other pancreatic cancers.

Why pancreatic cancer occurs
Healthy cells grow and divide in an orderly way. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. When DNA is damaged, changes occur in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor — a mass of malignant cells.

Researchers don't know exactly what damages DNA in the vast majority of cases of pancreatic cancer. But it is known that a small percentage of people develop the disease as a result of a genetic predisposition. These people who have a close relative, such as a parent or sibling, with pancreatic cancer have a higher risk of developing pancreatic cancer themselves.

In addition, a number of genetic diseases have been associated with an increased risk of pancreatic cancer, including familial adenomatous polyposis, nonpolyposis colon cancer, familial breast cancer associated with the BRCA2 gene, hereditary pancreatitis, and familial atypical multiple mole-melanoma syndrome — a serious type of skin cancer. This means that people who have a hereditary predisposition to develop these cancers are also more likely to develop pancreatic cancer.

Yet only about 10 percent of pancreatic cancers result from an inherited tendency. A greater number are caused by environmental or lifestyle factors, such as smoking, diet and chemical exposure.

The vast majority of pancreatic cancers occur in people older than 65. Other important risk factors include:

• Race. Black men and women have a higher risk of pancreatic cancer.
• Sex. More men than women develop pancreatic cancer.
• Cigarette smoking. If you smoke, you're two to three times more likely to develop pancreatic cancer than nonsmokers are. This is probably the greatest known risk factor for pancreatic cancer, with smoking associated with almost one in three cases of pancreatic cancer.
• Abnormal glucose metabolism. Having diabetes may increase your risk of pancreatic cancer. Insulin resistance or high insulin levels may also be risk factors for pancreatic cancer.
• Hereditary pancreatitis. Your chances of developing pancreatic cancer increase if you have hereditary chronic pancreatitis. Hereditary pancreatitis (HP) is a rare genetic condition marked by recurrent attacks of pancreatitis — a painful inflammation of your pancreas.
• Excess weight. People who are very overweight or obese may have a greater risk of developing pancreatic cancer than do people of normal weight.
• Diet. A diet high in animal fat and low in fruits and vegetables may increase your risk of pancreatic cancer.
• Chemical exposure. People who work with petroleum compounds, including gasoline and other chemicals, have a higher incidence of pancreatic cancer than people not exposed to these chemicals.

See your doctor if you experience an unexplained weight loss, abdominal pain or jaundice. Many problems other than cancer may cause similar signs and symptoms, so your doctor will check for these conditions as well as for pancreatic cancer. If cancer is present, early diagnosis and treatment offer the best chance of recovery.

Detecting pancreatic cancer in its early stages is difficult. Signs and symptoms usually don't appear until the cancer is large or has spread (metastasized) to other tissues. And because your pancreas is relatively hidden — tucked behind your stomach and inside a loop of your small intestine — small tumors can't be seen or felt during routine exams.

For this reason, and because pancreatic cancer spreads so quickly, researchers have focused on finding a reliable screening test. At one time, scientists thought a substance called CA 19-9 was the answer. CA 19-9 is produced by pancreatic cancer cells and can be detected by a blood test. But by the time blood levels are high enough to be measured, the cancer is no longer in its early stages. Currently there is no effective screening test for pancreatic cancer.

If your doctor suspects pancreatic cancer, you may have one or more of the following tests to diagnose the cancer:

• Ultrasound imaging. In this test, a device called a transducer is placed on your upper abdomen. High-frequency sound waves from the transducer reflect off your abdominal tissues and are translated by a computer into moving images of your internal organs, including your pancreas. Ultrasound tests are safe, noninvasive and relatively brief — a typical test takes less than an hour.
• Computerized tomography (CT) scan. This imaging test allows your doctor to visualize your organs, including your pancreas, in two-dimensional slices. Split-second computer processing creates these images as a series of very thin X-ray beams pass through your body. Sometimes you may have a dye (contrast medium) injected into a vein before the test. The clearer images produced with the dye make it easier to distinguish a tumor from normal tissue. A CT scan exposes you to more radiation than do conventional X-rays, but in most cases, the benefits of the test outweigh the risks.
• Magnetic resonance imaging (MRI). Instead of X-rays, this test uses a powerful magnetic field and radio waves to create images of your pancreas. During the test, you're placed in a cylindrical tube that can seem confining to some people. The machine also makes a loud thumping noise you might find disturbing. In most cases you'll be given headphones for the noise.
• Endoscopic retrograde cholangiopancreatiography (ERCP). In this procedure, a thin, flexible tube (endoscope) is gently passed down your throat, through your stomach and into the upper part of your small intestine. Air is used to inflate your intestinal tract so your doctor can more easily see the openings of your pancreatic and bile ducts. The bile ducts are thin tubes that carry bile, a fluid produced in your liver that helps digest fats. These ducts are often the site of pancreatic tumors. A dye is then injected into the ducts through a small hollow tube (catheter) that's passed through the endoscope. Finally, X-rays are taken of the ducts. Your throat may be sore for a time after the procedure, and you may feel bloated from the air introduced into your intestine.
• Endoscopic ultrasound (EUS). In this test, an ultrasound device is passed through an endoscope into your stomach. The device directs sound waves to your pancreas. A computer then translates the sound waves into close-up images of your pancreas and your bile and pancreatic ducts. The images are superior to those produced by standard ultrasound and are particularly useful for detecting small pancreatic tumors.
• Percutaneous transhepatic cholangiography (PTC). In this test, your doctor carefully inserts a thin needle into your liver while you lie on a movable X-ray table. A dye is then injected into the bile ducts in your liver, and a special X-ray machine (fluoroscope) tracks the dye as it moves through the ducts. Any obstructions should show up on the X-ray. The table is rotated several times during the procedure so you can assume a variety of positions. During the test, you may have a feeling of pressure or fullness, or have slight discomfort in the right side of your back.
• Biopsy. In this procedure, a small sample of tissue is removed and examined for malignant cells under a microscope. It's the only way to make a definitive diagnosis of cancer. Biopsies of the pancreas and bile ducts can be performed in several ways. If you have a mass that can be reached with a needle, your doctor may choose to perform a fine-needle aspiration (FNA) — a procedure in which a very thin needle is inserted through your skin and into your pancreas. An ultrasound or CT scan is often used to guide the needle's placement. When the needle has reached the tumor, cells are withdrawn and sent to a lab for further study. Tissue samples can also be removed during ERCP or EUS. Sometimes, in a procedure similar to ERCP, your surgeon uses an endoscope to pass a catheter into your bile duct where it empties into your small intestine. But instead of injecting dye, your surgeon uses a small brush introduced through the catheter to scrape cells and bits of tissue from the lining of the duct.
• Laparoscopy. This procedure uses a small, lighted instrument (laparoscope) to view your pancreas and surrounding tissue. The instrument is attached to a television camera and inserted through a small incision in your abdomen. The camera allows your surgeon to clearly see what's happening inside you. During laparoscopy, your surgeon can take tissue samples to help confirm a diagnosis of cancer. Laparoscopy may also be used to determine how far cancer has spread. Risks include bleeding and infection and a slight chance of injury to your abdominal organs or blood vessels.

Staging pancreatic cancer
Staging tests help determine the size and location of cancer and whether it has spread. They're crucial in helping your doctor determine the best treatment for you. Pancreatic cancer may be staged in several ways. One method is to use these terms:

• Resectable. All the tumor nodules can be removed.
• Locally advanced. Because the cancer has spread to tissues around the pancreas or into the blood vessels, it can no longer be completely removed.
• Metastatic. At this stage, the cancer has spread to distant organs, such as the lungs and liver.

Your doctor may also refer to your cancer as stage 1, 2, 3, or 4:

• Stage 1 pancreatic cancer is confined to the pancreas.
• Stage 2 pancreatic cancer has spread somewhat, possibly to the lymph nodes, but not into large blood vessels nearby.
• Stage 3 pancreatic cancer has invaded large blood vessels, may be in the lymph nodes, but hasn't spread to distant sites.
• Stage 4 means the cancer has spread to a distant site or sites in your body.

Your pancreas produces a number of enzymes that break down food so your body can absorb the nutrients it contains. But pancreatic tumors often interfere with the production or flow of these enzymes. As a result, your body can't easily absorb nutrients, which can lead to diarrhea and severe weight loss.

Other complications of pancreatic cancer include:

• Problems with glucose metabolism. Tumors that affect the ability of your pancreas to produce insulin can lead to problems with glucose metabolism, including diabetes.
• Jaundice, sometimes with severe itching. Yellowing of your skin and the whites of your eyes can develop when a pancreatic tumor blocks your bile duct, the thin tube that carries bile from your liver to your duodenum. The yellow color comes from excess bilirubin. Bile acids may cause intense itching when they build up in your skin.
• Pain. Large pancreatic tumors may press on surrounding nerves, leading to back or abdominal pain that may sometimes be severe. Often, your doctor can prescribe medications that help relieve pain. When medications aren't enough, cutting or injecting alcohol into some of the affected nerves may be an option.
• Metastasis. This is the most serious complication of pancreatic cancer. Your pancreas is surrounded by a number of vital organs, including your stomach, spleen, liver, lungs and intestine. Because pancreatic tumors are rarely discovered in the early stages, they often have time to spread to these organs or to nearby lymph nodes.

Treatment for pancreatic cancer depends on the stage and location of the cancer as well as on your age, overall health and personal preferences. Especially when cancer is advanced, choosing a treatment plan is a major decision, and it's important to carefully evaluate your choices.

You may also want to consider seeking a second opinion. This can provide additional information to help you feel more certain about the option you're considering.

The first goal of treatment is always to eliminate the cancer completely. When that isn't possible, the focus may be on preventing the tumor from growing or causing more harm. In some cases, an approach called palliative care may be best. Palliative care refers to treatment aimed not at removing or slowing the disease, but at helping relieve symptoms and making you as comfortable as possible.

Surgical options
The only way to eliminate pancreatic cancer is an operation to remove the tumor. Unfortunately, this is possible only in a small percent of people. Once the cancer has spread beyond the pancreas to other organs, lymph nodes or blood vessels, surgery is usually no longer an option. When surgery is possible, your surgeon may use one of the following procedures, depending on the extent and location of the tumor:

• Whipple procedure (pancreatoduodenectomy). This is the most common procedure for treating pancreatic cancer, including resectable cancers of the ampulla of Vater. In general, the Whipple procedure involves removing the wide end (head) of your pancreas. To do that, your surgeon must also remove your duodenum, gallbladder and the end of the common bile duct. Sometimes part of your stomach is removed as well. The end of your bile duct and remaining part of your pancreas are then connected to your small intestine so that bile and pancreatic enzymes continue to reach the small intestine. The procedure has risks, including infection and bleeding.
• Total pancreatectomy. In this procedure, your surgeon removes your entire pancreas as well as your bile duct, gallbladder and spleen; part of your small intestine and stomach; and most of the lymph nodes in the area. After a total pancreatectomy, you'll need insulin injections and pancreatic enzymes, and the operation presents serious risks. Total pancreatectomy isn't often used for people with pancreatic cancer because there doesn't appear to be enough benefit from the procedure to justify the risks.
• Distal pancreatectomy. In this procedure, which is primarily used to treat islet cell cancers, only the tail — or the tail and a small portion of the body of your pancreas — is removed. Sometimes your spleen may also be removed.

Operations for pancreatic cancer are complex. The most successful outcomes generally occur when these procedures are performed in cancer centers by highly experienced surgeons.

Radiation therapy
Radiation therapy uses high-energy X-rays to destroy cancer cells. You may receive radiation treatments before or after cancer surgery, often in combination with chemotherapy. Or, your doctor may recommend a combination of radiation and chemotherapy treatments when your cancer can't be treated surgically.

Radiation that comes from a machine outside your body (external beam radiation) is generally used to treat pancreatic cancer. Side effects of radiation therapy may include a burn on your skin similar to sunburn where the radiation enters your body, nausea, vomiting and fatigue.

Doctors at some cancer centers are studying a new approach to radiation therapy, called intraoperative electron beam radiation. In this procedure, a type of external beam radiation that uses high-energy particles (electrons) is directed at your pancreas during surgery. This allows doctors to treat a pancreatic tumor with a high dose of radiation while sparing nearby organs.

Chemotherapy
Chemotherapy uses drugs to help kill cancer cells. Injected into a vein or taken orally, these drugs travel through your bloodstream. For that reason, they're often used to treat cancers that have spread. Chemotherapy, or chemotherapy in combination with radiation, is the usual treatment for pancreatic cancers that have spread to nearby tissues or distant organs. Although chemotherapy won't eliminate the cancer, it may help relieve symptoms. It may also help improve survival when used as an adjuvant therapy after an operation to remove a tumor in the pancreas.

For years, the drug fluorouracil (5-FU) was the only chemotherapy option for people with pancreatic cancer. But fluorouracil wasn't always effective. Now doctors are having more success with a newer drug, gemcitabine. The drug is normally used alone but may be used in combination with other drugs as part of a clinical trial. In November 2005, the U.S Food and Drug Administration (FDA) approved the combination of gemcitabine and erlotinib to treat advanced pancreatic cancer that hasn't responded to other treatments. While this combination isn't a cure, it does increase the life expectancy for some people. Doctors are also testing a number of other new medications and new combinations of older medicines.

Chemotherapy drugs affect normal cells as well as malignant ones, especially fast-growing cells in your digestive tract and bone marrow. For that reason, side effects — including nausea and vomiting, mouth sores, an increased chance of infection due to a shortage of white blood cells, and fatigue — are common. Not everyone experiences side effects, however, and there are new and better ways to control them if you do. Be sure to discuss any questions you may have about side effects with your treatment team.

Clinical trials
If you have advanced pancreatic cancer, you may want to consider participating in a clinical trial. This is a study that is used to test new forms of therapy — typically new drugs, different approaches to surgery or radiation treatments, and novel methods such as gene therapy. If the therapy being tested proves to be safer or more effective than current treatments, it will become the new standard of care.

Remember that the treatments used in clinical trials haven't yet been shown to be effective. They may have serious or unexpected side effects, and there's no guarantee you'll benefit from them.

On the other hand, cancer clinical trials are closely monitored by the federal government to ensure they're conducted as safely as possible. And they offer access to treatments that wouldn't otherwise be available to you.

If you're interested in finding out more about clinical trials, talk to your treatment team. You can also call the National Cancer Institute's Cancer Information Service at (800) 4-CANCER, or (800) 422-6237.

Palliative procedures
If your cancer has spread too far to be completely removed by an operation, the primary goal will be to relieve your signs and symptoms. Treatments that focus on making you more comfortable include:

• Surgical bypass. Tumors that block your bile duct, pancreatic duct or duodenum can cause pain, digestive difficulties, nausea, vomiting, jaundice and severe itching. To help ease some of these symptoms, you may have an operation to reroute the flow of bile by going around (bypassing) the tumor.
• Stent insertion. When a bypass operation isn't an option, your surgeon may place a stainless steel or plastic tube (stent) in the bile duct to keep it open. A stent is usually the best choice for people who have metastatic cancer or who are very weak.
• Pain management. Tumors pressing on surrounding nerves can cause severe pain, especially in the later stages of the disease. Although pain is a real concern for people with pancreatic cancer, treatment with morphine or similar medications can provide relief in many cases. Long-lasting forms of morphine that need to be taken only once or twice a day may be especially helpful. When medication isn't enough, your doctor may discuss other options with you, such as cutting some of the nerves that transmit pain signals or injecting alcohol into these nerves to block the sensation of pain.
• Pancreatic enzyme tablets. By replacing the digestive enzymes your pancreas no longer produces, these tablets can improve your body's ability to absorb nutrients and may help reduce diarrhea and weight loss.
• Insulin therapy. When pancreatic cancer affects insulin production, you may need insulin injections to help control your blood sugar levels.

New treatments
Researchers are studying a number of other approaches to treating pancreatic cancer, including:

• Anti-angiogenesis factors. Cancer cells need angiogenesis factors to produce new blood vessels so they can grow and spread. Scientists have developed drugs that stop this process.
• Farnesyl transferase inhibitors. Most people with pancreatic cancer have cells that contain a specific genetic mutation. In order to function, the mutated cells need an enzyme called farnesyl transferase. Now researchers have developed drugs that block the action of farnesyl transferase, causing the mutated cells to die. Studies of these drugs are under way.
• Growth factor inhibitors. Growth factor receptors help some malignant cells grow. Drugs that block these receptors, such as cetuximab, may help fight pancreatic cancer.

Although it's not always possible to prevent pancreatic cancer, these lifestyle changes may help reduce your risk:

• Quit smoking. Cigarette smoke contains carcinogens that can damage the DNA that regulates cell growth. Talk to your doctor about the best ways to quit, or contact the American Cancer Society or American Lung Association for more information.
• Maintain a healthy weight. Being overweight increases your risk of pancreatic cancer. If you need to lose weight, keep in mind that a slow, steady loss is the healthiest way to reach your goals. Aim for no more than 1 to 2 pounds a week. Add 30 minutes or more of aerobic exercise — such as walking, jogging or biking — on most days, and you can increase the amount of weight you lose.
• Exercise regularly. Experts believe that getting even a moderate amount of exercise every week can cut your risk of pancreatic cancer. For overall health, aim for 30 minutes of exercise on most days. If you're not used to exercising, start out slowly and work up to your goal.
• Eat a healthy diet. A diet high in fruits and vegetables and low in animal fat can reduce your risk of pancreatic cancer.

Poor appetite, weight loss and muscle wasting are often problems for people with pancreatic cancer. These symptoms may be compounded by cancer treatments as well as by the emotional toll of living with the disease. For that reason, your doctor may recommend talking to a registered dietitian. He or she can help you find ways to get the nourishment you need.

These suggestions also may help:

• Reduce the size of your meals. Try eating several small meals throughout the day instead of two or three larger ones. If you're nauseous, choose foods that are soothing and easy-to-digest, such as soups, rice or a plain baked potato.
• Restrict dietary fat. Follow your doctor's recommendations for reducing fat in your diet. Pancreatic cancer affects your body's ability to digest fats.
• Consider dietary supplements. With pancreatic cancer, your body can't easily absorb nutrients. Talk to your doctor about vitamin and mineral supplements.
• Have nourishing snacks within easy reach. That way, you're more likely to eat. Fresh fruit, nonfat yogurt or carrot sticks are all good choices.
• Don't worry if you have days when you can't eat at all. In the meantime, do whatever you can to make yourself feel better. Let your doctor know if you don't feel better in a couple of days.
• Try to drink plenty of fluids. Water is essential for your body's proper functioning.

Learning you have any life-threatening illness can be devastating. But coping with a diagnosis of pancreatic cancer can be especially difficult. The more advanced the disease when it's discovered, the less likely the chance of real recovery. As a result, you may feel especially overwhelmed just when you need to make crucial decisions. Although there are no easy answers for people dealing with pancreatic cancer, some of the following suggestions may help:

• Learn all you can about your illness. Learn everything you can about pancreatic cancer — how the disease progresses, your prognosis and your treatment options, including both experimental and standard treatments and their side effects. Be sure you understand whether a particular approach is used to treat cancer or provide palliative care. Don't be afraid to seek a second opinion and to explore treatments available through clinical trials. You will have many decisions to make in the weeks and months ahead. The more you know, the more active a role you can take in the decision-making process.

  In addition to talking to your medical team, look for information in books and reputable sources on the Internet. Some reliable sites are listed at the end of this article. In addition, the National Cancer Institute offers a toll-free information line called the Cancer Information Service that you can reach at (800) 4-CANCER, or (800) 422-6237.

• Maintain a strong support system. Strong relationships are crucial to dealing with life-threatening illnesses. Although friends and family can be your best allies, in some cases they may have trouble dealing with your illness. Or you may not have a large social network. If so, the concern and understanding of a counselor, medical social worker, pastoral or religious counselor, or even a formal support group can be helpful. Although support groups aren't for everyone, they can sometimes be a good resource for practical information about your disease. You may also find strength and encouragement in being with people who are facing the same challenges you are.

  If you're interested in learning more about support groups, talk to a doctor, nurse, social worker or psychologist. They may be able to put you in touch with a group in your area. Or check your local phone book, library or cancer organization. The National Cancer Institute also can provide a list of support groups. After deciding to participate in a group, try it out a few times. If it doesn't seem useful or comfortable, you don't have to continue.

• Come to terms with your illness. Coming to terms with your illness may be the hardest thing you've ever done. For some people, having a strong faith or a sense of something greater than themselves makes this process easier. Others seek counseling from someone who understands life-threatening illnesses, such as a medical social worker, psychologist or chaplain. Many people also take steps to ensure that their end-of-life wishes are known and respected.

  A great fear of many people with a life-threatening illness is being subjected to treatments they don't want or spending their last weeks or months in a hospital away from loved ones and familiar surroundings. The welcome news is that many choices exist for people with a terminal illness.

  Hospice care, for example, provides a special course of treatment to terminally ill people. This allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one at home or in hospice residences. It also provides emotional, social and spiritual support for people who are ill and those closest to them. Although most people under hospice care remain in their own homes, the program is available anywhere — including nursing homes and assisted-living centers. For people who stay in a hospital, palliative care specialists can provide comfort, compassionate care and dignity.

  Although it can be extremely difficult, discuss end-of-life issues with your family and medical team. Part of this discussion will likely involve advance directives — a general term for oral and written instructions you give concerning your medical care should you become unable to speak for yourself.

  One type of advance directive is known as a durable power of attorney (POA) for health care. In this case, you sign a legal document authorizing a person you respect and trust to make legally binding medical decisions for you if you're unable to do so. A POA is often recommended because the appointed person can make decisions in situations not covered in a regular advance directive. Whatever you decide, it's important to put your wishes in writing. Laws regarding advance directives and POAs vary from state to state, but a written document is more likely to be respected.

  To learn more about advance directives, you can contact the National Hospice and Palliative Care Organization at (800) 658-8898.

More and more people are interested in nontraditional approaches to healing, especially when standard treatments produce intolerable side effects or aren't able to provide a cure. To address this growing interest, the National Institutes of Health established the National Center for Complementary and Alternative Medicine (NCCAM).

The center's mission is to explore nontraditional therapies in a scientifically rigorous way. NCCAM and the National Cancer Institute have teamed up specifically to look at the role complementary and alternative medicine may play in the treatment of cancer.

In general, alternative medicine refers to therapies, such as mistletoe or coenzyme Q-10, that may be used instead of conventional treatments. Complementary or integrative medicine, on the other hand, usually means therapies used in conjunction with traditional treatments.

Rather than simply addressing a problem with the body, complementary and alternative treatments often focus on the entire person — body, mind and spirit. As a result, they can be especially effective at reducing stress, alleviating the side effects of conventional treatments such as chemotherapy, and improving quality of life. However, these products aren't regulated by the FDA, so you can't be sure of a product's quality. Additionally, some of these substances can interfere with your treatment. Check with your doctor before taking alternative medications.

NCCAM's findings are available on its Web site. You can also talk to information specialists at NCCAM's clearinghouse by calling (888) 644-6226.