• CancerNews' Avatar

    CancerNews posted a blog post

    Of Tennis Shoes, Sidewalks, and Crosswalks

    By Colleen Doyle, MS, RD
    I wrote this blog in my head first, while I was on a walk. I was thinking about how fortunate I am to live in an area that I can walk - safely - for fitness and fun, for date nights and errands. But it wasn't always that way.
    My family and I used to live in a neighborhood where we could not walk to anything from our home. Besides having no stores, restaurants, schools, dry cleaners - you name it - within a reasonable walking distance, the road leading to our neighborhood was narrow, had no sidewalks, and people sped down that road with reckless abandon.
    When we decided to move "in town," we were ecstatic. I could walk or ride my bike to work, our kids could bike to school, and we could even walk to the gym to get our workouts in. We saved lots of money by not having to fill up our gas tanks so frequently. We felt less stress from not having to drive as often on traffic-packed highways and roads.  Physical, financial and quality of life benefits -- all from living in an area where we could get out and walk, safely, and for multiple purposes. 
    The Surgeon General's Call to Action
    All this has been on my mind because a new report is being released today: The Surgeon General's Call to Action on Walking and Walkable Communities. And I am hopeful that individuals, organizations, and communities will step up and take notice. And take action.
    Encouraging walking, and working together with partners to make it easier for all Americans to walk more and to be more active, is critical to the mission of the American Cancer Society. For the 80% of Americans who do not use tobacco products, living a physically active lifestyle is one of the most important ways to reduce cancer risk. And among some groups of cancer survivors, physical activity has been linked to improvements in survival, as well as in fatigue, anxiety, depression, self-esteem, happiness, and quality of life. 
    The issue of reducing barriers to physical activity in communities is so critical to our mission, in fact, that our Guidelines on Nutrition and Physical Activity for Cancer Prevention include what we call our Recommendation for Community Action: that public, private, and community organizations work collaboratively at national, state, and local levels to implement policy and environmental changes that provide safe, enjoyable, and accessible environments for physical activity in schools and worksites, and for transportation and recreation in communities. 
    For many, but not all of us, walking is one of the easiest and most convenient ways to add more activity throughout each and every day. It has many health benefits - both short-term and long-term - and while we need good shoes (and sunscreen), we don't need much else. But we do need communities that make it easier for us to walk and enjoy other physical activity opportunities safely. Unfortunately, many of us do not live in such communities. We may not have sidewalks and bike lanes. We may not have safe places for our children to play. We may live in areas of 'sprawl' that include large distances between homes and places of business, like grocery stores and restaurants.
    This Call to Action challenges all of us to work together to increase physical activity and walking, in particular. Volunteer and non-profit organizations; business and industry; employers and schools; health care and public health professionals; community design experts; and the media: We all have a role to play.
    What you can do: Speak up
    So, what can you do? As an individual, make a commitment to walk more - to look for opportunities each and every day to get more steps. As a parent, be a good role model for your kids. Parents who are more active tend to have children who are more active. Speak up at their schools, ensuring that physical education classes are held regularly, and that activity is incorporated throughout the school day; and encourage participation in Walk and Bike to School initiatives.
    As an employee, speak up for participation in Walk and Bike to Work initiatives (even if you don't live close enough to walk or bike!). Ask for programs and policies that encourage and support more activity throughout the day.
    As a community member, speak up at City Council meetings for more sidewalks, crosswalks, bike lanes, parks, and green space. Speak up for public transportation (it's estimated that 90% of transit trips include walking at the beginning or ending of a trip). Speak up for "traffic calming" efforts, designed to slow down cars driving through your neighborhood.  Speak up for more neighborhood watch groups and police patrols to help promote safer environments.
    Currently, only 50% of adults and 25% of our youth meet the Physical Activity Guidelines for Americans recommendations. For adults, that recommendation is at least 150 minutes of an activity like walking each week and for youth, it's 60 minutes each day. Working together to make it easier for all Americans to be active - where they live, work, play and learn - can help improve the health of our nation and importantly, set our kids on a path to lifelong good health. What will you do, starting today, to help  achieve that goal?
     
    Doyle is managing director of Healthy Eating, Active Living Environments for the American Cancer Society.

  • CancerNews' Avatar

    CancerNews posted a blog post

    When Cancer Spreads: Understanding Metastasis

    By Louise Chang, MD
    How does lung cancer reach other areas of my body? Why did breast cancer show up in my bones? What does it mean to have metastatic cancer?
    It can be hard to understand how cancer starts in one place and also shows up in other places in the body that are far from where it started. The ability to spread, called metastasis, speaks to the aggressive nature of cancer and the challenge it poses.
    Cancer starts from cells in our body that have gone rogue. The body has ways to monitor and dispose of abnormal cells that develop, but cancer cells are able to avoid the body's defense system. They grow out of control and form into cancerous tumors.
    As cancer cells multiply, they can get into the bloodstream and lymph system. This allows the cancer cells to travel and settle in other parts of the body. When cancer spreads like this, it is described as "metastatic" - because cancer cells have moved toa different location in the body. But metastatic tumors are still considered to be the same cancer type as where the cancer first started. This is why breast cancer that has spread to the bone or lungs is still breast cancer. Lung cancer that has spread to the liver is still lung cancer.
    Whether cancer is diagnosed at an early stage or more advanced stage, spread may occur despite best efforts in screening and treatment. When this happens, the approach to treatment will depend on a number of factors including the type of cancer, location, and extent of its spread, and a person's overall health.
    Each person's case is different. Here are some questions you can ask your cancer care team or if you are getting a second opinion to help you understand your case and what to expect.
    Where has the cancer spread?
    Are there additional tests or exams that you recommend? If so, what are they and how often will I need them?
    What symptoms or effects could I experience from the cancer now? What can we do to avoid or lessen them?
    How will my treatment plan change? What are the options for treatment?
    What are the benefits and risks of the treatment options?
    What side effects can I expect from treatment? What can be done to help with side effects of treatment?
    What is your experience with treating metastatic cancer?
    Are you involved in clinical trials? Would you be able to help me look into clinical trials if I am eligible?
    Researchers continue to study ways to curb cancer and its ability to spread. For example, researchers funded by the American Cancer Society are studying ways to stop the spread of breast cancer and skin cancer.
    Learn more about metastatic cancer, how it is found, and how it is treated.
     
    Dr. Chang is director of medical information for the American Cancer Society.

  • CancerNews' Avatar

    CancerNews posted a blog post

    Can Vitamin D prevent cancer?

    By Marji McCullough, ScD, RD
    You may be aware that vitamin D is important for helping make strong bones, but vitamin D often appears in the media for its potential role in a host of other health effects, from preventing diabetes, heart disease, and cancer to simply living longer. However, these "non-skeletal" (not having to do with your bones) roles of vitamin D are not clearly established, and remain a topic of active investigation and debate. To add to the confusion, several recent scientific reviews of the vast data on vitamin D arrived at different conclusions about whether it helps prevent disease or not.
    In this blog, I am going to focus on the evidence for vitamin D and cancer prevention, highlight some key unresolved questions and give some advice to consider while we await the answers (which may take a while).
    Where does vitamin D come from?
    People can get vitamin D from exposure to sunlight, from certain foods, and from supplements.
    Current vitamin D recommendations from the Institute of Medicine (IOM), the organization tasked with developing the Recommended Daily Allowances (RDAs), are 600 IU (International Units) per day for most adults, and 800 IU of vitamin D per day for those over age 70.
    Vitamin D is found naturally in very few foods, including cod liver oil, fatty fish like sardines or salmon, and smaller amounts in eggs and leafy greens. In the U.S., vitamin D is added to milk, some yogurts, orange juices, and cereals. One cup of milk or yogurt contains about 100 IU, whereas fatty fish contains about 500 IU per serving. Learn about other sources here. Vitamin D supplements are available in a range of doses. 
    Sun exposure can provide a wallop of vitamin D, depending on amount of skin exposed, skin tone, time of day, time of year, location, and a variety of other factors.  For example, a Caucasian adult wearing a bathing suit exposed to enough sun to have a light pink sunburn has received roughly 10,000-20,000 IU of vitamin D. (It takes dark-skinned individuals 5-10 times longer to form the vitamin because of higher concentrations of melanin in the skin, and dark-skinned individuals often have lower vitamin D levels.  Other factors that can influence vitamin D formation in the skin include use of sunscreens and sun-protective clothing (because they block UV rays).  
    But don't look to the sun as a source of vitamin D because the same UV radiation that forms vitamin D in the skin also burns the skin and can lead to skin cancer, including melanoma (the most serious type of skin cancer). Studies have not identified a level of sun exposure that is safe for avoiding skin cancer. The American Cancer Society recommends limiting sun exposure to prevent these forms of cancer. 
    What the studies say
    It has been suggested that vitamin D itself may prevent, or even increase the risk for, some forms of cancer. Different types of studies are used to understand whether vitamin D increases or lowers the risk of cancer. All have their strengths and weaknesses and add a piece to the puzzle.
    Laboratory studies provide some strong biological evidence to support a role for vitamin D in cancer prevention. Vitamin D can "turn on" or "turn off" a host of genes, including some that regulate cell growth, limit inflammation, and reduce levels of a signaling protein that can allow cancer cells to spread. The exact role of vitamin D in these processes is a very active area of research.
    Observational studies
    In humans, the idea that vitamin D might help protect against cancer first came from studies that mapped cancer death rates in the US by region. These studies showed that Northern states, where sun exposure was lowest, had higher death rates from several different cancers compared to the Southern, sunnier states.  Because the sun is a source of vitamin D, scientists thought that vitamin D might protect against cancer. However, different cancer rates by region also may be due to other factors, like smoking rates and obesity, that vary among people living in different parts of the country.
    Some of the most compelling data on vitamin D and cancer comes from observational studies, in particular prospective cohort studies, in which thousands of people who have not been diagnosed with cancer provide information on diet and other lifestyle factors, and/or provide a blood sample before cancer diagnosis, are then are followed over several years. Researchers then examine links between lifestyle factors and new cancer diagnoses. Some of these studies have shown that having more vitamin D in the diet or in the blood (which takes into account vitamin D from all sources), is associated with a slightly lower risk of certain cancers.
    So far, the most support for a role of vitamin D comes from prospective studies of colorectal cancer (includes both colon and rectal cancers). IIn several studies, compared to people with low blood vitamin D levels, people with higher blood levels have a significantly lower risk of colorectal cancer. However, there are inconsistencies in results across studies, potentially due to different methods used, such as how vitamin D was measured. An ongoing study called the "Vitamin D Pooling Project of Breast and Colorectal Cancer" is carefully measuring blood levels of vitamin D and examining their association with colorectal and breast cancer in 21 prospective studies, using the same methods. These findings should be published in the next year.
    The evidence from observational studies for other cancers is less consistent, and it may be that vitamin D has different roles (or no role), depending on cancer type. In a study that combined results from 10 studies, vitamin D levels in the blood before diagnosis did not seem was not associated with the risk of kidney, lymphoid, ovarian, endometrial, or upper gastrointestinal cancers like stomach or esophagus. For other cancers, including prostate and pancreas, studies have had inconsistent results, some even suggesting increased risk of cancer in those with the highest levels.
    A strength of observational studies like prospective cohort studies is that they can typically examine wide ranges of vitamin D in the blood that occur naturally in a population. Their main limitation is that they cannot prove that it's the vitamin D in the blood that really prevents cancer. For example, people with low vitamin D levels may also tend to be less physically active and more overweight or obese, both of which are risk factors for colorectal cancer. For this reason, researchers conducting observational studies collect detailed information on these types of risk factors and account for them when they're examining the results.  
     
    Randomized controlled trials
    Other RCTs of vitamin D that reported on development of cancer or death from cancer had very small sample sizes and did not provide conclusive results. For some of these trials, the goal was to study bone health, not cancer, increasing the likelihood of "chance" findings. There are currently a handful of larger trials underway, including the large U.S. VITAL trial, which will examine vitamin D and fish oil supplements in relation to cancer outcomes and heart disease. Study results are not expected for several years.
     
    When they're done right, RCTs can prove if something prevents disease because people are randomly assigned to get vitamin D or a placebo (sugar pill). The randomization makes sure that people are alike in other ways (e.g. body weight, physical activity, and other known or unknown risk factors), so researchers can isolate the effect of the vitamin D supplement. So far, a large RCT did not find that 400 IU vitamin D combined with calcium lowered colorectal or breast cancer risks. In this study, women were allowed to take their own supplements, and by the end of the trial, most were. In other words, the placebo group and hte interventiuon group were exposed to vitamin D, increasing the risk of null results (left to chance).
    What to do in the meantime?
    The key for research will be to identify the amount of vitamin D that may lower the risk of certain diseases, but not increase the risk of others. Until we know more, make sure you meet the IOM recommendations for bone health of 600 IU for most adults or 800 IU of vitamin D/day for those over age 70. Even for people who are not exposed to the sun, the recommended doses are thought to be enough for 97.5% of people in the US.. Depending on your health status, your doctor may choose to measure how much vitamin D you have in your blood, but routine vitamin D measurements are currently not recommended by any agency for cancer prevention or to avoid other serious illnesses. Bottom line: we don't know yet if vitamin D can help prevent cancer or other diseases, but we're working on finding out. In the meantime, make sure to meet the IOM recommendations for bone health through food choices as much as you can, and discuss with your health care provider whether you need a supplement to help.
     
    McCullough is strategic director of nutritional epidemiology for the American Cancer Society.

  • CancerNews' Avatar

    CancerNews posted a blog post

    World No Tobacco Day is about Driving Down Tobacco Use

    By Jeffrey Drope, PhD
    May 31 is World No Tobacco Day, an important annual event when we pause to reflect on how to move the world away from tobacco use and toward improved public health.  
    Tobacco is one of the leading risk factors for non-communicable diseases, including cancer - 32% of all cancer deaths in the United States, including a staggering 87% of lung cancer deaths, are attributable to tobacco use. Tobacco use is also one of the most preventable causes of cancer deaths.  
    This year's World No Tobacco Day theme is illicit trade - tobacco products produced, exported, imported, purchased, sold, or possessed illegally. While illicit trade in tobacco products is undoubtedly troubling from a number of perspectives, including lost tax revenue for governments, increased revenue to tobacco companies, and links to organized crime and possibly terrorism, it's important to look at the whole picture. The tobacco industry consistently tries to claim that strong tobacco control policies increase illicit trade. But, in fact, the single best way to fight the illicit trade in tobacco products is to redouble efforts to use what we already know works to drive down the use of all cigarettes, legal and illegal. Such practices include:
    increasing tobacco excise taxes,
    requiring graphic warning labels on tobacco packaging,
    making laws to ban tobacco marketing and
    demanding smoke-free public and work places and anywhere where children might be present.
    It's also important to make very clear some fundamental truths about illicit trade.
    First, almost all illicit cigarettes start as legal ones: by the industry's own admissions, the proportion is about 95%. There's overwhelming evidence that the tobacco industry itself is regularly involved in some way in the illegal trade of their products. Furthermore, the tobacco industry often claims that illicit cigarettes are more unhealthy, but this is a ridiculous notion considering that these manufacturers make almost all cigarettes . More to the point, we know without question that all cigarettes - legal or otherwise - will eventually kill you if used "as prescribed" by the manufacturer.
    Second, although many governments believe it's convenient and useful to work with the tobacco industry on illicit trade, governments should be very wary because the tobacco industry will do what's best for the tobacco industry, not necessarily what's best for public health. For example, certain companies have developed so-called "track and trace" systems to ensure the legal supply chain of tobacco products, but it's best to keep the industry at arm's length and implement an independent program, such as the one that Kenya is now using to fight the illicit cigarette trade successfully. In other words, government should set up their own systems to fight illicit trade and shouldn't rely on the companies' often-deceptive practices. In the European Union, a forthcoming study involving American Cancer Society research staff shows that since signing agreements with several major tobacco companies about illicit trade, financial losses have not been recovered nearly as well as expected. Additionally, these agreements have effectively served to secure the tobacco industry's political presence in Europe, thereby threatening progress in helping people quit tobacco or avoid it in the first place.
    The existence of illicit trade should never distract us from the critical job of implementing strong tobacco control policies and saving lives. Moreover, we've seen that it's possible for governments to create effective tobacco control policies and save lives, even in the presence of illicit trade.
    We invite you to visit our website, tobaccoatlas.org, to learn more not only about the illicit trade in tobacco products, but more importantly about the steps that must be taken to fight the tobacco epidemic and create a tobacco-free world with less cancer and other preventable diseases.
    Drope is vice president of the American Cancer Society's Economic & Health Policy Research Program.

  • CancerNews' Avatar

    CancerNews posted a blog post

    Recent progress in cancer research, prevention, and treatment

    By Fadlo R. Khuri, MD, FACP
    2014 was another banner year for cancer research, particularly in the areas of treatment, prevention, and early detection. While there were several significant spheres of progress, we find the following five major advances particularly noteworthy.   
    Targeted therapies
    First is the development of new targeted therapies for cancer. Targeted therapies specifically block key molecules that are crucial for cancer cell growth and survival.
    The promise of such therapies was first established about 15 years ago by the development of imatinib (Gleevec), which blocks the oncogene (cancer-promoting gene) responsible for development of chronic myelogenous leukemia (CML), and led to dramatic responses in patients with this cancer. Many more targeted agents have since been developed. This development has been greatly helped in recent years by the sequencing of the human and the cancer genome, which has led to a more complete understanding of genes that drive cancer. 
    Targeted agents have transformed modern cancer care by keeping cancer under control for longer periods of time and reducing side effects. However, for all but a handful of patients, cancer is able to develop resistance to targeted therapy over time.
    A number of newer, more potent targeted therapies were developed in 2014 that further reduce side effects and help overcome resistance, at least for some time. Targeted therapy treatments have evolved and improved for patients with certain forms of lung cancer, leukemia, breast cancer and renal cell carcinoma.
    Patients with cancer and their family members should be prepared to ask how specific the targeted treatment is for their own type of cancer (how well does it target their type of cancer cell), how long most people stay on the treatment, the benefits from the treatment, and what the side effects could be like.
    Immunotherapy
    More dramatic strides in cancer therapy in 2014 revolved around major advances in harnessing the power of the immune system to fight the disease. Given that cancer often arises slowly in a patient's body, the immune system gradually becomes more tolerant of the steadily increasing amount of cancer. It eventually ignores the cancer altogether. 
    In the last few years, scientists have developed powerful new tools that can reactivate the immune system. These treatments are in the form of potent cancer vaccines and other immune-provoking agents. Several such new immunotherapies were approved in the last year alone, particularly for patients with melanoma and lung cancer. 
    These new immune "awakening" approaches are able to activate the patient's immune system to attack the cancer and keep it at bay, in some cases for several years. Cancer patients should inform themselves about the very different and, in some cases, milder side effects that immunotherapies bring.
    However, only a minority of patients treated with immunotherapy see significant benefits from the treatments. Researchers are looking for better ways to determine which patients are likely to benefit from these treatments and which biomarkers can be used to predict benefits from specific immunotherapies.
    Tracking cancer in the body
    Another recent discovery that's helping us figure out how to better care for people with cancer is our growing ability to detect very low levels of circulating cancer cells or pieces of cancer DNA in the blood. 
    Progress is being achieved in learning, for example, when an ongoing treatment is working in a patient, when resistance to treatment is starting, and perhaps most significantly, in catching disease that cannot be found even through the most sophisticated modern cancer imaging techniques, such as PET and MRI scans. 
    While this method is not ready for wide-spread use, research so far strongly suggests that this will become a powerful tool to help us manage the cancer experience in a more timely, accurate way.  
    Better imaging tests to find cancer early
    Speaking of improved imaging, it's not only in the area of cancer treatment that these advances are making a difference. 
    When expert organizations, including the American Cancer Society, recommended using CT scans to screen high-risk smokers for lung cancer in order to detect the disease earlier and save lives, they understood this could have enormous impact on the number of lives lost to lung cancer. There are up to 90 million current or former smokers in the United States today, many of whom stand to gain from being screened for lung cancer.
    This adds momentum to significant progress in screening for breast, colorectal (commonly called colon), cervical, and prostate cancers. These cancers, along with lung, are the among the most common in US adults, and better tools to find these cancers early will save many lives.
    Current and former smokers who are at high risk for lung cancer, including those who have been successfully treated for prior tobacco-related cancers, should ask whether evidence supporting lung cancer screening applies to them.
    Using radiation instead of surgery
    Interestingly, it's the therapeutic application of radiation that represents the final major area of progress. Radiation therapy has long been known to be a powerful and highly effective treatment for controlling cancers in defined areas. However, for patients whose disease is localized to one area and a few surrounding lymph nodes, surgery has long been the first and often the best approach. 
    Recent evidence strongly suggests that a few highly accurate treatments with high-dose radiation therapy can approach and even equal the success of limited surgery. This would provide a powerful tool in the hands of doctors treating patients who are poor candidates for surgery due to their general health or other illnesses. 
    This increasingly effective approach, called Stereotactic Body Radiotherapy (SBRT), has opened up a number of opportunities for those patients who couldn't have surgery. Patients who are not ideal candidates for surgery (your health care team would have told you this) should strongly consider this approach, and discuss it with their cancer care team.
    These exciting and revolutionary advances all arise from discoveries in laboratory-based and clinical sciences. They represent a major return on the longstanding commitments of the United States government (through the National Institutes of Health, Department of Defense, National Science Foundation and other agencies) and major philanthropic organizations, such as the American Cancer Society, to funding biologic discovery. Without this support, none of these major strides in cancer treatment would be possible.
    Cancer patients today are having their diseases detected earlier, are facing a higher likelihood of cure, and are living with a better quality of life. Even patients with metastatic disease are living substantially longer compared to just 5 years ago. Still, while much progress has been made, much more remains to be accomplished so that our cancer patients' lives can be managed more like the lives of those with heart problems, diabetes, or other chronic diseases. For this goal to become a reality, the continued support and growth of our fundamental and clinical science research efforts through funding and support has never been more vital.
     
    Dr. Khuri is executive associate dean for research at the Emory University School of Medicine; professor and chair of hematology and medical oncology, adjunct professor of medicine, pharmacology and otolaryngology; Roberto C. Goizueta Distinguished Chair in Translational Cancer Research; and deputy director, Winship Cancer Institute, Emory University. He also serves as editor-in-chief of CANCER. 

  • CancerNews' Avatar

    CancerNews posted a blog post

    Making End-of-Life Plans

    By Agnes Beasley, MSN, RN, OCN
    A lot of us are planners. We plan work projects, celebrations, careers, family vacations, and retirements. However, the one area that most of us avoid thinking about, much less planning, is the end of our life. After all, we don't plan on having a terminal illness. We don't plan on dying any time soon. Decisions about end-of-life care are deeply personal, and are based on personal values and beliefs. No one wants to think about end-of-life issues when there are so many other happier activities to fill our calendars.
    Still, at some point in time many of us will face making decisions about the dying process. How do you bring up the topic? When do you bring up the topic? Who do you talk to? Thinking about your end-of-life wishes, also known as advance care planning, can be hard and overwhelming. Most people expect their doctors to start the conversation about end-of-life planning - but only when it's necessary and not a moment sooner! That's especially true for people with cancer, especially when treatment may no longer be working. Many cancer patients and close family members may be thinking about discussing end-of-life issues with their doctor when the time comes, but where do they begin?  
    How to begin
    It starts with you. You must take the first step by beginning the hard work of emotional homework: exploring your values, beliefs, desires, and fears regarding end-of-life issues. During my career as an oncology nurse, many terminally ill patients and families have shared with me a wide range of concerns: fears about dying, understanding prognosis, achieving important end-of-life goals, and attending to physical needs.  
    You might ask yourself: what are my fears? Am I afraid of the possibility of pain? Not being clearly understood by those around me? Dying alone? Being overly-sedated or in a lingering state of unconsciousness? Leaving loved ones or unfinished projects behind? Leaving your loved ones without adequate financial resources? Dying in a strange place? The answers to these questions will be different for everyone. It's important to get a clear understanding of your feelings around these topics before planning. Would you plan a vacation without doing some homework first? It should be no different when tackling important conversations about the end of your life.  
    Getting the conversation started
    It's all about talking. Talk openly to family and friends about your values and beliefs, your hopes and fears about the last stages of your life.  
    Good open and honest communication between you, your loved ones, and your doctor before an emergency happens can jump start the process of creating a comprehensive treatment plan that's medically sound and matches your wishes and values. It's important to have this plan in place before it's actually needed.  
    Ask your doctor for a time when you can share your ideas and questions about end-of-life treatment and medical decisions. You might suggest setting some time aside during your next scheduled appointment with your doctor. Tell him or her you want guidance in preparing advance directives, like health care power of attorney, living wills, do-not-resuscitate, and other agreements like these, especially if you are already ill or treatment is no longer working. Ask your doctor what you might expect to happen when you begin to feel worse. Let him or her know how much information you wish to receive about your illness, prognosis, care options (like hospice), and what you might expect this time to be like.
    You may ask your doctor specifically:
    Will you talk openly and honestly with me and my family about my illness?
    What decisions will my family and I have to make, and can you make recommendations to help us make these decisions?
    What will you do if I have a lot of pain or other uncomfortable symptoms?
    How will you help us find professionals with special training when we need them (e.g., hospice care, palliative care specialists, spiritual leaders, social workers, etc.)?
    Will you let me know if treatment stops working so that my family and I can make appropriate decisions?
    Will you support me in getting hospice care?
    Is there someone on your staff who can help me understand if/how my health insurance will help me get the care I need?
    Will you still be available to me even when I'm sick and close to the end of my life?
    Preferences for the end of life
    Even after asking and getting answers to all the hard questions and concerns regarding end-of-life issues, it's hard to predict what the dying process will be like for any one person - it's also hard to know when it will happen. Preferences for care at this time will be different from person to person. For example, you may decide to spend your final days at home, surrounded by family and friends while under the care of hospice. Yet others may prefer to be alone, or they may want to be in the hospital getting treatment right until the very end.
    Your decisions may also change over time - you may have wanted everything possible done to prolong your life at one point, but decide to change your focus to comfort care only as time goes on. Someone else who originally declined treatment may agree to an experimental therapy or clinical trial that may benefit future patients with the same condition.
    No matter how a person chooses to approach the end of their life, planning for end-of-life care can help them be sure their values and preferences are honored. It all starts with you, your honest examination of what you want and what's important to you. Once you have clear picture of what you want or don't want at the end of life, don't keep it to yourself. Talk openly, honestly and frequently with your family and healthcare team about your wishes. And perhaps most importantly, get your plans written out. Create the documents needed to make your wishes as clear as possible and share them with your loved ones and your medical team. 
     
    Beasley is an oncology nurse education for the American Cancer Society.