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Terminal Illness

Terminal illness

Terminal illness is a medical term popularized in the 20th century for an active and progressive disease which cannot be cured and is expected to lead to death. Palliative care is often prescribed to manage symptoms and improve quality of life.

Disease

A disease is any abnormal condition of the body or mind that causes discomfort, dysfunction, or distress to the person affected or those in contact with the person. Sometimes the term is used broadly to include injuries, disabilities, syndromes, symptoms, deviant behaviors, and atypical variations of structure and function, while in other contexts these may be considered distinguishable categories. Pathology is the study of diseases. The subject of systematic classification of diseases is referred to as nosology. The broader body of knowledge about diseases and their treatments is medicine.

Syndromes, illness and disease

Medical usage sometimes distinguishes a disease, which has a known specific cause or causes (called its etiology), from a syndrome, which is a collection of signs or symptoms that occur together. However, many conditions have been identified, yet continue to be referred to as "syndromes". Furthermore, numerous conditions of unknown etiology are referred to as "diseases" in many contexts. Illness, although often used to mean disease, can also refer to a person's perception of their health, regardless of whether they in fact have a disease. A person without any disease may feel unhealthy and believe he has an illness. Another person may feel healthy and believe he does not have an illness even though he may have a disease such as dangerously high blood pressure which may lead to a fatal heart attack or stroke.

Transmission of disease

Some diseases, such as influenza, are contagious or infectious, and can be transmitted by any of a variety of mechanisms, including droplets from coughs and sneezes, by bites of insects or other vectors, from contaminated water or food, etc. Other diseases, such as cancer and heart disease are not considered to be due to infection, although micro-organisms may play a role.

Social significance of disease

The identification of a condition as a disease, rather than as simply a variation of human structure or function, can have significant social or economic implications. The controversial recognitions as diseases of post-traumatic stress disorder, also known as "shell shock"; repetitive motion injury or repetitive stress injury (RSI); and Gulf War syndrome has had a number of positive and negative effects on the financial and other responsibilities of governments, corporations and institutions towards individuals, as well as on the individuals themselves. The social implication of viewing aging as a disease could be profound, though this classification is not yet widespread. A condition may be considered to be a disease in some cultures or eras but not in others. Oppositional-defiant disorder, attention-deficit hyperactivity disorder, and, increasingly, obesity are conditions considered to be diseases in the United States and Canada today, but were not so-considered decades ago and are not so-considered in some other countries. Conversely, the number of people in the West who consider homosexuality to be a disease became widespread in the 20th century but has been decreasing in the last two decades. To consider a condition to be a disease can sometimes involve a negative social value judgement. Lepers were a group of afflicted individuals who were historically shunned and the term "leper" still evokes social stigma. Fear of disease can still be a widespread social phenomena, though not all diseases evoke extreme social stigma.

Other uses of the term

In biology, disease refers to any abnormal condition of an organism that impairs function. The term disease is often used metaphorically for disordered, dysfunctional, or distressing conditions of other things, as in disease of society.

External links

- [http://www.nlm.nih.gov/medlineplus/healthtopics.html Health Topics], MedlinePlus descriptions of most diseases, with access to current research articles.
- [http://www.cdc.gov/health/default.htm Center for Disease Control Health Topics A-Z], fact sheets about many common diseases
- [http://rarediseases.about.com/ Rare/Orphan Diseases]
- [http://www.national-health.org/rarediseases/ National Organization for Rare Disorders] Extensive, useful information on rare diseases.
- [http://www.merck.com/pubs/mmanual/sections.htm The Merck Manual], detailed description of most diseases, freely searchable online. Category:Diseases Category:Medical terms als:Krankheit zh-min-nan:Pīⁿ ms:Penyakit ja:病気 simple:Disease th:โรค

Death

:For other uses, see Death (disambiguation) or Dead (disambiguation). Death is the cessation of physical life in a living organism or the state of the organism after that event.

Interpretations of "death"

In almost all societies, death has one or several symbols associated with it. Common symbols of death in Western cultures include the grim reaper and the color black; conversely, in certain Eastern cultures, the color white is considered symbolic of death. The grave is a metonym for death. Biologically, death can occur to wholes, to parts of wholes, or to both. For example, it is possible for individual cells and even organs to die, and yet for the organism as a whole to continue to live; many individual cells can live for only a short time, and so most of an organism's cells are continually dying and being replaced by new ones. Conversely, when organisms die their cells can live for some time afterward. Organs, for instance, can be removed for transplantation. They must be removed and transplanted quickly, or they too will soon die without the support of their host. Rarely, cell cultures can be "immortal" as in the case of Henrietta Lacks' HeLa cell line. Fingernails and hair appear to grow after a person's death, as, due to bodily dehydration, the flesh pulls away from the hair and nails. In ancient times, this led to confusion about whether a body was actually dead, and added to the myth of vampires. Irreversibility is often cited as a key feature of death. By definition, a dead organism cannot be brought back to life; if it were to be, that would indicate that it had never been dead. Nonetheless, many people do not believe that death is necessarily irreversible; thus some have a religious belief in bodily or spiritual resurrection, while others have hope for the eventual prospects of cryonics or other technological means of reversing what is currently thought of as death. It has been hypothesized that a limited lifespan is a consequence of evolution not selecting for extreme longevity in most species, as evolutionary selection only need apply to the organism up to the point of reproduction; after that, except for caring for kin, the continued existence of an individual can have little effect on the survival of its gene line. A common assumption is that the Second Law of Thermodynamics dictates that all complex systems must eventually deteriorate, so it is not likely that any species could ever be immortal. However, this aspect of the Second Law of Thermodynamics only applies to closed systems, which organisms are not.

Ways of defining human death: medical, religious, and legal

Human death can be defined by three dramatically different but overlapping domains: medical, religious, and legal. These different domains and their importance have evolved over time and can vary from person to person. So when talking about death, it is important to differentiate which domain we are speaking of and to have a general understanding of how each defines death. There are various ways of defining medical death. Early in western culture, death was connected to the heart first and then later the lungs. When these stopped working, a person was dead. It was sometime later that the brain came into the definition. In 1963 a device called an electroencephalogram (EEG) was invented that could very accurately measure the electrical output of the brain. The test showed that when the machine registered zero electrical output from a person's brain (also known as a flat EEG) for 36 hours, the patient could be considered dead. We now know that a person can continue to be medically alive until their brain stem dies. Patients in a persistent vegetative state still have an active brain stem. Legally, a person can be pronounced dead in three different ways. By far the most common is pronouncement by a medical doctor. The second most common is pronouncement by a coroner or a state medical examiner. The third way a person can be pronounced legally dead is by the courts; after a person has disappeared for some time, the courts will pronounce them dead so that their property can be distributed appropriately. A death certificate is a legal document which states how and when a person died, and who pronounced them dead. In religous terms, death is believed to refer to the departure from the body of the soul, or essence.

When is a person dead?

Identifying the exact moment of death is important for a number of reasons. It allows for the correct time on death certificates, and helps ensure that a person's will is enacted only after they are truly deceased. In particular, identifying the moment of death is important in cases of transplantation, as organs must be harvested as quickly as possible after death. Historically, attempts to define the exact moment of death have been problematic. Death was once defined as the cessation of heartbeat (cardiac arrest) and of breathing, for example, but the development of CPR and early defibrillation posed a challenge: either the definition of death was incorrect, or techniques had been discovered that really allowed one to reverse death (because, in some cases, breathing and heartbeat can be restarted). Generally, the first option was chosen. (Today this definition of death is known as "clinical death".) Today, where a definition of the moment of death is required, doctors and coroners usually turn to "brain death" or "biological death": people are considered dead when the electrical activity in their brain ceases (cf. persistent vegetative state). It is presumed that a stoppage of electrical activity indicates the end of consciousness. Brain activity is a necessary condition to legal personhood, and, perhaps with the exception of the fetus, it is a sufficient condition for legal personhood. "It appears that once brain death has been determined … no criminal or civil liability will result from disconnecting the life-support devices." Dority v. Superior Court of San Bernardino County, 193 Cal.Rptr. 288, 291 (1983) However, those maintaining that only the neo-cortex of the brain is necessary for consciousness sometimes argue that only electrical activity there should be considered when defining death. In most places the more conservative definition of death (cessation of electrical activity in the whole brain, as opposed to just in the neo-cortex) has been adopted (for example the Uniform Determination Of Death Act in the United States). In 2005, the case of Terri Schiavo brought the question of brain-death and artificial sustainment to the front of American politics. However, in all cases the common cause of death is anoxia. Even in these cases, the determination of death can be difficult. EEGs can detect spurious electrical impulses when none exists, while there have been cases in which electrical activity in a living brain has been too low for EEGs to detect. Because of this, hospitals often have elaborate protocols for determining death involving EEGs at widely separated intervals. Medical history contains many anecdotal references to people being declared dead by physicians and coming back to life, sometimes days later in their own coffin or when embalming procedures are about to get underway. Stories of people actually being buried alive (which must assume embalming has not occurred) led at least one inventor in the early 20th century to design an alarm system that could be activated from within the coffin. Because of the difficulties in determining death, under most emergency protocols, a first responder is not authorized to pronounce a patient dead; some EMT training manuals, for example, specifically state that a person is not to be assumed dead unless there are clear and obvious indications that death has occurred, such as mortal decapitation, rigor mortis (the stiffening of the body), livor mortis (blood pooling in the lowest part of the body), decomposition, or incineration. If there is any possibility of life and in the absence of a do not resuscitate order, emergency workers must begin rescue and not end it until a patient has been brought to a hospital to be examined by a physician. This frequently leads to situation of a patient being pronounced dead on arrival.

The process of dying

Cell death

A. Normal cellular function :1. Production of energy required for vital cellular processes :2. Production of enzymatic and structural protein :3. Maintenance of chemical and osmotic homeostasis of cell :4. Cell reproduction B. Needs of cell :1. Oxygen, phosphate, calcium :2. Nutritional substrates :3. ADP - needed to produce ATP :4. Intact cell membranes :5. Steady state of activity enhances 02 consumption

Physiological changes during the process of dying

A. Events leading to death: :1. Brain ceases to supply information vital for controlling ventilation, heart rhythm, and/or vasodilation :2. Lungs unable to supply 0₂ exchange with blood stream :3. Heart and blood vessels unable to maintain adequate circulation of blood to vital tissues B. Cerebrovascular system: :1. Hemorrhage :2. Pump failure :3. Decreased CO₂ leads to decreased PCO2 leads to Cheyne-Stokes respiration C. CNS problems: :1. Infection :2. Blood vessel disruption :3. Malignant tumors :4. Metabolic changes ::a. Renal failure ::b. Hepatic failure ::c. Pancreatic failure D. CNS decompensation: :1. Early signs: ::a. Sluggish pupils :::(1) Non reactive :::(2) Dilated and fixed - drugs also affect this ::b. Confusion ::c. Inability to orient :2. Later signs: ::a. Lethargy ::b. Decreased ability to perform simple cognitive functions ::c. Attention only by tactile, auditory or visual stimuli :3. Late signs: ::a. Stupor, sleep ::b. Withdrawal of purposeless involvement to stimuli without wakefulness or arousal :4. Semicomatose - movement only with pain :5. Deep coma - no response E. Respiratory system: :1. CBF :2. COPD :3. Infections :4. Cancer metutasis :Changes after death: :A. Body cools 1.5 degrees/hr :B. Rigor mortis begins prior to decomposition and liver mortis begins with death :C. Rigor mortis: ::1. Muscles gradually become hard due to decreased ATP and lactic acidosis within muscle febrils ::2. Begins 2-4 hours after death but may be sooner ::3. May disappear 9-12 hours in hot climate :D. Liver mortis: ::1. Body becomes distended ::2. Skin color changes from green to purple to black ::3. Dependent areas fust due to pooling of blood ::4. Seen within 2 hours of death, maximum at 8-12 hours

Signs of approaching death

When death is imminent

• Physical death is a progressive process, during which there are some signs that usually indicate that death is imminent. Not all of the following changes occur, nor do they necessarily occur in any particular order, as the body shuts down during the dying process. In general, the following information may help anticipate and understand changes that appear as an individual approaches death and is “actively dying.” • The dying individual may become increasingly tired and sleepy, and may be difficult to arouse. • The dying individual may become confused much of the time and may no longer recognize familiar persons, places, or objects. • Hearing and vision may become impaired, and speech may be slurred, difficult to understand, or nonsensical. • A few patients become restless or very anxious and move about frequently in the bed, pull at the bed clothes or bedding (linen clutch), and reach out. • The person may hallucinate, seeing things or people which may not appear to anyone else. • Less nourishment will be required, and the person’s intake of food and water will diminish. Difficulty in swallowing (dysphagia) may also occur. • The person may sweat profusely. • The dying individual may lose control of his/her urine or bowels ( incontinence), necessitating that the dying individual be kept especially clean and dry in order to prevent bed sores (decubitis ulcers). • Urination may become darker and diminish or stop. • The mouth of the dying individual may become dry, and then secretions may accumulate in the back of the throat. Breathing may become noisy because of the gurgling or rattling of the secretions in the mouth or chest (“death rattle”). • The pattern of breathing may change; become slower or faster, deeper or shallower, or irregular. Often the patient will have periods of rapid breathing followed by periods in which breathing is very slow or is even absent for as long as 15 seconds. • The legs, and then arms, may become cold and nonreflexive as the circulation slows down. • The skin may be pale or mottled, and some parts, particularly the underside of the body, may become a dark color as the blood pools, usually a deep blue or purple.

When death occurs

• Breathing ceases entirely. • Heartbeat and pulse stop. • The person is entirely unresponsive to stimulus. • The eyes may be fixed in directions. The pupils are dilated and fixed to light. The eyelids may be open or closed. • A loss of control of urine and/or bowels may occur. • The person becomes progressively mottled and cold and stiff (known as rigor mortis) • The skin may become pale; there may be signs of blood buildup on the side the person is laying on.

Cause of death in the United States

The cause of death varies by area and age group. In 2002 in the U.S. the top 10 causes of death were:
- Heart Disease: 696,947
- Cancer: 557,271
- Stroke: 162,672
- Chronic lower respiratory diseases: 124,816
- Accidents (unintentional injuries): 106,742
- Diabetes: 73,249
- Influenza/Pneumonia: 65,681
- Alzheimer's disease: 58,866
- Nephritis, nephrotic syndrome, and nephrosis: 40,974
- Septicemia: 33,865

Other notable causes of death in the United States (2002)

- Murder: 16,110
- Execution: 71
- Intentional Abortion: 1,293,000
- Note that there is much debate as to when a fetus should be considered "human." The death of a human zygote — a one-celled combination of a sperm and an egg — is counted by some as the death of a human, and by others as simply the death of a cell. The above number would apparently include abortions to save the life of the mother, abortions of obviously highly defective fetuses, and abortions of fetuses unlikely to reach term. Statistical data from [http://www.cdc.gov/nchs/fastats/lcod.htm U.S. Department of Health & Human Services] [http://www.deathpenaltyinfo.org/ Death Penalty Information Center] [http://www.nrlc.org/abortion/facts/abortionstats.html National Right To Life], and [http://www.agi-usa.org/media/presskits/2005/06/28/abortionoverview.html The Alan Guttmacher Institute]

What happens to humans after death?

The second question is of what, apart from the cessation of metabolism and the onset of physiological processes of decay, happens, especially to humans, during and after death (or "once dead", thinking of death as a permanent state). In particular, there is the question of what becomes of consciousness or the soul. Such questions are of long standing, and belief in an afterlife (such as an underworld), or in reincarnation, are common and ancient. The belief that any and all consciousness ceases to exist at death, and that death ("after-life") itself is ultimately the exact same experience as prior to conception ("before life"), is common in atheism/agnosticism. Conversely, religious belief in and information about an afterlife is a consolation in connection with the death of a beloved one or the prospect of one's own death. On the other hand, fear of hell or other negative consequences may make death worse. Human contemplation about death is an important motivation for the development of organized religion. Traditions exist across most cultures to mourn the death of loved ones. Many archaeologists feel that the careful burials among Homo neanderthalensis, where ochre ornamented bodies were laid in carefully dug graves, is evidence of ritualised burial. This may indicate early religious belief which, furthermore, might include a concept of an afterlife.

Physiological consequences of human death

For the human body, the physiological consequences of death follow a recognized sequence through early changes into bloating, then decay to changes after decay and finally skeletal remains. The changes in the immediate post-death stage have received the most attention for two reasons—firstly it is the stage mostly likely to be seen by the living and secondly because of the research of forensics in potential crimes. Soon after death (15–120 minutes depending on various factors), the body begins to cool (algor mortis), becomes pallid (pallor mortis), and internal sphincter muscles relax, leading to the release of urine, feces, and stomach contents if the body is moved. The blood moves to pool in the lowest parts of the body, livor mortis (dependent lividity), within 30 minutes and then begins to coagulate. The body experiences muscle stiffening (rigor mortis) which peaks at around 12 hours after death and is gone in another 24, depending on temperature. Within a day, the body starts to show signs of decomposition (decay), both autolytic changes and from 'attacking' organisms—bacteria, fungi, insects, mammalian scavengers, etc. Internally, the body structures begin to collapse, the skin loses integration with the underlying tissues, and bacterial action creates gases which cause bloating and swelling. The rate of decay is enormously variable; a body can be reduced to skeletal remains in days, or remain largely intact for thousands of years.

Settlement of dead human bodies

In most cultures, before the onset of significant decay, the body undergoes some type of ritual disposal, usually either cremation or deposition in a tomb that is often a hole in the ground called a grave, but may also be a sarcophagus, crypt, sepulchre, or ossuary, a mound or barrow, or a monumental surface structure such as a mausoleum (exemplified by the Taj Mahal). In Tibet, one method of corpse disposal is sky burial, which involves placing the body of the deceased on high ground (a mountain) and leaving it for birds of prey to dispose of. Sometimes this is because in some religious views, birds of prey are carriers of the soul to the heavens, but at other times this simply reflects the fact that when terrain (as in Tibet) makes the ground too hard to dig, there are few trees around to burn and the local religion (Buddhism) believes that the body after death is only an empty shell, there are more practical ways of disposing of a body, such as leaving it for animals to consume. On the other hand, in certain cultures, efforts are made to retard the decay processes before burial (resulting even in the retardation of decay processes after the burial), as in mummification or embalming. This happens during or after a funeral ceremony. Many funeral customs exist in different cultures. In some fishing or navy communities, the body is sent into the water aquatic burial. Several mountain villages have a tradition of hanging the coffin in woods. A new alternative is ecological burial. This is a sequence of deep-freezing, pulverisation by vibration, freeze-drying, removing metals, and burying the resulting powder, which has 30% of the body mass. Space burial is also talked about, using rocket to launch part of the cremated body. Graves are usually grouped together in a plot of land called a cemetery or graveyard, and burials can be arranged by a funeral home, mortuary , undertaker or by a religious body such as a church or (for some Jews) the community's Burial Society, a charitable or voluntary body charged with these duties.

Personification of death

Main article: Death (personification) Death is also a mythological figure who has existed in popular culture since the earliest days of storytelling. The traditional Western image of Death, known as the Grim Reaper - usually resembling a skeleton, wearing black robes and carrying a scythe - is employed on a tarot card and in various television shows and films. Some examples:
- Death is a major character in the Discworld series by Terry Pratchett.
- Humorous depictions of Death, often with a Grim Reaper-esque feel, are common during the Día de los Muertos in Mexico, especially in the state of Michoacán.
- An unusual personification of Death appears in Neil Gaiman's Sandman graphic novels.
- In Ingmar Bergman's The Seventh Seal, a knight plays a game of chess against Death.
- Death is also portrayed as a Grim Reaper-esque character in TV shows such as Family Guy and video and computer games such as The Sims.
- In the film, Meet Joe Black, a remake of Death Takes a Holiday, Death inhabits the body of a young man to experience life firsthand.
- In the film, Bill & Ted's Bogus Journey, Death is the bassist for Wyld Stallyns.
- In the TV series Dead Like Me, the main characters are all Grim Reapers as part of a post-life bureaucracy.
- The series Touched by an Angel featured the Angel of Death as a regular character, depicted as a kindly, soft-spoken man in his mid-30s.
- The Angel of Death also appeared in the show Charmed as a man that appeared before those who had died to take them to the afterlife. He was neither good nor evil.
- Death is also a recurring character in the Castlevania video games. He is usually described as Dracula's servant, and is therefore evil. He is almost always a boss, and appears usually near the end of the game. He uses the scythe, and often transforms into more hideous forms.
- Death 'stalks' people who avoided their demise in the Final Destination series.
- Death appears as a character in a sketch in the Monty Python film The Meaning of Life.
- In the cartoon Futurama, Death is represented by the "Sunset Squad", a group of robots who take people away to an unknown destination when they reach the age of 160.
- In the book On a Pale Horse the main character becomes Death himself after killing the previous Death.

External links

- [http://www.disastercenter.com/cdc/111riska.html Deaths and death rates for the 10 leading causes of death in specified age groups: United States, preliminary 1996]
- [http://www.nsc.org/lrs/statinfo/odds.htm Odds of dying due to various injuries or accidents] Source: National Safety Council, United States, 2001
- [http://www.veda.harekrsna.cz/encyclopedia/dying.htm Dying, Yamaraja and Yamadutas + terminal restlessness] (Vedic/Hindu view)
- [http://www.quranichealing.com/bp.asp?caid=65 Death & Dying in Islam]What does a man feel at the time of death? and Is death something to be feared?
- [http://www.zyworld.com/jamus/LifeCycle.htm The Cycle of Life] In context of the page New Age of Aquarius.
- [http://samvak.tripod.com/death.html Death, life, and personal identity] In regard to memetics.
- [http://www.quotesandpoem.com/poems/SelectedPoetryTopic/Death Poems on Death and Dying]
- [http://www.answersingenesis.org/docs2002/death_suffering.asp Why is there death and suffering?] From a creationist point of view.
- [http://www.ogrish.com Deaths and death scenes. WARNING: very explicit]
- [http://www.elijahwald.com/origin.html George Wald: The Origin of Death] A biologist explains life and death in different kinds of organisms in relation to evolution.
- [http://plato.stanford.edu/entries/death/ Stanford Encyclopedia of Philosophy entry on death]
- [http://www.deathclock.com Death Clock] A little joke telling how much time remains for your death
- [http://www.autopsyvideo.com www.autopsyvideo.com] - This site offers documentaries about autopsy, one produced with the cooperation of the Los Angeles County Coroner's Office.
- [http://www.chabad.org/article.asp?AID=281541 The Jewish Way in Death and Mourning] By Maurice Lamm Category:Biology
- ms:Ajal ja:死 simple:Death

Palliative care

Palliative care is any form of medical care or treatment that concentrates on reducing the severity of the symptoms of a disease or slows its progress rather than providing a cure. It aims at improving quality of life, by reducing or eliminating pain and other physical symptoms, enabling the patient to ease or resolve psychological and spiritual problems, and supporting the partner and family. The World Health Organisation (WHO), in a 1990 report on the topic, defined palliative care as "the active total care of patients whose disease is not responsive to curative treatment". This definition stresses the terminal nature of the disease. However, the term can also be used more generally to refer to anything that alleviates symptoms, even if there is also hope of a cure by other means; thus, a more recent WHO statement [http://www.who.int/cancer/palliative/definition/en/] calls palliative care "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness." In some cases, palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving the nausea associated with chemotherapy. The term is not generally used with regard to a chronic disease such as diabetes which, although currently incurable, has treatments that are (ideally) effective enough that it is not considered a progressive or life-threatening disease in the same sense as cancer or progressive neurological conditions. It is, however, occasionally used with regard to some diseases, such as chronic, progressive pulmonary disorders and end stage renal disease or chronic heart failure. Though the concept of palliative care is not new, in the past most doctors have concentrated on aggressively trying to cure patients, so that concentrating on making a patient comfortable was seen as "giving up" on them. In recent times the concept of having a good quality of life has gained ground, although many would argue that there is a long way to go yet. A relatively recent development is the concept of a health care team that is entirely geared toward palliation; this is often called hospice or palliative care.

Hospice and palliative care goals

More than a place, hospice care is a philosophy that is now called "palliative care." [http://dictionary.reference.com/search?q=hospice&db=
- Dictionary.com] defines a hospice as "A program that provides palliative care and attends to the emotional and spiritual needs of terminally ill patients at an inpatient facility or at the patient's home," and the [http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=hospice&action=Search+OMD Cancer Web] Internet site defines a hospice as "An institution that provides a centralised program of palliative and supportive services to dying persons and their families, in the form of physical, psychological, social, and spiritual care; such services are provided by an interdisciplinary team of professionals and volunteers who are available at home and in specialised inpatient settings. Origin: L. Hospitium, hospitality, lodging, fr. Hospes, guest" Palliative care neither aims to hasten death nor to postpone death. It is characterized by concern for symptom relief and promotion of general well-being and spiritual, psychological and social comfort for the person with a life-threatening or life-limiting illness. The need to maintain quality of life has become increasingly important, not just in the dying stages, but also in the weeks, months and years before death. As the worldwide increase in life expectancy has led to a corresponding increase in the incidence of age-related chronic illnesses and palliative care increasingly cares for patients with illnesses other than cancer such as motor neurone disease and heart failure. The patient and family are both the focus of palliative care, with emphasis placed upon the well-being of family caregivers as well as the patient. In addition, palliative care is no longer restricted to adults and many teams and hospices now exist for children of any age. Palliative care has been described as "Intensive care without the hardware."

Hospice history

Hospices were originally places of rest for travellers in the 4th century AD. In the 19th century a religious order established hospices for the dying in Ireland and London. The modern hospice is a relatively recent concept that originated and gained momentum in the United Kingdom after the founding of St. Christopher's Hospice in 1967. Dr. Cicely Saunders is regarded as the founder of the hospice movement. Since its beginning, the hospice movement has grown dramatically. In the UK in 2005 there were 200 hospices for adults and 33 for children, offering 3,411 beds. There were also 361 community palliative care teams, one third based in hospices, as well as 361 day centres and palliative care teams in nearly all larger hospitals. Funding varies from 100% funding by the National Health Service to almost 100% funding by charities, but the service is always free to patients. The first hospice in the United States was established in 1974. Relatively generous Medicare reimbursement for hospice treatement has greatly increased hospice usage in the United States.

Palliative care practice

Palliative care most often occurs in the dying person's home. It is also provided in free-standing inpatient (hospice) units and within regular hospital units. In most countries, hospice care is provided by an interdisciplinary team consisting of physicians, registered nurses, chaplains, social workers, physiotherapists, occupational therapists, complimentary therapists, volunteers and, most importantly, the family. The focus of the team is to optimize the patient's comfort. Additional members of the team are likely to include home health care aides, volunteers from the community, and housekeepers. In the UK palliative care services offer inpatient care, day care, day treatment and outpatients and work in close partnership with mainstream services. Hospices often house a full range of services and professionals. In the US, a patient is usually admitted into a palliative care program if there is a reasonable expectation of death within 6 months. This does not mean, however, that if a patient is still living after six months in hospice, he or she will be discharged from the service. Such restrictions do not exist in other countries such as the UK. Opportunities for caregiver respite are some of the services hospices provide to promote caregiver well-being. Respite may be for several hours or up to several days (the latter being done usually by placing the patient in a nursing home or in-patient hospice unit for several days). Because palliative care sees an increasingly wide range of conditions in patients at varying stages of their illness, it follows that palliative care teams offer a wide range of care. This may range from managing the physical symptoms in patients receiving active treatment for cancer, through depression in patients with advanced disease, to the care of patients in their last hours and days. Much of the work involves helping patients with complex or severe physical, psychological, social and spiritual problems. In the UK over half of patients are improved sufficiently to return home. If a patient dies, it is common for most hospice organizations to offer bereavement counseling to the patient's partner or family. In the US, board certification for physicians in palliative care is through the American Board of Hospice and Palliative Medicine. In the UK, palliative care has been a full speciality of medicine since 1989 and training is governed by the same regulations through the Royal Colleges of Medicine as with any other medical speciality. In the United States it is important to note that while in hospice care, a Medicare patient gives up his or her claims to reimbursement for any treatment of the terminal condition, with the exception of what the hospice considers palliative treatment. (Though a hospice patient may later opt out of hospice care.) Also, Medicare does not reimburse for what is considered custodial care. In the UK and many other countries all palliaitve care is offered free to the patient and their family, either through the National Health Service or through charities working in partnership with the NHS.

Treatment of distress

The key to effective palliative care is to provide a safe place for the individual to express their distress. This involves treating physical symptoms such as pain, nausea and breathlessness so that the patient is able to express any psychological and spiritual distress. These are then addressed in turn, all the while supporting the partner and family. Palliative care teams have become very skillful in prescribing drugs for physical symptoms, and have been instrumental in showing how drugs such as morphine can be used safely while maintaining a patient's full faculties and function. For a free, self learning online programme covering all aspects of palliative care, including the treatment of distress, see [http://www.helpthehospices.org.uk/elearning/] Alternative medical treatments such as relaxation therapy [http://jama.ama-assn.org/cgi/content/abstract/276/4/313][http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10390006&dopt=Abstract], massage [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10851775&dopt=Abstract], music therapy [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=14669295&dopt=Abstract], and acupuncture [http://www.jco.org/cgi/content/abstract/21/22/4120] can relieve some cancer-related symptoms and other causes of pain. Treatment that integrates complementary therapies with conventional cancer care is integrative oncology.

External links

- [http://www.caringtotheend.ca/ Caring to the End of Life, a Web site for anyone who needs information about palliative care for cancer patients.]
- [http://www.hospiceinformation.info/ UK Hospice Information]
- [http://www.palliativedrugs.com/ Palliative Care Drug Information]
- [http://www.pallcare.info/ Welsh Palliative Care information site]
- [http://www.helpthehospices.org.uk/ UK national hospice organisation]
- [http://www.helpthehospices.org.uk/elearning/ Free online Palliative Care e-Learning]
- [http://www.compassionandchoices.org/ Compassion & Choices]
- [http://www.aromacaring.co.uk/palliative_care.htm Palliative care]
- [http://www.uhn.ca/programs/obd/psychosocial_oncology.asp Psychosocial Oncology and Palliative Care]
- [http://www.bccancer.bc.ca/PPI/PSMPC/default.htm Pain & Symptom Management and Palliative Care]
- [http://www.virtualcancercentre.com/asp/documents/what_is_palliative_care.asp?sPageType=palliative Palliative Care]
- [http://www.aahpm.org/ American Academy of Hospice and Palliative Medicine]
- [http://www.abhpm.org/ American Board of Hospice and Palliative Medicine]
- [http://www.nhpco.org The National Hospice and Palliative Care Organization (NHPCO)]
- [http://www.capc.org The Center to Advance Palliative Care (CAPC)]
- [http://www.hospice-america.org/ Hospice Association of America (HAA)]
- [http://www.pain.remedica.com International Journal of Pain Medicine and Palliative Care]
- [http://pallimed.blogspot.com Pallimed: A Palliative Medicine Blog] Category:Nursing specialties Category:Oncology

Alternative medicine

Alternative medicine broadly describes methods and practices used in place of, or in addition to, conventional medical treatments. The precise scope of alternative medicine is a matter of some debate and depends to a great extent on the definition of "conventional medicine." The debate on alternative medicine is complicated further by the diversity of treatments that are categorized as "alternative." These include practices that incorporate spiritual, metaphysical, or religious underpinnings; non-European medical traditions; newly developed approaches to healing; and a number of others. Proponents of one class of alternative medicine may reject others. Detractors from alternative medicine may also define it as "diagnosis, treatment, or therapy which can be provided legally by persons who are not licensed to diagnose and treat illness", although some medical doctor find value using alternative therapies in the practice of "complementary medicine". Many in the scientific community define alternative medicine as any treatment, the efficacy and safety of which has not been verified through peer-reviewed, controlled studies. The boundaries of alternative medicine have changed over time as a number of techniques and therapies once considered to be "alternative" have been accepted by mainstream medicine.

Complementary and alternative medicine

The National Center for Complementary and Alternative Medicine defines complementary and alternative medicine as "a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine". One distinction that the NCCAM makes is that complementary medicine is used in conjunction with conventional medicine whereas alternative medicine is used in place of conventional medicine. The NCCAM also defines integrative medicine as the combination of "mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness". "Importantly, integrative medicine is not synonymous with complementary and alternative medicine (CAM). It has a far larger meaning and mission in that it calls for restoration of the focus of medicine on health and healing and emphasizes the centrality of the patient-physician relationship." (Snyderman, Weil 2002)

Legality and regulation

Jurisdiction differs concerning which branches of alternative medicine are legal, which are regulated, and which (if any) are provided by a government-controlled health service or reimbursed by a private health medical insurance company. A number of alternative medicine advocates disagree with the restrictions of government agencies that approve medical treatments (such as the American Food and Drug Administration) and the agencies' adherence to experimental evaluation methods. They claim that this impedes those seeking to bring useful and effective treatments and approaches to the public, and protest that their contributions and discoveries are unfairly dismissed, overlooked or suppressed. Alternative medicine providers often argue that health fraud should be dealt with appropriately when it occurs.

Contemporary use of alternative medicine

Edzard Ernst wrote in the Medical Journal of Australia that "about half the general population in developed countries use complementary and alternative medicine (CAM)" (Ernst 2003). A [http://nccam.nih.gov/news/2004/052704.htm survey] (Barnes et al 2004) released in May 2004 by the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health in the United States, found that in 2002, 36% of Americans used some form of alternative therapy in the past 12 months — a category that included yoga, meditation, herbal treatments and the Atkins diet. If prayer was counted as an alternative therapy, the figure rose to 62.1%. Another study by Astin et al (1998) suggests a similar figure of 40%. A British telephone survey by the BBC of 1209 adults in 1998 shows that around 20% of adults in Britain had used alternative medicine in the past 12 months (Ernst & White 1999) The use of alternative medicine appears to be increasing. Eisenburg et al carried out a study in 1998 which showed that use of alternative medicine had risen from 33.8% in 1990 to 42.1% in 1997. In the United Kingdom, a 2000 report ordered by the House of Lords suggested that "limited data seem to support the idea that CAM use in the United Kingdom is high and is increasing"[http://www.parliament.the-stationery-office.co.uk/pa/ld199900/ldselect/ldsctech/123/12301.htm].

Medical education

Increasing numbers of medical colleges have begun offering courses in alternative medicine. For example, the University of Arizona College of Medicine offers a program in Integrative Medicine under the leadership of Dr. Andrew Weil which trains physicians in various branches of alternative medicine which "neither rejects conventional medicine, nor embraces alternative practices uncritically." [http://www.ahsc.arizona.edu/opa/horizons/1997/integrate.htm] In three separate research surveys that surveyed the 125 medical schools offering a MD degree, the 19 medical schools offering a DO degree, and 585 schools of nursing in the United States: 60 percent of U.S. medical schools offering a MD degree teach CAM, 95% of Osteopathic medical school teach CAM, and 84.8% of US schools of nursing teach CAM. (Wetzel et al 1998, Saxon et al 2004, Fenton & Morris 2003) In the UK, no medical schools offer courses that teach the clinical practise of alternative medicine. However, alternative medicine is taught in several schools as part of the curriculum. Teaching is based mostly on theory and understanding alternative medicine, with emphasis on being able to communicate with alternative medicine specialists. To obtain competence in practising clinical alternative medicine, qualifications must be obtained from individual medical societies. The student must have graduated and be a qualified doctor. The [http://www.medical-acupuncture.co.uk British Medical Acupuncture Society], which offers medical acupuncture certificates to doctors, is one such example.

Support for alternative medicine

Advocates of alternative medicine hold that alternative therapies often provide the public with services not available from conventional medicine. This argument covers a range of areas, such as patient empowerment, alternative methods of pain management, treatment methods that support the biopsychosocial model of health, cures for specific health concerns, stress reduction services, other preventive health services that are not typically a part of conventional medicine, and of course complementary medicine's palliative care which is practiced by such world renowned cancer centers such as Memorial Sloan-Kettering (see Vickers 2004).

Efficacy

Advocates of alternative medicine hold that the various alternative treatment methods are effective in treating a wide range of major and minor medical conditions, and contend that recently published research (such as Michalsen 2003, Gonsalkorale 2003, and Berga 2003) proves the effectiveness of specific alternative treatments. They assert that a PubMed search revealed over 370,000 research papers classified as alternative medicine published in Medline-recognized journals since 1966 in the National Library of Medicine database (such as Kleijnen 1991, Linde 1997, Michalsen 2003, Gonsalkorale 2003, and Berga 2003). Advocates of alternative medicine hold that alternative medicine may provide health benefits through patient empowerment, by offering more choices to the public, including treatments that are simply not available in conventional medicine. "Most Americans who consult alternative providers would probably jump at the chance to consult a physician who is well trained in scientifically based medicine and who is also open-minded and knowledgeable about the body's innate mechanisms of healing, the role of lifestyle factors in influencing health, and the appropriate uses of dietary supplements, herbs, and other forms of treatment, from osteopathic manipulation to Chinese and Ayurvedic medicine. In other words, they want competent help in navigating the confusing maze of therapeutic options that are available today, especially in those cases in which conventional approaches are relatively ineffective or harmful." (Snyderman, Weil 2002) Some physicians are willing to embrace some aspects of alternative medicine. Although advocates of alternative medicine acknowledge that the placebo effect may play a role in the benefits that some receive from alternative therapies, they point out that this does not diminish their validity. Skeptics are confounded by this view and claim that it is acknowledgement of the inefficacy of alternative treatments.

Danger reduced when used as a complement to conventional medicine

A major objection to alternative medicine is that it is done in place of conventional medical treatments. As long as alternative treatments are used alongside standard conventional medical treatments, most medical doctors find most forms of complementary medicine acceptable (Vickers 2004). Consistent with previous studies, the CDC recently reported that the majority of individuals in the United States (i.e., 54.9%) used CAM in conjunction with conventional medicine. (CDC Advance Data Report #343, 2002) Patients should however always inform their medical doctor they are using alternative medicine. Some patients do not tell their medical doctors since they fear it will hurt their patient-doctor relationship. Some alternative treatments however can interfere with regular treatments. An example is the combination of chemotherapy and large doses of vitamin C, which can severely damage the kidneys. The boundary lines between alternative and mainstream medicine have changed over time. Some methods once considered alternative have later been adopted by conventional medicine, when confirmed by controlled studies. Many very old conventional medical practices are now seen as alternative medicine, as modern controlled studies have shown that certain treatments were not actually effective. Supporters of alternative methods suggest that much of what is currently called alternative medicine will be similarly assimilated by the mainstream in the future. The issue of alternative medicine interfering with conventional medical practices is minimized when it is only turned to after the conventional medicine path has been exhausted. Many patients believe alternative medicine can help in coping with chronic illnesses for which conventional medicine offers no cure and only management. It is becoming more common for a patient's own MD to suggest alternatives when they cannot offer a treatment.

Criticism of alternative medicine

Due to the wide range of therapies that are considered to be "alternative medicine" few criticisms apply across the board. For more information about a particular therapy or branch of alternative medicine, including specific criticism, please refer to the following link: List of branches of alternative medicine. Criticisms directed at specific branches of alternative medicine range from the fairly minor (conventional treament is believed to be more effective in a particular area) to incompatibility with the known laws of physics (for example, in homeopathy). Proponents of the various forms of alternative medicine reject criticism as being founded in prejudice, financial self-interest, or ignorance.

Efficacy

Problems with the label "alternative"

Some doctors and scientists feel that the term "alternative medicine" is misleading, as these treatments have not been proven to be an effective alternative to regulated conventional medicine. However, conventional medicine can overlap with alternative medicine, when and only when the alternative treatment is proven to be effective. Richard Dawkins, professor of the Public Understanding of Science at Oxford University, defines alternative medicine as "that set of practices that cannot be tested, refuse to be tested or consistently fail tests" (See Diamond 2003).

Lack of proper testing

Despite the large number of studies regarding alternative therapies, critics contend that there are no statistics on exactly how many of these studies were controlled, double-blind peer-reviewed experiments or how many produced results supporting alternative medicine or parts thereof. They contend that many forms of alternative medicine are rejected by conventional medicine because the efficacy of the treatments has not been demonstrated through double-blind randomized controlled trials. Some skeptics of alternative practices point out that a person may attribute symptomatic relief to an otherwise ineffective therapy due to the natural recovery from or the cyclical nature of an illness, the placebo effect, or the possibility that the person never originally had a true illness [http://www.quackwatch.org/01QuackeryRelatedTopics/altpsych.html].

Problems with known tests and studies

Critics contend that observer bias and poor study design invalidate the results of many studies carried out by alternative medicine promoters. A review of the effectiveness of certain alternative medicine techniques for cancer treatment (Vickers 2004), while finding that most of these treatments are not merely "unproven" but are proven not to work, notes that several studies have found evidence that the psychosocial treatment of patients by psychologists is linked to survival advantages (although it comments that these results are not consistently replicated). The same review, while specifically noting that "complementary therapies for cancer-related symptoms were not part of this review", cites studies indicating that several complementary therapies can provide benefits by, for example, reducing pain and improving the mood of patients. Some argue that less research is carried out on alternative medicine because many alternative medicine techniques cannot be patented, and hence there is little financial incentive to study them. Drug research, by contrast, can be very lucrative, which has resulted in funding of trials by pharmaceutical companies. Many people, including conventional and alternative medical practitioners, contend that this funding has led to corruption of the scientific process for approval of drug usage, and that ghostwritten work has appeared in major peer-reviewed medical journals. (Flanagin et al. 1998, Larkin 1999). Increasing the funding for research of alternative medicine techniques was the purpose of the National Center for Complementary and Alternative Medicine. NCCAM and its predecessor, the Office of Alternative Medicine, have spent more than $200 million on such research since 1991. The German Federal Institute for Drugs and Medical Devices Commission E has studied many herbal remedies for efficacy. [http://www.csicop.org/si/2003-09/alternative-medicine.html]

Safety

Critics contend that "dubious therapies can cause death, serious injury, unnecessary suffering, and disfigurement" [http://www.quackwatch.org/01QuackeryRelatedTopics/harmquack.html] and that some people have been hurt or killed directly from the various practices or indirectly by failed diagnoses or the subsequent avoidance of conventional medicine which they believe is truly efficacious [http://www.valleyskeptic.com/perrot.htm]. Alternative medicine critics agree with its proponents that people should be free to choose whatever method of healthcare they want, but stipulate that people must be informed as to the safety and efficacy of whatever method they choose. People who choose alternative medicine may think they are choosing a safe, effective medicine, while they may only be getting quack remedies.

Delay in seeking conventional medical treatment

They state that those who have had success with one alternative therapy for a minor ailment may be convinced of its efficacy and persuaded to extrapolate that success to some other alternative therapy for a more serious, possibly life-threatening illness. For this reason, they contend that therapies that rely on the placebo effect to define success are very dangerous.

Issues of regulation

Critics contend that some branches of alternative medicine are often not properly regulated in some countries to identify who practices or know what training or expertise they may possess. Critics argue that the governmental regulation of any particular alternative therapy does necessitate that the therapy is effective.

References

Dictionary definitions

- [http://www.best-home-remedies.com Alternative Medicine]
- [http://cancerweb.ncl.ac.uk/cgi-bin/omd?query=Complementary+medicine&action=Search+OMD Complementary medicine]
- [http://www.ahsc.arizona.edu/opa/horizons/1997/integrate.htm Integrative Medicine]: "Program Goals-Train physicians to combine the best ideas and practices of conventional and alternative medicine."

Journals dedicated to alternative medicine research

- Alternative therapies in health and medicine. Aliso Viejo, CA : InnoVision Communications, c1995- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9502013&Search_Code=0359&CNT=20&SID=1 9502013]
- Alternative medicine review : a journal of clinical therapeutic. Sandpoint, Idaho : Thorne Research, Inc., c1996- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9705340&Search_Code=0359&CNT=20&SID=1 9705340]
- [http://www.biomedcentral.com/1472-6882 BMC complementary and alternative medicine]. London : BioMed Central, 2001- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=101088661&Search_Code=0359&CNT=20&SID=1 101088661]
- Complementary therapies in medicine. Edinburgh ; New York : Churchill Livingstone, c1993- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9308777&Search_Code=0359&CNT=20&SID=1 9308777]
- [http://ecam.oxfordjournals.org/ Evidence based complementary and alternative medicine]
- [http://www.openmindjournals.com/EBInteg.html Evidence Based journal of Integrative medicine]
- [http://www.jintmed.com/ Journal of Integrative medicine.]
- [http://www.catchword.com/titles/10755535.htm The journal of alternative and complementary medicine : research on paradigm, practice, and policy.] New York, NY : Mary Ann Liebert, Inc., c1995- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9508124&Search_Code=0359&CNT=20&SID=1 9508124]
- Journal of alternative & complementary medicine. London : Argus Health Publications, c1989- NLM ID: [http://locatorplus.gov/cgi-bin/Pwebrecon.cgi?DB=local&v2=1&ti=1,1&Search_Arg=9883124&Search_Code=0359&CNT=20&SID=1 9883124]
- [http://www.liebertpub.com/publication.aspx?pub_id=26 Journal for Alternative and Complementary Medicine]

Research articles cited in the text

# Astin JA "Why patients use alternative medicine: results of a national study" JAMA 1998; 279(19): 1548-1553 # Barnes P, Powell-Griner E, McFann K, Nahin R. "Complementary and Alternative Medicine Use Among Adults: United States, 2002." Advanced data from vital health and statistics 2004; Hyattsville, Maryland:NCHS [http://nccam.nih.gov/news/report.pdf Online] # Benedetti F, Maggi G, Lopiano L. "Open Versus Hidden Medical Treatments: The Patient's Knowledge About a Therapy Affects the Therapy Outcome." Prevention & Treatment, 2003; 6(1), [http://journals.apa.org/prevention/volume6/pre0060001a.html APA online] # Berga SL, Marcus MD, Loucks TL. "Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy." Fertility and Sterility 2003; 80(4): 976-981 [http://www.fertstert.org/article/PIIS0015028203011245/abstract Abstract] # Downing AM, Hunter DG. "Validating clinical reasoning: a question of perspective, but whose perspective?" Man Ther, 2003; 8(2): 117-9. PMID 12890440 [http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WN0-487KJXH-3&_coverDate=05%2F31%2F2003&_alid=110095405&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=6948&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=8da5eb9e5359691e31c6cee489724da8 Manual Therapy Online] # Eisenberg DM. "Advising patients who seek alternative medical therapies." Ann Intern Med 1997; 127:61-69. PMID 9214254 # Eisenberg, DM, Davis RB, Ettner SL "Trends in alternative medicine use in the United States 1990-1997." JAMA, 1998; 280:1569-1575. PMID 9820257 # Ernst E. "Obstacles to research in complementary and alternative medicine." Medical Journal of Australia, 2003; 179(6): 279-80. PMID 12964907 http://www.mja.com.au/public/issues/179_06_150903/ern10442_fm-1.html MJA online] # Fenton MV, Morris DL. "The integration of holistic nursing practices and complementary and alternative modalities into curricula of schools of nursing." Altern Ther Health Med, 2003; 9(4):62-7. PMID 12868254 # Flanagin A, Carey LA, Fontanarosa PB. "Prevalence of articles with honorary authors and ghost authors in peer-reviewed medical journals." JAMA, 1998; 280(3):222-4. [http://jama.ama-assn.org/cgi/content/full/280/3/222 Full text] # Gonsalkorale WM, Miller V, Afzal A, Whorwell PJ. "Long term benefits of hypnotherapy for irritable bowel syndrome." Gut, 2003; 52(11):1623-9. PMID 14570733 # Gunn IP. "A critique of Michael L. Millenson's book, Demanding medical excellence: doctors and accountability in the information age, and its relevance to CRNAs and nursing." AANA J, 1998 66(6):575-82. Review. PMID 10488264 # Kleijnen J, Knipschild P, ter Riet G. "Clinical trials of homoeopathy." BMJ, 1991; 302:316-23. Erratum in: BMJ, 1991;302:818. PMID 1825800 # Larkin M. "Whose article is it anyway?" Lancet, 1999; 354:136. [http://www.thelancet.com/journal/vol354/iss9173/full/llan.354.9173.news.3708.1 Editorial] # Linde K, Clausius N, Ramirez G. "Are the clinical effects of homeopathy placebo effects? A meta-analysis of placebo-controlled trials." Lancet, 1997; 350: 834-43. Erratum in: Lancet 1998 Jan 17;351(9097):220. PMID 9310601 # Michalsen A, Ludtke R, Buhring M. "Thermal hydrotherapy improves quality of life and hemodynamic function in patients with chronic heart failure." Am Heart J, 2003; 146(4):E11. PMID 14564334 # Saxon DW, Tunnicliff G, Brokaw JJ, Raess BU. "Status of complementary and alternative medicine in the osteopathic medical school curriculum." J Am Osteopath Assoc 2004; 104(3):121-6. PMID 15083987 # Snyderman R, Weil AT. "Integrative medicine: bringing medicine back to its roots." Arch Intern Med 2002; 162:395–397. # Tonelli MR. "The limits of evidence-based medicine." Respir Care, 2001; 46(12): 1435-40; discussion 1440-1. Review. PMID 11728302 [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11863470 PMID: 11863470] # Vickers A. "Alternative Cancer Cures: "Unproven" or "Disproven"?" CA Cancer J Clin 2004; 54: 110-118. [http://caonline.amcancersoc.org/cgi/content/full/54/2/110 Online] # Wetzel MS, Eisenberg DM, Kaptchuk TJ. "Courses involving complementary and alternative medicine at US medical schools." JAMA 1998; 280(9):784 -787. PMID 9729989 # Zalewski Z. "Importance of Philosophy of Science to the History of Medical Thinking." CMJ 1999; 40: 8-13. [http://www.bsb.mefst.hr/cmj/1999/4001/400102.htm CMJ online]
Other works that discuss alternative medicine

- Diamond, J. Snake Oil and Other Preoccupations 2001 (ISBN 0099428334), foreword by Richard Dawkins reprinted in Dawkins, R. A Devil's Chaplain 2003 (ISBN 0753817500).
- [http://www.cwru.edu/med/epidbio/mphp439/Sources_of_Healthcare.htm WHERE DO AMERICANS GO FOR HEALTHCARE?] by Anna Rosenfeld, Case Western Reserve University, Cleveland, Ohio, USA.
- Planer, Felix E. 1988 Superstition Revised ed. Buffalo, New York: Prometheus Books
- Hand, Wayland D. 1980 Folk Magical Medicine and Symbolism in the West in Magical Medicine Berkeley: University of California Press, pp. 305-319.
- Phillips Stevens Jr. Nov./Dec. 2001 Magical Thinking in Complementary and Alternative Medicine Skeptical Inquirer Magazine, Nov.Dec/2001
- Illich I. Limits to Medicine. Medical Nemesis: The expropriation of Health. Penguin Books, 1976.
- Dillard, James and Terra Ziporyn. Alternative Medicine for Dummies. Foster City, CA: IDG Books Worldwide, Inc., 1998.
External links

General information

- [http://nccam.nih.gov/ The National Center for Complementary and Alternative Medicine] - US National Institutes of Health
- [http://www.nlm.nih.gov/nccam/camonpubmed.html Complementary and Alternative Medicine on PubMed] - Alternative Medicine Research Database
Advocacy

- [http://www.noah-health.org/en/alternative/ Consumer focused alternative medicine information] - in English and Spanish
- [http://www.rosenthal.hs.columbia.edu/ Complementary and alternative medicine information] - Columbia University supported and ad-free
- [http://www.wholehealthmd.com/ WholeHealth Networks' CAM education website] - created by practicing MD's
- [http://goldbamboo.com/ Traditional and Alternative Medicine] - both clinical and alternative health perspectives
- [http://chinese-school.netfirms.com/Chinese-medicine.html Alternative Medicine: Chinese medicine]
- [http://www.hands-on-london.com Alternative Medicine: Osteopathy]
- [http://circleofhealers.com Circle of Healers] - Alternative Medicine News and Resources
- [http://tutorials.naturalhealthperspective.com/history.html A History of Western Natural Healing Practices]
- [http://autopenhosting.org/whatismedicine/ What is Medicine?] - Historical perspective of various modes of medicine
- [http://www.dailystar.com/dailystar/printDS/6529.php "Weil's integrative medicine gathering steam"], by Carla McClain, Arizona Daily Star, Published: 01-20-2004
- [http://health.dailynewscentral.com/content/view/0001181/31/ Alternative Medicine Becoming Mainstream]
- [http://www.alternativehealth.co.uk/ Alternative Health & Complementary Medicine UK Directory]
- [http://www.althealthinfo.com/ Alternative Medicine and Natural Health] Information and news on alternative medicine
Critiques

- [http://www.skepdic.com/tialtmed.html Skeptic's Dictionary: Alternative Medicine]
- [http://www.canoe.ca/HealthAlternative/home.html Alternative medicine: A Skeptical Look]
- [http://www.quackwatch.org/index.html Quackwatch: Your Guide to Health Fraud, Quackery, and Intelligent Decisions]
- 0 Category:Pseudoscience Category:Protoscience ko:대체의학 ja:代替医療

Cancer

Cancer is a class of diseases characterized by uncontrolled cell division and the ability of these cells to invade other tissues, either by direct growth into adjacent tissue (invasion) or by migration of cells to distant sites (metastasis). This unregulated growth is caused by damage to DNA, resulting in mutations to vital genes that control cell division, among other functions. One or more of these mutations, which can be inherited or acquired, can lead to uncontrolled cell division and tumor formation. Tumor ("swelling" in Latin) refers to any abnormal mass of tissue, but may be either malignant (cancerous) or benign (noncancerous). Only malignant tumors are capable of invading other tissues or metastasizing. Cancer can cause many different symptoms, depending on the site and character of the malignancy and whether there is metastasis. A definitive diagnosis usually requires the microscopic examination of tissue obtained by biopsy. Once diagnosed, cancer is usually treated with surgery, chemotherapy and/or radiation. If untreated, most cancers eventually cause death; cancer is one of the leading causes of death in developed countries. Most cancers can be treated and many cured, especially if treatment begins early. Many forms of cancer are associated with environmental factors, which may be avoidable. Cigarette smoking leads to more cancers than any other environmental factor.

Diagnosing cancer

Most cancers are initially recognized either because signs or symptoms appear or through screening. Neither of these lead to a definitive diagnosis, which usually requires a biopsy. Some cancers are discovered accidentally during medical evaluation of an unrelated problem.

Signs and symptoms

Roughly, cancer symptoms can be divided into three groups:
- Local symptoms: unusual lumps or swelling (tumor), hemorrhage (bleeding), pain and/or ulceration. Compression of surrounding tissues may cause symptoms such as jaundice.
- Symptoms of metastasis (spreading): enlarged lymph nodes, cough and hemoptysis, hepatomegaly (enlarged liver), bone pain, fracture of affected bones and neurological symptoms. Although advanced cancer may cause pain, it is often not the first symptom.
- Systemic symptoms: weight loss, poor appetite and cachexia (wasting), excessive sweating (night sweats), anemia and specific paraneoplastic phenomena, i.e. specific conditions that are due to an active cancer, such as thrombosis or hormonal changes. Every single item in the above list can be caused by a variety of conditions (a list of which is referred to as the differential diagnosis). Cancer may be a common or uncommon cause of each item.

Biopsy

A cancer may be suspected for a variety of reasons, but the definitive diagnosis of most malignancies must be confirmed by microscopic examination of the cancerous cells by a pathologist. The procedure of obtaining cells and/or pieces of tissue, and their examination, is referred to as a biopsy. The tissue diagnosis indicates the type of cell that is proliferating, its severity (degree of dysplasia), and its extent and size. Cytogenetics and immunohistochemistry may provide information about future behavior of the cancer (prognosis) and best treatment. All cancers can be cured if entirely removed, and sometimes this can be accomplished by the biopsy procedure. When the whole mass of abnormal tissue (the "lesion") is removed, the borders of the sample are examined closely to see if all malignant tissue has truly been excised. If the cancer has spread to other sites in the body (metastasis), complete surgical excision is impossible. The nature of the biopsy depends on the organ that is sampled. Many biopsies (such as those of the skin, breast or liver) can happen on an outpatient basis. Biopsies of other organs are performed under anesthesia and require surgery.

Screening

Cancer screening is an attempt to detect unsuspected cancers in the population. Screening tests suitable for large numbers of healthy people must be relatively affordable, safe, noninvasive procedures with acceptably low rates of false positive results. If signs of cancer are detected, more definitive and invasive followup tests are performed to confirm the diagnosis. Screening for cancer can lead to earlier diagnosis. Early diagnosis may lead to extended life. A number of different screening tests have been developed. Breast cancer screening can be done by breast self-examination. Screening by regular mammograms detects tumors even earlier than self-examination, and many countries use it to systematically screen all middle-aged women. Colorectal cancer can be detected through fecal occult blood testing and colonoscopy, which reduces both colon cancer incidence and mortality, presumably through the detection and removal of premalignant polyps. Similarly, cervical cytology testing (using the Pap smear) leads to the identification and excision of precancerous lesions. Over time, such testing has been followed by a dramatic reduction of cervical cancer incidence and mortality. Testicular self-examination is recommended for men beginning at the age of 15 years to detect testicular cancer. Prostate cancer can be screened for by a digital rectal exam along with prostate specific antigen (PSA) blood testing. Screening for cancer is controversial in cases when it is not yet known if the test actually saves lives. The controversy arises when it is not clear if the benefits of screening outweigh the risks of follow-up diagnostic tests and cancer treatments. For example: when screening for prostate cancer, the PSA test may detect small cancers that would never become life threatening, but once detected will lead to treatment. This situation, called overdiagnosis, puts men at risk for complications from unnecessary treatment such as surgery or radiation. Followup procedures used to diagnose prostate cancer (prostate biopsy) may cause side effects, including bleeding and infection. Prostate cancer treatment may cause incontinence (inability to control urine flow) and erectile dysfunction (erections inadequate for intercourse). Similarly, for breast cancer, there have recently been criticisms that breast screening programs in some countries cause more problems than they solve. This is because screening of women in the general population will result in a large number of women with false positive results which require extensive follow-up investigations to exclude cancer, leading to having a high number-to-treat (or number-to-screen) to prevent or catch a single case of breast cancer early. Cervical cancer screening via the Pap smear has the best cost-benefit profile of all the forms of cancer screening from a public health perspective as, being a cancer, it has clear risk factors (sexual contact), and the natural progression of cervical cancer is that it normally spreads slowly over a number of years therefore giving more time for the screening program to catch it early. Moreover, the test itself is easy to perform and relatively cheap. For these reasons, it is important that the benefits and risks of diagnostic procedures and treatment be taken into account when considering whether to undertake cancer screening. Use of medical imaging to search for cancer in people without clear symptoms is similarly marred with problems. There is a significant risk of detection of what has been recently called an incidentaloma - a benign lesion that may be interpreted as a malignancy and be subjected to potentially dangerous investigations.

Types of cancer

Cancer cells within a tumor are the descendants of a single cell, even after it has metastasized. Hence, a cancer can be classified by the type of cell in which it originates and by the location of the cell. Carcinomas originate in epithelial cells (e.g. the digestive tract or glands). Hematological malignancies, such as leukemia and lymphoma, arise from cells of hematopoeitic origin, such as blood and bone marrow. Sarcoma arises from connective tissue, bone or muscle. Malignant tumors usually end in suffix "-carcinoma" for epithelial cancers, and "-sarcomas" for connective tissue tumors. Otherwise, benign tumors of both origins are denoted as "-omas." For instance, benign tumor of fat cells are known as "lipoma," while its malignant form is known as "liposarcoma."

Adult cancers

In the USA and other developed countries, cancer is presently responsible for about 25% of all deaths. On a yearly basis, 0.5% of the population is diagnosed with cancer. For adult males in the United States, the most common cancers are prostate cancer (33% of all cancer cases), lung cancer (13%), colorectal cancer (10%), bladder cancer (7%) and cutaneous melanoma (5%). As a cause of death lung cancer is the most common (31%) cause, followed by prostate cancer (10%), colorectal cancer (10%), pancreatic cancer (5%) and leukemia (4%). For adult females in the United States, breast cancer is the most common cancer (32% of all cancer cases) followed by lung cancer (12%), colorectal cancer (11%), endometrial cancer (6%, uterus) and non-Hodgkin's lymphoma (4%). By cause of death, lung cancer is again the most common (27% of all cancer deaths), followed by breast cancer (15%), colorectal cancer (10%), ovarian cancer (6%) and pancreatic cancer (6%). These statistics vary substantially in other countries. Other cancers not mentioned:
- Epithelial tumors: skin cancer (this is in fact the most common cancer but often not classified as such in health statistics), cervical cancer, anal carcinoma, esophageal cancer, hepatocellular carcinoma (in the liver), laryngeal cancer, renal cell carcinoma (in the kidneys), stomach cancer, many testicular cancers, and thyroid cancer.
- Hematological malignancies (blood and bone marrow): leukemia, lymphoma, multiple myeloma.
- Sarcomas: osteosarcoma (in bone), chondrosarcoma (arising from cartilage), rhabdomyosarcoma (in muscle)
- Miscellaneous origin: brain tumors, gastrointestinal stromal tumors (GIST), mesothelioma (in the pleura or pericardium), thymoma and teratomas, melanoma

Childhood cancers

Cancer can also occur in young children and adolescents. Here, the aberrant genetic processes that fail to safeguard against the clonal proliferation of cells with unregulated growth potential occur early in life and can progress quickly. The age of peak incidence of cancer in children occurs during the first year of life. Leukemia (usually ALL) is the most common infant malignancy (30%), followed by the central nervous system cancers and neuroblastoma. The remainder consists of Wilms' tumor, lymphomas, rhabdomyosarcoma (arising from muscle), retinoblastoma, osteosarcoma and Ewing's sarcoma. Female infants and male infants have essentially the same overall cancer incidence rates, but white infants have substantially higher cancer rates than black infants for most cancer types. Relative survival for infants is very good for neuroblastoma, Wilms' tumor and retinoblastoma, and fairly good (80%) for leukemia, but not for most other types of cancer.

Causes and pathophysiology

Origins of cancer

Cell division (proliferation) is a physiological process that occurs in almost all tissues and under many circumstances. Normally the balance between proliferation and cell death is tightly regulated to ensure the integrity of organs and tissues. Mutations in DNA that lead to cancer disrupt these orderly processes. The uncontrolled and often rapid proliferation of cells can lead to either a benign tumor or a malignant tumor (cancer). Benign tumors do not spread to other parts of the body or invade other tissues, and they are rarely a threat to life unless they extrinsically compress vital structures. Malignant tumors can invade other organs, spread to distant locations (metastasize) and become life-threatening.

Molecular biology

metastasize Carcinogenesis (meaning literally, the creation of cancer) is the process of derangement of the rate of cell division due to damage to DNA. Cancer is, ultimately, a disease of genes. Carcinogenesis usually requires multiple mutations in many genes, thus mutations in single gene is simply not enough. A cell divides without any regulatory manner when its normal program of proliferation is disrupted, and often times these disruptions are about promotion of mitogenic signals and suppression of anti-mitogenic signals. These two processes involve oncogenes, and tumor suppressor genes, respectively. Proto-oncogenes, broadly defined, are genes whose gene products promote cellular growth. These products can be hormones, mitogens, cell surface receptors, members of intracellular signaling pathways, and transcription factors. Often mutations in these proto-oncogenes cause them to become overactive, thus signalling the cells to divide and undergo uncontrolled growth. Tumor suppressor genes typically encode for anti-proliferation signals and proteins that suppresses mitosis. Generally tumor suppressors are transcription factors that are activated by cellular stress or DNA damage. Their main function is to arrest the progression of cell cycle before any DNA damage is repared. Otherwise, these genetic lesions, which may contribute to further genomic instability, may be passed on to daughter cells. Canonical tumor suppressors include p53, which is a transcription factor activated by many cellular stress including hypoxia and UV damage. In general, mutations in both types of genes are required for cancer to occur. For example, a mutation limited to one oncogene would be suppressed by normal mitosis control (the Knudson or 1-2-hit hypothesis) and tumor suppressor genes. A mutation to only one tumor suppressor gene would not cause cancer either, due to the presence of many "backup" genes that duplicate its functions. It is only when enough proto-oncogenes have mutated into oncogenes, and enough tumor suppressor genes deactivated or damaged, that the signals for cell growth overwhelm the signals to regulate it, that cell growth quickly spirals out of control. On a genetic side note, mutations in proto-oncogenes are dominant, or gain of function mutations, while mutations in tumor suppressors are recessive, or loss of function mutations. Each cell has two copies of a same gene (one inherited from each parent), and under most cases gain of function mutation in one copy of a particular proto-oncogene is enough to make that gene a true oncogene, while usually loss of function mutation need to happen in both copies of a tumor suppressor gene to render that gene completely non-functional. However, cases exist in which one loss of function copy of a tumor suppressor gene can render (or poison) the other copy non-functional, and this is called dominant negative effect. This is observed in many p53 mutations. Tumor suppressors are indicated in many families with hereditary cancers. Members within these families have increased incidence and decreased latency of multiple tumors. The mode of inheritance of mutant tumor suppressors is that affected member inherits a defective copy from one parent, and a normal copy from another. Because mutations in tumor suppressers act in a recessive manner (note, however, there are exceptions), the loss of the normal copy creates the cancer phenotype. For instance, individuals who are heterozygous for p53 mutations are often victims of Li-Fraumeni Syndrome, and those who are heterozygous for Rb mutations develop retinoblastoma. Similarly, mutations in APC are linked to adenopolyposis colon cancer (thousands of polyps in colon while young), while mutations in BRCA lead to early onset of breast cancer (often bilateral). Cancer is ultimately due to accumulation of genetic insults, which are fundamentally mutations in the DNA. Substances that cause these mutations are known as mutagens, and mutagens that cause cancers are known as carcinogens. Particular substances have been linked to specific types of cancer. Tobacco smoking is associated with lung cancer. Breathing asbestos fibers is associated with mesothelioma. Prolonged exposure to radiation, particularly ultraviolet radiation from the sun, leads to melanoma and other skin malignancies. Even though most carcinogens are mutagens, some carcinogens are not. For instance estrogen is required for proliferation in a subset of breast tumor (estrogen-dependent breast cancer), even though estrogen does not induce DNA damage. These mitogens promote cancers through their stimulatory effect on the rate of cell mitosis. Faster rates of mitosis increasingly leave less time for DNA repair, therefore increasingly the likelihood of a genetic mistake being passed onto daughter cells, which in turn accumulates multiple mutations that may lead to carcinogenesis or progression of the disease. Furthermore, many cancers are viral in origin; this is especially true in animals such as birds, but less so in humans. The mode of virally-induce tumors can be divided into two, acutely or slowly- transforming. In acutely transforming viruses, the viral particles carry a gene that encodes for a overactive oncogene called viral-oncogene (or v-onc), and the infected cell is transformed as soon as v-onc is expressed. In contrast, in slowly-transforming viruses, virus genome is inserted (viral genome insertion is obligatory part of retroviruses) near a proto-oncogene in the host genome and the viral promoter or other transcription regulatory elements in turn cause overexpression of that proto-oncogene, which in turn induces uncontrolled cellular proliferation. Because viral genome insertion is not specific to proto-oncogenes and the chance of insertion near that proto-onc is low, slowly-transforming viruses have very long tumor latency compared to acutely-transforming virus, which already carries the v-onc. Most cases the etiology of cancer is unknown. However, with the help of molecular biological and gross karyotyping techniques, it is possible to characterize the mutations and chromosomal aberrations of tumor cells, and rapid progress is being made in prognosis based on the type and spectrum of mutations in some cases. For example, up to half of all tumors have a defective p53 gene, a tumor suppressor gene also known as "the guardian of the genome". This mutation is associated with poor prognosis, since those tumor cells are less likely to go into apoptosis (programmed cell death) when cells are challenged by chemotherapeutics and radiation. Malignant tumors cells have distinct properties (examples):
- evading apoptosis (down-regulation of death ligands in tumor cells)
- unlimited growth potential (immortalitization) (loss of regulatory region of receptor)
- self-sufficiency of growth factors (see above)
- insensitivity to anti-growth factors (see above)
- increased cell division rate (loss of Rb, which induces mitosis arrest)
- altered ability to differentiate (expression of embryonic markers)
- no ability for contact inhibition (down-regulation of E-cadherin, a celllular adhesion molecule)
- ability to invade neighbouring tissues (expression of metalloproteinases, which break down extracellular matrix)
- ability to build metastases at distant sites
- ability to promote blood vessel growth (angiogenesis) (expression of VEGF)

Morphology

angiogenesis Cancer tissue has a distinctive appearance under the microscope. Among the distinguishing traits are a large number of dividing cells, variation in nuclear size and shape, variation in cell size and shape, loss of specialized cell features, loss of normal tissue organization, and a poorly defined tumor boundary. Immunohistochemistry and other molecular methods may characterise specific markers on tumor cells, which may aid in diagnosis and prognosis. Biopsy and microscopical examination can also distinguish between malignancy and hyperplasia, which refers to tissue growth based on an excessive rate of cell division, leading to a larger than usual number of cells but with a normal orderly arrangement of cells within the tissue. This process is considered reversible. Hyperplasia can be a normal tissue response to an irritating stimulus, for example callus. Dysplasia is an abnormal type of excessive cell proliferation characterized by loss of normal tissue arrangement and cell structure. Often such cells revert back to normal behavior, but occasionally, they gradually become malignant. The most severe cases of dysplasia are referred to as "carcinoma in situ." In Latin, the term "in situ" means "in place", so carcinoma in situ refers to an uncontrolled growth of cells that remains in the original location and shows no propensity to invade other tissues. Nevertheless, carcinoma in situ may develop into an invasive malignancy and is usually removed surgically, if possible.

Heredity

Most forms of cancer are "sporadic", and have no basis in heredity. There are, however, a number of recognised syndromes of cancer with a hereditary component. Examples are:
- certain inherited mutations in the genes BRCA1 and BRCA2 are associated with an elevated risk of breast cancer and ovarian cancer
- tumors of various endocrine organs in multiple endocrine neoplasia (MEN types 1, 2a, 2b)
- Li-Fraumeni syndrome (various tumors such as osteosarcoma, breast cancer, soft-tissue sarcoma, brain tumors) due to mutations of p53
- Turcot syndrome (brain tumors and colonic polyposis)
- Familial adenomatous polyposis an inherited mutation of the APC gene that leads to early onset of colon carcinoma.
- Retinoblastoma in young children is an inherited cancer

Environment and diet

colon carcinoma The most consistent finding, over decades of research, is the strong association between tobacco use and cancers of many sites. Hundreds of epidemiological studies have confirmed this association. Further support comes from the fact that lung cancer death rates in the United States have mirrored smoking patterns, with increases in smoking followed by dramatic increases in lung cancer death rates and, more recently, decreases in smoking followed by decreases in lung cancer death rates in men. Up to half of all cancer cases can be attributed to smoking, diet, and environmental pollution.

Treatment of cancer

Cancer can be treated by surgery, chemotherapy, radiation therapy, immunotherapy or other methods. The choice of therapy depends upon the location and grade of the tumor and the stage of the disease, as well as the general state of the patient (performance status). A number of experimental cancer treatments are also under development. Complete removal of the cancer without damage to the rest of the body is the goal of treatment. Sometimes this can be accomplished by surgery, but the propensity of cancers to invade adjacent tissue or to spread to distant sites by microscopic metastasis often limits its effectiveness. The effectiveness of chemotherapy is often limited by toxicity to other tissues in the body. Radiation can also cause damage to normal tissue. Because "cancer" refers to a class of diseases, it is unlikely that there will ever be a single "cure for cancer" any more than there will be a single treatment for all infectious diseases.

Surgery

If the tumor is localized, surgery is often the preferred treatment. Example procedures include mastectomy for breast cancer and prostatectomy for prostate cancer. The goal of the surgery can be either the removal of only the tumor, or the entire organ. Since a single cancer cell can grow into a sizable tumor, removing only the tumor leads to a greater chance of recurrence. A margin of healthy tissue is often resected to make sure all cancerous tissue is removed. In addition to removal of the primary tumor, surgery is often necessary for staging, e.g. determining the extent of the disease and whether there has been metastasis to regional lymph nodes. Staging determines the prognosis and the need for adjuvant therapy. Occasionally, surgery is necessary to control symptoms, such as spinal cord compression or bowel obstruction. This is referred to as palliative treatment.

Chemotherapy

Chemotherapy is the treatment of cancer with drugs ("anticancer drugs") that can destroy cancer cells. It interferes with cell division in various possible ways, e.g. with the duplication of DNA or the separation of newly formed chromosomes. Most forms of chemotherapy target all rapidly dividing cells and are not specific for cancer cells. Hence, chemotherapy has the potential to harm healthy tissue, especially those tissues that have a high replacement rate (e.g. intestinal lining). These cells usually repair themselves after chemotherapy. Because some drugs work better together than alone, two or more drugs are often given at the same time. This is called "combination chemotherapy"; most chemotherapy regimens are given in a combination. A novel technique involves taking samples of the patient's tissue before chemotherapy. These tissues samples are screened to ensure they do not contain cancerous cells. The samples are expanded using tissue engineering techniques, and are then re-implanted following high dose chemotherapy in order to recolonise the damaged and somewhat destroyed tissue. A variation upon this method uses allogenic samples (samples donated by a different donor) instead of the patient's own tissue.

Immunotherapy

Immunotherapy is the use of immune mechanisms against tumors. These are used in various forms of cancer, such as breast cancer (trastuzumab/Herceptin®) but also in leukemia (gemtuzumab ozogamicin/Mylotarg®). The agents are monoclonal antibodies directed against proteins that are characteristic to the cells of the cancer in question, or cytokines that modulate the immune system's response.

Radiation therapy

Radiation therapy (also called radiotherapy, X-ray therapy, or irradiation) is the use of ionizing radiation to kill cancer cells and shrink tumors. Radiation therapy can be administered externally via external beam radiotherapy (EBRT) or internally via brachytherapy. The effects of radiation therapy are localised and confined to the region being treated. Radiation therapy injures or destroys cells in the area being treated (the "target tissue") by damaging their genetic material, making it impossible for these cells to continue to grow and divide. In addition, they cut off

Terminal illness

See also

Disease

Syndromes, illness and disease

Transmission of disease

Social significance of disease

Other uses of the term

See also

External links

Death

Interpretations of "death"

Ways of defining human death: medical, religious, and legal

When is a person dead?

The process of dying

Cell death

Physiological changes during the process of dying

Signs of approaching death

When death is imminent

When death occurs

Cause of death in the United States

Other notable causes of death in the United States (2002)

What happens to humans after death?

Physiological consequences of human death

Settlement of dead human bodies

Personification of death

See also

External links

Palliative care

Hospice and palliative care goals

Hospice history

Palliative care practice

Treatment of distress

See also

External links

Alternative medicine

Complementary and alternative medicine

Legality and regulation

Contemporary use of alternative medicine

Medical education

Support for alternative medicine

Efficacy

Danger reduced when used as a complement to conventional medicine

Criticism of alternative medicine

Efficacy

Problems with the label "alternative"

Lack of proper testing

Problems with known tests and studies

Safety

Delay in seeking conventional medical treatment

Issues of regulation

See also

References

Dictionary definitions

Journals dedicated to alternative medicine research

Research articles cited in the text

Other works that discuss alternative medicine

External links

General information

Advocacy

Critiques

Cancer

Diagnosing cancer

Signs and symptoms

Biopsy

Screening

Types of cancer

Adult cancers

Childhood cancers

Causes and pathophysiology

Origins of cancer

Molecular biology

Morphology

Heredity

Environment and diet

Treatment of cancer

Surgery

Chemotherapy

Immunotherapy

Radiation therapy