Although the incidence of stomach cancer has declined dramatically in the United States and Western Europe in the last 50 years, the disease remains a serious problem in much of the rest of the world, where it's a leading cause of cancer death.

This global variation is almost certainly linked to two factors that play a major role in the development of stomach cancer: Infection with Helicobacter pylori (H. pylori) bacteria and the type of diet.

Stomach cancer is more readily treated when caught early. Unfortunately, by the time it causes symptoms, the disease is often at an advanced stage and may have spread beyond the stomach. Yet there is encouraging news. You can reduce your risk of this serious cancer by making a few changes in your lifestyle.

The earliest sign of both noncancerous (benign) and cancerous (malignant) stomach tumors is microscopic internal bleeding, which is usually only detected by tests that check your stool for blood. You may also feel tired if this bleeding causes the loss of too many healthy red blood cells (anemia).

When the cancer is more advanced, you may experience signs and symptoms such as:

• Discomfort in the upper or middle region of your abdomen that may not be relieved by food or antacids. In the early stages of stomach cancer, pain is often masked by food or acid-buffering medications.
• Abdominal discomfort aggravated by eating.
• Black, tarry stools.
• The vomiting of blood.
• Vomiting after meals.
• Weakness, fatigue and weight loss.
• Full feeling after meals, even when eating less than normal.

Having one or more of these signs and symptoms doesn't necessarily mean you have stomach cancer. Other conditions, especially peptic ulcers, can cause similar problems.

Your stomach is a muscular sac located in the upper middle of your abdomen, just below your ribs. If you're an average adult, it's about the size of a small melon, but can stretch at the sides to hold nearly 1 gallon of food and liquid. Your stomach folds in on itself when it's empty and expands when you eat or drink.

The stomach walls are lined with three layers of powerful muscles that mix food with enzymes and acids produced by glands in the stomach's inner lining. Under normal conditions, your stomach produces 2 to 3 quarts of gastric juices every day. One of these, hydrochloric acid, is so corrosive it can dissolve iron nails. Your stomach's delicate tissues are protected from this powerful acid by a thick, jelly-like mucus that coats the stomach lining.

Once the food in your stomach is thoroughly broken down and mixed, muscular contractions push it toward the pyloric valve, which leads into the upper portion of your small intestine (duodenum). The valve opens just enough to release a scant eighth of an ounce of food at a time. It may take three to four hours for your stomach to empty after you eat, depending on your diet. Foods high in fat increase the amount of time it takes for your stomach to empty.

Types of stomach cancer
The great majority of stomach cancers are adenocarcinomas, which start in the glandular cells in the mucosa, the stomach's innermost lining. Adenocarcinomas are sometimes divided into types 1 and 2:

• Type 1. This type tends to occur in the distal stomach, the portion closest to the first part of your small intestine (duodenum), and usually results from chronic infection with H. pylori bacteria or from eating a diet high in certain foods.
• Type 2. This type can occur throughout your stomach and is most often caused by genetic factors. Because it's aggressive, type 2 adenocarcinoma is more likely to spread than type 1 is and may extend through the stomach wall to nearby lymph nodes, eventually spreading to other organs such as the pancreas, liver and colon.

Although adenocarcinomas account for about 95 percent of all stomach cancers, other forms of the disease can sometimes occur, including:

• Lymphomas. These are cancers of immune system tissue in the stomach wall. Some lymphomas are aggressive whereas others grow much more slowly. The latter, known medically as mucosa-associated lymphoid tissue (MALT) lymphomas, usually stem from H. pylori infection and are often curable when found in the early stages.
• Carcinoid tumors. A small percentage of stomach cancers are carcinoid tumors that originate in the stomach's hormone-producing cells. Carcinoid tumors tend to grow less quickly and metastasize less frequently than do the more common stomach cancers.
• Gastrointestinal stromal tumors (GISTs). Doctors once thought that these rare tumors formed in the nerve or muscle cells of the intestinal tract. But they now believe they develop from cells called interstitial cells of Cajal, which are part of the autonomic nervous system. Although GISTs can be found anywhere from the esophagus to the rectum, the majority occur in the stomach. Yet GISTs are not the same as other gastric cancers, differing not only in the cells in which they originate but also in their prognosis and treatment. GISTs spread rapidly, prove fatal in a relatively short time and don't respond to treatment with the most common cancer therapies.

Why stomach cancer develops
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. Some of the genes in your DNA promote cell division and some slow cell division or program cells to die at the right time. Still other genes control processes that help repair DNA. When DNA is damaged, these genes may not function properly, causing cells to grow out of control and eventually form a tumor — a mass of malignant cells.

Although the causes of many types of cancer aren't clear, researchers have made progress in pinpointing factors that damage DNA in stomach cells and in understanding how that damage leads to cancer. These factors include:

• H. pylori infection. A majority of the world's population is infected with corkscrew-shaped bacteria called Helicobacter pylori (H. pylori) that live deep in the mucous layer that coats the lining of the stomach. Although it's not entirely clear how the bacteria are transmitted, it's likely they spread from person to person through the oral-fecal route or are ingested in contaminated drinking water. H. pylori infection frequently occurs in childhood and can last throughout life if not treated. It's the primary cause of stomach ulcers, accounting for at least 80 percent of all cases. It may also be the main cause of stomach cancer. According to the World Health Organization, close to half the annual new cases of stomach cancer can be attributed to H. pylori infection. Having ulcers doesn't necessarily put you at higher risk of stomach cancer, but having H. pylori infection does. That's because long-term infection causes inflammation that can lead to precancerous changes in the stomach lining. One of these changes is atrophic gastritis, a condition in which the acid-producing glands are slowly destroyed. It's likely that low acid levels prevent cancer-causing toxins from being properly broken down or flushed out of your stomach. Countries such as China and Colombia, where a majority of children are infected with H. pylori, have a correspondingly high rate of stomach cancer.
• Nitrates and nitrites. These are nitrogen-based chemicals that are added to certain foods, especially cured meats such as ham and bacon, hot dogs and deli meats. Both nitrates and nitrites combine with other nitrogen-containing substances in your stomach to form N-nitroso compounds — carcinogens that are known to cause stomach cancer.
• Salted, smoked or pickled foods and red meat. Before the advent of refrigeration, people commonly preserved food by salting, smoking or pickling. But these foods often contain large amounts of nitrites and nitrates, which can be converted in your stomach into cancer-causing compounds. Countries where consumption of salted meat and fish and pickled vegetables is high — Japan and Korea are notable examples — tend to have correspondingly high rates of stomach cancer. Eating a diet high in red meat, especially when the meat is barbecued or well done, also has been linked to stomach cancer.
• Tobacco and alcohol use. Both can irritate the stomach lining and are especially likely to cause cancer in the upper part of the stomach closest to the esophagus.
• Low socioeconomic level. Low-income children and adults are more likely to develop stomach cancer than are those with higher incomes. Researchers believe this may be due to the rapid spread of H. pylori in crowded living conditions. In addition, breast-feeding can help protect infants against H. pylori, and low-income mothers are more likely to bottle-feed their babies.

Having H. pylori infection makes you more likely to develop stomach cancer than someone who doesn't have the infection. Even so, most people with H. pylori don't get stomach cancer, and researchers believe that genetic factors make some people more susceptible to the disease. Having both H. pylori and a form of a gene that causes low stomach acid greatly increases your risk of stomach cancer.

Other risk factors for stomach cancer include:

• Your sex. Stomach cancer is twice as common in men as it is in women.
• Age. Most people who develop stomach cancer are between the ages of 50 and 80. The disease rarely occurs in people younger than 40.
• Diet. A diet high in foods preserved by smoking, salting or pickling increases your risk of stomach cancer. So do foods that contain nitrites and nitrates, such as bacon, ham and processed meats. Eating large amounts of red meat — particularly if it's barbecued or well done — also increases your risk. On the other hand, using plenty of fruits and vegetables, especially those that are red or deep yellow, such as tomatoes, carrots and sweet potatoes, helps protect against stomach cancer.
• Tobacco use. Smoking also has been implicated in stomach cancer. In 2004, the Surgeon General issued a report linking smoking to a range of diseases, including stomach cancer. Men who smoke are more than twice as likely to die of stomach cancer as are those who don't smoke, and rates are even higher for men who have smoked longer or who have a history of ulcers and heartburn. Women who smoke also have an increased risk of stomach cancer.
• Previous stomach surgery. The risk of stomach cancer may increase in people who have had part of their stomach and the opening to the small intestine (pyloric valve) removed — usually as a treatment for peptic ulcers. After stomach surgery, bile and sometimes pancreatic juices can back up, causing irritation and inflammation of the stomach lining (gastritis). In addition, the amount of protective stomach acid decreases while nitrite-producing bacteria may increase. These factors can lead to stomach cancer in some people. In general, the risk is greatest about 20 years after the initial surgery.
• Stomach polyps. These are small growths in the lining of your stomach. Most are benign, but adenomatous polyps — especially those larger than 1 centimeter in diameter — are often precancerous.
• Familial cancer syndromes. These include hereditary nonpolyposis colon cancer and familial adenomatous polyposis, inherited disorders that slightly increase your risk of stomach cancer. People who carry mutations in the BRCA1 and BRCA2 genes also have an increased stomach cancer risk. In the past, BRCA mutations were associated only with breast and ovarian cancers.
• Family history. You're more likely to develop stomach cancer if you have a parent or sibling with the disease. This is equally true of both common and uncommon types of stomach cancer. Hereditary diffuse gastric cancer, for example, is a rare form of stomach cancer associated with mutations in a gene called CDH1. A parent with the defective gene has a 50 percent chance of passing it on to each child. Because nearly three-fourths of people who inherit the gene eventually develop stomach cancer, doctors once recommended surgery to remove all or part of the stomach for all children of parents with the gene. But DNA testing now can determine exactly who is at risk. If you have a family history of diffuse gastric cancer, your doctor or a genetic counselor can answer your questions about DNA tests.
• Pernicious anemia. This condition, which is often associated with atrophic gastritis, develops when your stomach is no longer able to make a protein called intrinsic factor that helps your body absorb vitamin B-12. Although pernicious anemia is easily treated with B-12 injections, having the disease can slightly increase your risk of stomach cancer.
• Type A blood. Your blood type is determined by the presence or absence of two proteins — A and B — that occur on red blood cells. For unknown reasons, people with type A blood have a somewhat higher risk of stomach cancer than do people with other blood types.
• Country of origin. Stomach cancer is more common in some parts of the world — especially Japan, Korea, parts of Eastern Europe, and Latin America — than it is in the United States. These differences are likely related to diet and H. pylori infection. Stomach cancer occurs most often in countries where large amounts of meat or smoked, heavily salted or pickled foods are consumed.
• Environmental exposure. Certain workplace contaminants, including coal dust, asbestos and nickel, have been linked to an increased risk of stomach cancer.
• Obesity. Men weighing 25 to 30 pounds more than their ideal weight may be at increased risk of stomach cancer.

Stomach cancer is treatable if caught early. Unfortunately, it rarely causes symptoms in the beginning stages. When symptoms do occur, they're often vague and can easily be mistaken for other, more common but less serious problems such as a stomach virus or heartburn.

See your doctor if you have a persistent feeling of discomfort in the upper or middle region of your abdomen, especially if it occurs in conjunction with fatigue and weight loss.

And see your doctor right away if you develop black, tarry stools or if you vomit after meals. Although not always indicative of stomach cancer, these signs may result from other conditions that require medical care.

To help diagnose stomach cancer and rule out other possibilities, your doctor may recommend one or more of the following diagnostic tests:

• Upper endoscopy. This procedure allows your doctor to see abnormalities in your upper gastrointestinal (GI) tract that may not be visible on X-rays. For the test, your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus, stomach and the first part of your small intestine. Your throat is usually numbed before you're asked to swallow the endoscope, and you'll receive additional medication to ensure that you're comfortable during the procedure. If any tissue in your upper intestinal tract looks suspicious, your doctor can remove a small sample (biopsy) using instruments inserted through the endoscope. The sample is then sent to a lab for examination by a pathologist. Upper endoscopy takes about 20 to 30 minutes, although you won't be sent home until the medication wears off — usually one to two hours later. Risks of the procedure are rare and include bleeding and perforation of the stomach lining. The most common complication is a slight sore throat from swallowing the endoscope.
• Stomach X-ray (barium upper GI series). This test uses a series of X-rays to examine your esophagus, your stomach and the first part of your small intestine. Before the test, you'll drink a thick liquid (barium) that temporarily coats the lining of your stomach so that it shows up clearly on the X-rays. You may also be asked to swallow a gas-producing liquid or pill, such as sodium bicarbonate, which stretches the stomach and separates its folds, thereby providing a better view of the inner lining. After the test you can eat normally and resume your usual activities, although you'll need to drink extra water to help flush the barium from your system. The most common complication of the procedure is temporary constipation.

If you receive a diagnosis of stomach cancer, your doctor is likely to recommend additional tests to help determine the extent of the disease (staging tests) and the best course of treatment. These may include:

• Endoscopic ultrasound. This test helps determine whether cancer has spread into the walls of your stomach or to nearby tissues and lymph nodes. Endoscopic ultrasound is similar to upper endoscopy, but in this case, the endoscope carries a small ultrasound probe that uses high-frequency sound waves to create images of your stomach and surrounding tissues, including lymph nodes.
• Computerized tomography (CT) scan. Used to help check for the spread of cancer outside the stomach — especially to organs such as the liver and lungs — this test uses split-second computer processing and X-ray beams to produce detailed cross-sectional images of your internal organs. A CT scan exposes you to more radiation than conventional X-rays do, but in most cases, the benefits outweigh the risks.
• Magnetic resonance imaging (MRI). This test also looks for the spread of cancer beyond your stomach. But unlike a CT scan, MRI uses a powerful magnetic field and radio waves — not X-rays — to produce cross-sectional images of your body.
• Chest X-ray. This test checks whether cancer has spread to your lungs but isn't as sensitive as a CT scan.

The kind of treatment you receive for stomach cancer depends on a number of factors, including the location of the cancer, how advanced it is, your overall health and your own preferences. Especially when cancer is advanced, choosing a treatment plan is a major decision, and it's important to take time to 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 goal of any 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.

Treatment options include the following:

• Surgery. This is the most common treatment for stomach cancer. Depending on the extent of the cancer, your doctor may remove part (subtotal, or partial, gastrectomy) or all (total gastrectomy) of your stomach as well as some of the surrounding tissue. Lymph nodes near the tumor also are often removed during surgery. After a subtotal gastrectomy, the remaining part of your stomach is connected to your esophagus and your small intestine. If your entire stomach is removed, your surgeon attaches your esophagus directly to your small intestine. A 2006 study suggests that chemotherapy before and after surgery may improve outcomes for certain people, so discuss this with your doctor.

  When stomach cancer is caught at an early stage and your surgeon is able to remove the entire tumor, a complete recovery is possible. Unfortunately, diagnosis usually doesn't occur until stomach cancer has spread through the stomach wall to nearby lymph nodes or other organs. At this point, it's not possible to remove all the cancer surgically, but your doctor may still recommend an operation to alleviate pain, intractable bleeding or obstruction. In some cases of advanced stomach cancer, a laser beam directed through an endoscope can vaporize most of the tumor and relieve obstruction without an operation.

  After gastrectomy, some people experience leakage or obstruction where the intestinal tract has been reconstructed. More common problems associated with partial or total gastrectomy include diarrhea, vomiting and dumping syndrome, which occurs when the small intestine fills too quickly with undigested food. Symptoms of dumping may occur immediately after eating (early dumping) or two to three hours after a meal (late dumping) and include nausea, vomiting, diarrhea, shortness of breath, weakness, sweating and dizziness.

• Chemotherapy. This treatment uses drugs to help kill cancer cells. Injected into a vein or taken orally, chemotherapy medications travel through your bloodstream and are often used to eliminate cancer cells that may remain after surgery or to treat cancers that have spread to other parts of the body. Chemotherapy may also be used to control cancer growth, prolong life or relieve symptoms of advanced disease. Although it sometimes may be the only treatment needed, doctors most often use chemotherapy in conjunction with other therapies. For example, in locally advanced stomach cancer, which occurs when the tumor affects only the stomach and nearby tissues, chemotherapy and radiation (radiotherapy) may be offered after surgery to help increase survival and improve quality of life.

  A 2006 study found that people whose stomach cancer hadn't spread (metastasized) had better outcomes when chemotherapy was used both before and after surgery to remove the cancer. In the study, people with stomach cancer were randomly assigned to receive surgery alone or to receive three cycles of chemotherapy before surgery and three cycles of chemotherapy after recovering from surgery. People in this study who received surgery combined with chemotherapy lived somewhat longer and had a lower risk of the cancer returning than did people who received surgery only.

  Because anti-cancer drugs affect healthy cells as well as cancerous ones — especially fast-growing cells in your digestive tract and bone marrow — side effects such as nausea and vomiting, fatigue, and an increased risk of infection due to a shortage of white blood cells are common. Although not everyone experiences these side effects, chemotherapy can sometimes feel like another illness and is often the part of treatment about which people are most apprehensive. But newer anti-nausea medications can prevent or reduce most nausea. Sometimes acupuncture or relaxation techniques, such as guided imagery, meditation and deep breathing, also may help control nausea and vomiting. Chemotherapy is normally administered in cycles, with periods of treatment alternating with periods of recovery during which your body can recover. Ask your treatment team about the side effects of any treatment you're considering and the best ways to minimize those effects.

• Radiation therapy (radiotherapy). This therapy uses high-energy X-rays to kill cancer cells. Unlike chemotherapy, which affects your entire body, radiation affects only those parts of your body through which the radiation beam passes. Because any tissue touched by radiation can be damaged, doctors are careful to aim the beam in a way that's least likely to harm healthy tissue. Radiation that comes from a machine outside your body (external beam radiation) is generally used to treat stomach cancer, especially in conjunction with chemotherapy. It may also help relieve pain and blockages. Side effects may include a burn similar to sunburn on your skin where the radiation enters your body, nausea, vomiting, and fatigue that may increase over the course of treatment.

Drug therapy
In 2002, the Food and Drug Administration approved the anti-leukemia drug (Gleevec) to treat some gastrointestinal stromal tumors. Gleevec, which is taken in capsule form once a day, belongs to a new class of medications that specifically target cancer cells but leave healthy tissue relatively untouched. Side effects tend to be milder than with other types of cancer therapy and include fluid retention (edema), nausea, muscle cramps and rash.

Gleevec is approved only for GISTs and even then, it isn't for everyone — surgical removal remains the primary therapy for this type of cancer. Despite promising results in some people, Gleevec isn't effective in all cases nor are the long-term effects known.

Clinical trials
If you have advanced stomach cancer, you may want to consider participating in a clinical trial. This is a study that's 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.

The treatments used in clinical trials haven't yet proved 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. The call is free and trained specialists are available to answer your questions.

Although it may not be possible to prevent stomach cancer, the following steps can help reduce your risk:

• Emphasize fruits and vegetables. A diet rich in fresh fruits and vegetables, especially those high in vitamin C and beta carotene, has been shown to help protect against stomach cancer. Look for deep green and dark yellow or orange fruits and vegetables, such as Swiss chard, bok choy, spinach, cantaloupe, mango, acorn or butternut squash, and sweet potatoes. Also try to eat vegetables from the cabbage family, including broccoli, brussels sprouts and cauliflower. Lycopene, a nutrient found in tomatoes and other red fruits and vegetables such as strawberries and red bell peppers, may be a particularly powerful anti-cancer chemical.
• Avoid nitrites and nitrates. These nitrogen compounds are known to contribute to stomach cancer. They're found primarily in processed meats — bologna, salami and corned beef, for instance — and in cured meats such as ham and bacon.
• Limit smoked, pickled and heavily salted foods. These have been linked to an increased risk of stomach cancer. Countries where the consumption of smoked, pickled and salted food is high have correspondingly high stomach cancer rates.
• Don't smoke. Tobacco use greatly increases your risk of stomach cancer, especially cancer that occurs at the junction of the esophagus and stomach.
• Limit alcohol consumption. Alcohol causes changes in cells that can lead to cancer.
• Limit red meat. Eating large amounts of red meat — particularly when it's barbecued or well done — increases your risk of stomach cancer. Instead, choose fish or poultry.
• See your doctor if you suspect ulcers. Infection with H. pylori, the bacterium that causes most cases of gastric ulcers, is one of the leading causes of stomach cancer. Don't ignore symptoms of ulcers, such as a gnawing pain in your abdomen or chest that's worse when your stomach is empty or at night. Other, more severe signs and symptoms of ulcers include nausea, vomiting, bleeding and unintended weight loss.

After gastrectomy, it's not uncommon to experience nausea, vomiting, diarrhea, weight loss, nutritional deficiencies and dumping syndrome, which occurs when food enters your small intestine too quickly. These side effects usually result from eating more at one time than your digestive system can tolerate and can often be controlled with changes in the amount, frequency and kinds of food you eat.

You may also develop nutritional deficiencies because you're no longer able to absorb certain vitamins. Vitamin B-12, for example, can only be absorbed when it's attached to a protein produced in your stomach (intrinsic factor). For that reason, you'll need to receive vitamin B-12 injections for life. Your doctor may also recommend supplementing your diet with other nutrients especially folic acid, iron and calcium.

Although coping with the effects of gastrectomy can be challenging, the following measures may help improve or relieve your symptoms:

• Eat small, frequent meals. Normally, your stomach can expand to hold nearly a gallon of food and liquid, which it then releases slowly into your small intestine. After gastrectomy, you won't be able to eat as much at one sitting as you once did, although you likely can consume the same amount overall. To get the calories you need while minimizing intestinal symptoms, try eating six small meals a day, rather than two or three large ones.
• Avoid drinking with meals. Although it's important to drink plenty of fluids, especially water, drinking with meals hastens the movement of food through the upper part of your digestive tract and may reduce the absorption of nutrients. Instead, try to drink 30 minutes before or 60 minutes after you eat.
• Eat slowly and chew thoroughly. This can help reduce nausea and vomiting and increase your ability to absorb nutrients.
• Avoid extremely hot or cold foods or liquids. These may aggravate your symptoms.
• Rest after meals. It's best to relax after you eat because activity increases the likelihood of nausea and vomiting. Don't lie flat, however, for at least two to three hours after a meal.
• Avoid sugar. All forms of sugars and sweets aggravate dumping syndrome.
• Use dairy products cautiously. Some people find that dairy foods such as milk, cheese and even yogurt cause gas, bloating and abdominal pain. In that case, an enzyme product such as Lactaid or Dairy Ease may help break down lactose. Consuming small amounts of milk products or combining them with other foods to slow digestion also may help. In some cases, though, you may need to eliminate dairy foods completely. If so, be sure to get enough protein, calcium and B vitamins from other sources.
• Avoid troublesome foods. If certain foods make your symptoms worse, don't eat them. Common culprits include alcohol, chocolate, caffeinated beverages such as coffee and sodas, spicy foods, fruit juices, raw fruits and vegetables, beans, broccoli, cabbage and other gassy foods, and sugar-free sweeteners such as sorbitol or mannitol. Butter, margarine, oils and high-fat foods such as mayonnaise, nuts, cream, ice cream and red meat may be particularly troublesome. Instead, try eating softly cooked or pureed fruits and vegetables, rice, plain baked potatoes, soups, broth, and chicken or fish cooked without fat.
• Talk to a dietitian. It's difficult to get the calories and nutrition you need on a restricted diet. A dietitian can help you plan healthy meals that don't aggravate your symptoms.

A diagnosis of cancer can be extremely challenging. Remember that no matter what your concerns or prognosis, you're not alone. These strategies and resources may make dealing with cancer easier:

• Know what to expect. Find out everything you can about your cancer — the type, stage, your treatment options and their side effects. The more you know, the more active you can be in your own care. In addition to talking with your doctor, look for information in your local library and on the Internet. The National Cancer Institute will answer questions from the public. You can reach them at (800) 4-CANCER, or (800) 422-6237. Or contact the American Cancer Society at (800) 227-2345.
• Be proactive. Although you may feel tired and discouraged, don't let others — including your family or your doctor — make important decisions for you. Take an active role in your treatment.
• Maintain a strong support system. Having a support system can help you cope with any issues, pain and anxieties that might occur. Although friends and family can be your best allies, they sometimes may have trouble dealing with your illness. If so, the concern and understanding of a formal support group or others coping with cancer can be especially helpful. Although support groups aren't for everyone, they can be a good source for practical information. You may also find you develop deep and lasting bonds with people who are going through the same things you are.
• Set reasonable goals. Having goals helps you feel in control and can give you a sense of purpose. But don't choose goals you can't possibly reach. You may not be able to work a 40-hour week, for example, but you may be able to work part time. In fact, many people find that continuing to work can be helpful.
• Take time for yourself. Eating well, relaxing and getting enough rest can help combat the stress and fatigue of cancer. Also, plan ahead for the downtimes when you may need to rest more or limit what you do.
• Stay active. Being diagnosed with cancer doesn't mean you have to stop doing the things you enjoy or normally do. For the most part, if you feel well enough to do something, go ahead and do it. Stay involved as much as you can.

Coming to terms with your illness
Having a serious illness may be the hardest thing you've ever dealt with. 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.

In fact, the greatest fears of many people with a life-threatening illness include being subjected to treatments they don't want, becoming a burden to their loved ones, and spending their last weeks or months in a hospital away from familiar surroundings. The welcome news is that many more choices now 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 a hospice residence. 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 those who stay in a hospital, palliative care specialists can provide comfort, compassionate care and dignity.

Talking about end-of-life issues
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, 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.