Cancer Head And Neck

Head and neck cancer

The term head and neck cancer refers to a group of biologically similar cancers originating from the upper aerodigestive tract, including the lip, oral cavity (mouth), nasal cavity, paranasal sinuses, pharynx, and larynx. Most head and neck cancers are squamous cell carcinomas, originating from the mucosal lining (epithelium) of these regions.[1] Head and neck cancers often spread to the lymph nodes of the neck, and this is often the first (and sometimes only) manifestation of the disease at the time of diagnosis. Head and neck cancer is strongly associated with certain environmental and lifestyle risk factors, including tobacco smoking, alcohol consumption, UV light and occupational exposures, and certain strains of viruses, such as the sexually transmitted human papillomavirus.[2] These cancers are frequently aggressive in their biologic behavior; patients with these types of cancer often develop a second primary tumor.[2] Head and neck cancer is highly curable if detected early, usually with some form of surgery although chemotherapy and radiation therapy may also play an important role. The 2009 estimated number of head and neck cancer in the US is of 35,720 new cases.[3]

Classification: Head and neck squamous cell carcinomas (HNSCC's) make up the vast majority of head and neck cancers, and arise from mucosal surfaces throughout this anatomic region. These include tumors of the nasal cavities, paranasal sinuses, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx.

Oral cavity: quamous cell cancers are common in the oral cavity, including the inner lip, tongue, floor of mouth, gingivae, and hard palate. Cancers of the oral cavity are strongly associated with tobacco use, especially use of chewing tobacco or "dip", as well as heavy alcohol use. Cancers of this region, particularly the tongue, are more frequently treated with surgery than are other head and neck cancers.

Surgeries for oral cancers include:

Maxillectomy (can be done with or without Orbital exenteration)
Mandibulectomy (removal of the mandible or lower jaw or part of it)
Glossectomy (tongue removal, can be total, hemi or partial)
Radical neck dissection
Moh's procedure
Combinational e.g. glossectomy and laryngectomy done together.

The defect is covered/improved by using another part of the body and/or skin grafts and/or wearing a prosthesis.

Nasopharynx: Nasopharyngeal cancer arises in the nasopharynx, the region in which the nasal cavities and the Eustachian tubes connect with the upper part of the throat. While some nasopharyngeal cancers are biologically similar to the common HNSCC, "poorly differentiated" nasopharyngeal carcinoma is distinct in its epidemiology, biology, clinical behavior, and treatment, and is treated as a separate disease by many experts.

Oropharynx: Oropharyngeal squamous cell carcinomas (OSCC) begins in the oropharynx, the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils. Squamous cell cancers of the tonsils are more strongly associated with human papillomavirus infection than are cancers of other regions of the head and neck.

HPV-positive oropharyngeal cancer: Human papillomavirus (HPV)-positive oropharyngeal cancer, also known as HPV16-positive oropharyngeal cancer or HPV OPC, is a recognized subtype of OSCC,[4][5] associated with the HPV type 16 virus.

Diagnosis
Genetic signatures of HPV-related and HPV-unrelated OSCC are different.[6][7][8][9][10] HPV OPC is associated with expression level of the E6/E7 mRNAs and of p16.[11] Nonkeratinizing squamous cell carcinoma strongly predicts HPV-association.[12][13]

Prevention
Risk factors are high number of sexual partners,(>= 4)[14](2.7 6>25 partners)[15] history of oral-genital sex (4.3 >= 1 partner),[14](3.8 1>5 partners)[15], history of anal–oral sex[14], female partner had a history of either an abnormal Pap smear or a cervical dysplasia[14][16] , frequent marijuana use[17] and chronic periodontitis[18].

Treatment
Tumor HPV status is strongly associated with positive therapeutic response and survival compared with non HPV-positive oropharyngeal cancer.[19]

Epidemiology
Currently in the US there is a growing incidence of HPV-associated oropharyngeal cancers,[20][21][22] perhaps as a result of changing sexual behaviors.[23] The higher increase incidence is also seen in other countries, like Sweden[24] and Finland[25

Hypopharynx
The hypopharynx includes the pyriform sinuses, the posterior pharyngeal wall, and the postcricoid area. Tumors of the hypopharynx frequently have an advanced stage at diagnosis, and have the most adverse prognoses of pharyngeal tumors. They tend to metastasize early due to the extensive lymphatic network around the larynx.

Larynx
Laryngeal cancer begins in the larynx or "voice box." Cancer may occur on the vocal folds themselves ("glottic" cancer), or on tissues above and below the true cords ("supraglottic" and "subglottic" cancers respectively). Laryngeal cancer is strongly associated with tobacco smoking.

Surgeries can include partial laryngectomy (removal of part of the larynx) and total laryngectomy (removal of the whole larynx). If the whole larynx has been removed the person is left with a permanent tracheostomy opening and learns to speak again in a new way with the help of intensive teaching and speech therapy and/or an electronic device.

Also anyone who has had a glossectomy (tongue removal) will be taught to speak again in a new way and have intensive speech therapy.

Trachea: Cancer of the trachea is a rare malignancy which can be biologically similar in many ways to head and neck cancer, and is sometimes classified as such.

Most tumors of the salivary glands differ from the common carcinomas of the head and neck in etiology, histopathology, clinical presentation, and therapy, Other uncommon tumors arising in the head and neck include teratomas, adenocarcinomas, adenoid cystic carcinomas, and mucoepidermoid carcinomas.[2] Rarer still are melanomas and lymphomas of the upper aerodigestive tract.

Causes:
Alcohol[26] and tobacco use are the most common risk factors for head and neck cancer in the United States. Alcohol and tobacco are likely synergistic in causing cancer of the head and neck.[27] Smokeless tobacco is an etiologic agent for oral and pharyngeal cancers.[28] Cigar smoking is an important risk factor for oral cancers as well.[29] Other potential environmental carcinogens include marijuana and occupational exposures such as nickel refining, exposure to textile fibers, and woodworking. Cigarette smokers have a lifetime increased risk for head and neck cancers that is 5- to 25-fold increased over the general population.[30] The ex-smoker's risk for squamous cell cancer of the head and neck begins to approach the risk in the general population twenty years after smoking cessation. The high prevalence of tobacco and alcohol use worldwide and the high association of these cancers with these substances makes them ideal targets for enhanced cancer prevention.

Dietary factors:
Dietary factors may contribute. Excessive consumption of processed meats and red meat were associated with increased rates of cancer of the head and neck in one study, while consumption of raw and cooked vegetables seemed to be protective.[31]

Vitamin E was not found to prevent the development of leukoplakia, the white plaques that are the precursor for carcinomas of the mucosal surfaces, in adult smokers.[32] Another study examined a combination of Vitamin E and beta carotene in smokers with early-stage cancer of the oropharynx, and found a worse prognosis in the vitamin users.[33]

HPV:
HPV, in particular HPV16, is a suggested causal factor for head and neck squamous cell carcinoma (HNSCC).[36][37] Approximately 15 to 25% of HNSCC contain genomic DNA from HPV [38], and the association varies based on the site of the tumor, especially in the oropharynx, with highest distribution in the tonsils, where HPV DNA is found in (45 to 67%) of the cases,[39] less often in the hypopharynx (13%–25%), and least often in the oral cavity (12%–18%) and larynx (3%–7%)[40].

Some experts estimate that while up to 50% of cancers of the tonsil may be infected with HPV, only 50% of these are likely to be caused by HPV (as opposed to the usual tobacco and alcohol causes). The role of HPV in the remaining 25-30% is not yet clear.[41]

Epstein-Barr virus:
Epstein-Barr virus (EBV) infection is associated with nasopharyngeal cancer.[35] Nasopharyngeal cancer occurs endemically in some countries of the Mediterranean and Asia, where EBV antibody titers can be measured to screen high-risk populations.[35] Nasopharyngeal cancer has also been associated with consumption of salted fish, which may contain high levels of nitrites.

Gastroesophageal reflux disease:
The presence of acid reflux disease (GERD - gastroesphogeal reflux disease) or larynx reflux disease can also be a major factor. In the case of acid reflux disease, stomach acids flow up into the esophagus and damage its lining, making it more susceptible to throat cancer.

Ethnicity:
Ethnicity may also play a part, with African American men in the U.S. being found to be at a 50% higher risk of throat cancer than caucasian men.

Other possible causes:
There are a wide variety of factors which can put someone at a heightened risk for throat cancer. Such factors include smoking or chewing tobacco or other things, such as gutkha, marijuana or paan, heavy alcohol consumption, poor diet resulting in vitamin deficiencies (worse if this is caused by heavy alcohol intake), weakened immune system, asbestos exposure, prolonged exposure to wood dust or paint fumes, exposure to petroleum industry chemicals, and being over the age of 55 years. Another risk factor includes the appearance of white patches or spots in the mouth, known as leukoplakia;[2] in about ? of the cases this develops into cancer.

Diagnosis

Symptoms: Throat Cancer usually begins with symptoms that seem harmless enough, like an enlarged lymph node on the outside of the neck, a sore throat or a hoarse sounding voice. However, in the case of throat cancer, these conditions may persist and become chronic. There may be a lump or a sore in the throat or neck that does not heal or go away. There may be difficult or painful swallowing. Speaking may become difficult. There may be a persistent earache. Other possible but less common symptoms include some numbness or paralysis of the face muscles.

Presenting symptoms include:

Mass in the neck
Neck pain
Bleeding from the mouth
Sinus congestion, especially with nasopharyngeal carcinoma
Bad breath
Sometimes a sore tongue
Painless ulcer or sores in the mouth that do not heal.
White, red or dark patches in the mouth that will not go away.
Ear-ache.
Unusual bleeding or numbness in the mouth.
A lump in your lip, mouth or gums.
Enlarged lymph glands in the neck.
If the cancer affects the tongue it may cause some slurring of speech.
A hoarse voice, which persists for more than six weeks.
A sore throat which persists for more than six weeks
difficulty swallowing food,
change in diet or weight loss,
any neck lumps which persists for more than three weeks.
A mouth ulcer that does not heal

Treatment:
General considerations: Improvements in diagnosis and local management, as well as targeted therapy, have led to improvements in quality of life and survival for head and neck cancer patients since 1992[42]

After a histologic diagnosis has been established and tumor extent determined, the selection of appropriate treatment for a specific cancer depends on a complex array of variables, including tumor site, relative morbidity of various treatment options, patient performance and nutritional status, concomitant health problems, social and logistic factors, previous primary tumors, and patient preference. Treatment planning generally requires a multidisciplinary approach involving specialist surgeons and medical and radiation oncologists.

Several generalizations are useful in therapeutic decision making, but variations on these themes are numerous. Surgical resection and radiation therapy are the mainstays of treatment for most head and neck cancers and remain the standard of care in most cases. For small primary cancers without regional metastases (stage I or II), wide surgical excision alone or curative radiation therapy alone is used. More extensive primary tumors, or those with regional metastases (stage III or IV), planned combinations of pre- or postoperative radiation and complete surgical excision are generally used. Survival and recurrence risk has been roughly equivalent between surgical and radiation-based approaches, with a head-to-head comparison in only one randomized study[citation needed]. More recently, as historical survival and control rates are recognized as less than satisfactory, there has been an emphasis on the use of various induction or concomitant chemotherapy regimens.

Patients with head and neck cancer can be categorized into three clinical groups: those with localized disease, those with locally or regionally advanced disease, and those with recurrent and/or metastatic disease. Comorbidities (medical problems in addition to the diagnosed cancer) associated with tobacco and alcohol abuse can affect treatment outcome and the tolerability of aggressive treatment in a given patient.

Many different treatments and therapies are used in the treatment of throat cancer. The type of treatment and therapies used are largely determined by the location of the cancer in the throat area and also the extent to which the cancer has spread at time of diagnosis. Patients’ also have the right to decide whether or not they wish to consent to a particular treatment. For example, some may decide to not undergo radiation therapy which has serious side effects if it means they will be extending their lives by only a few months or so. Others may feel that the extra time is worth it and wish to pursue the treatments.

Cancer Head And Neck
Heart Murmur Adenoids Bursitis Eye Infections Hepatitis C Glomerulonephritis (GN) Male And Female Infertility - Causes Escherichia Coli O157 Clostridium Epstein-Barr virus Cervical cancer Allergy-Immunology Glossary Mumps Cancer Head And Neck Blood Coagulation Disorders Sickle-Cell Disease Gastrointestinal Disorders Common cold Warts - Causes, Symptoms, And Treatment What Causes Acne Clarithromycin Leishmania Infection Angiostrongylus Infection Tuberculosis Addison's disease Coming Soon Headaches And Allergies Hay fever Hand, Foot, & Mouth Disease Pubic Lice Infestation Psoriasis Protein Suppresses Allergy Prostate Cancer Prenatal Testing Prader-Willi Syndrome Post-Traumatic Stress Disorder (PTSD) Poison Plants Pneumococcal Disease Plague Pet Allergy Penicillin Allergy Patent Ductus Arteriosus (PDA) Polio Disease Pinworm Infection Pheochromocytoma Phenylketonuria Pertussis Disease PAD (Peripheral Arterial Disease) Peanut Allergy Symptoms Parvovirus B19 (Fifth Disease) Pacemaker	Head and neck cancer The term head and neck cancer refers to a group of biologically similar cancers originating from the upper aerodigestive tract, including the lip, oral cavity (mouth), nasal cavity, paranasal sinuses, pharynx, and larynx. Most head and neck cancers are squamous cell carcinomas, originating from the mucosal lining (epithelium) of these regions.[1] Head and neck cancers often spread to the lymph nodes of the neck, and this is often the first (and sometimes only) manifestation of the disease at the time of diagnosis. Head and neck cancer is strongly associated with certain environmental and lifestyle risk factors, including tobacco smoking, alcohol consumption, UV light and occupational exposures, and certain strains of viruses, such as the sexually transmitted human papillomavirus.[2] These cancers are frequently aggressive in their biologic behavior; patients with these types of cancer often develop a second primary tumor.[2] Head and neck cancer is highly curable if detected early, usually with some form of surgery although chemotherapy and radiation therapy may also play an important role. The 2009 estimated number of head and neck cancer in the US is of 35,720 new cases.[3] Classification: Head and neck squamous cell carcinomas (HNSCC's) make up the vast majority of head and neck cancers, and arise from mucosal surfaces throughout this anatomic region. These include tumors of the nasal cavities, paranasal sinuses, oral cavity, nasopharynx, oropharynx, hypopharynx, and larynx. Oral cavity: quamous cell cancers are common in the oral cavity, including the inner lip, tongue, floor of mouth, gingivae, and hard palate. Cancers of the oral cavity are strongly associated with tobacco use, especially use of chewing tobacco or "dip", as well as heavy alcohol use. Cancers of this region, particularly the tongue, are more frequently treated with surgery than are other head and neck cancers. Surgeries for oral cancers include: Maxillectomy (can be done with or without Orbital exenteration) Mandibulectomy (removal of the mandible or lower jaw or part of it) Glossectomy (tongue removal, can be total, hemi or partial) Radical neck dissection Moh's procedure Combinational e.g. glossectomy and laryngectomy done together. The defect is covered/improved by using another part of the body and/or skin grafts and/or wearing a prosthesis. Nasopharynx: Nasopharyngeal cancer arises in the nasopharynx, the region in which the nasal cavities and the Eustachian tubes connect with the upper part of the throat. While some nasopharyngeal cancers are biologically similar to the common HNSCC, "poorly differentiated" nasopharyngeal carcinoma is distinct in its epidemiology, biology, clinical behavior, and treatment, and is treated as a separate disease by many experts. Oropharynx: Oropharyngeal squamous cell carcinomas (OSCC) begins in the oropharynx, the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils. Squamous cell cancers of the tonsils are more strongly associated with human papillomavirus infection than are cancers of other regions of the head and neck. HPV-positive oropharyngeal cancer: Human papillomavirus (HPV)-positive oropharyngeal cancer, also known as HPV16-positive oropharyngeal cancer or HPV OPC, is a recognized subtype of OSCC,[4][5] associated with the HPV type 16 virus. Diagnosis Genetic signatures of HPV-related and HPV-unrelated OSCC are different.[6][7][8][9][10] HPV OPC is associated with expression level of the E6/E7 mRNAs and of p16.[11] Nonkeratinizing squamous cell carcinoma strongly predicts HPV-association.[12][13] Prevention Risk factors are high number of sexual partners,(>= 4)[14](2.7 6>25 partners)[15] history of oral-genital sex (4.3 >= 1 partner),[14](3.8 1>5 partners)[15], history of anal–oral sex[14], female partner had a history of either an abnormal Pap smear or a cervical dysplasia[14][16] , frequent marijuana use[17] and chronic periodontitis[18]. Treatment Tumor HPV status is strongly associated with positive therapeutic response and survival compared with non HPV-positive oropharyngeal cancer.[19] Epidemiology Currently in the US there is a growing incidence of HPV-associated oropharyngeal cancers,[20][21][22] perhaps as a result of changing sexual behaviors.[23] The higher increase incidence is also seen in other countries, like Sweden[24] and Finland[25 Hypopharynx The hypopharynx includes the pyriform sinuses, the posterior pharyngeal wall, and the postcricoid area. Tumors of the hypopharynx frequently have an advanced stage at diagnosis, and have the most adverse prognoses of pharyngeal tumors. They tend to metastasize early due to the extensive lymphatic network around the larynx. Larynx Laryngeal cancer begins in the larynx or "voice box." Cancer may occur on the vocal folds themselves ("glottic" cancer), or on tissues above and below the true cords ("supraglottic" and "subglottic" cancers respectively). Laryngeal cancer is strongly associated with tobacco smoking. Surgeries can include partial laryngectomy (removal of part of the larynx) and total laryngectomy (removal of the whole larynx). If the whole larynx has been removed the person is left with a permanent tracheostomy opening and learns to speak again in a new way with the help of intensive teaching and speech therapy and/or an electronic device. Also anyone who has had a glossectomy (tongue removal) will be taught to speak again in a new way and have intensive speech therapy. Trachea: Cancer of the trachea is a rare malignancy which can be biologically similar in many ways to head and neck cancer, and is sometimes classified as such. Most tumors of the salivary glands differ from the common carcinomas of the head and neck in etiology, histopathology, clinical presentation, and therapy, Other uncommon tumors arising in the head and neck include teratomas, adenocarcinomas, adenoid cystic carcinomas, and mucoepidermoid carcinomas.[2] Rarer still are melanomas and lymphomas of the upper aerodigestive tract. Causes: Alcohol[26] and tobacco use are the most common risk factors for head and neck cancer in the United States. Alcohol and tobacco are likely synergistic in causing cancer of the head and neck.[27] Smokeless tobacco is an etiologic agent for oral and pharyngeal cancers.[28] Cigar smoking is an important risk factor for oral cancers as well.[29] Other potential environmental carcinogens include marijuana and occupational exposures such as nickel refining, exposure to textile fibers, and woodworking. Cigarette smokers have a lifetime increased risk for head and neck cancers that is 5- to 25-fold increased over the general population.[30] The ex-smoker's risk for squamous cell cancer of the head and neck begins to approach the risk in the general population twenty years after smoking cessation. The high prevalence of tobacco and alcohol use worldwide and the high association of these cancers with these substances makes them ideal targets for enhanced cancer prevention. Dietary factors: Dietary factors may contribute. Excessive consumption of processed meats and red meat were associated with increased rates of cancer of the head and neck in one study, while consumption of raw and cooked vegetables seemed to be protective.[31] Vitamin E was not found to prevent the development of leukoplakia, the white plaques that are the precursor for carcinomas of the mucosal surfaces, in adult smokers.[32] Another study examined a combination of Vitamin E and beta carotene in smokers with early-stage cancer of the oropharynx, and found a worse prognosis in the vitamin users.[33] HPV: HPV, in particular HPV16, is a suggested causal factor for head and neck squamous cell carcinoma (HNSCC).[36][37] Approximately 15 to 25% of HNSCC contain genomic DNA from HPV [38], and the association varies based on the site of the tumor, especially in the oropharynx, with highest distribution in the tonsils, where HPV DNA is found in (45 to 67%) of the cases,[39] less often in the hypopharynx (13%–25%), and least often in the oral cavity (12%–18%) and larynx (3%–7%)[40]. Some experts estimate that while up to 50% of cancers of the tonsil may be infected with HPV, only 50% of these are likely to be caused by HPV (as opposed to the usual tobacco and alcohol causes). The role of HPV in the remaining 25-30% is not yet clear.[41] Epstein-Barr virus: Epstein-Barr virus (EBV) infection is associated with nasopharyngeal cancer.[35] Nasopharyngeal cancer occurs endemically in some countries of the Mediterranean and Asia, where EBV antibody titers can be measured to screen high-risk populations.[35] Nasopharyngeal cancer has also been associated with consumption of salted fish, which may contain high levels of nitrites. Gastroesophageal reflux disease: The presence of acid reflux disease (GERD - gastroesphogeal reflux disease) or larynx reflux disease can also be a major factor. In the case of acid reflux disease, stomach acids flow up into the esophagus and damage its lining, making it more susceptible to throat cancer. Ethnicity: Ethnicity may also play a part, with African American men in the U.S. being found to be at a 50% higher risk of throat cancer than caucasian men. Other possible causes: There are a wide variety of factors which can put someone at a heightened risk for throat cancer. Such factors include smoking or chewing tobacco or other things, such as gutkha, marijuana or paan, heavy alcohol consumption, poor diet resulting in vitamin deficiencies (worse if this is caused by heavy alcohol intake), weakened immune system, asbestos exposure, prolonged exposure to wood dust or paint fumes, exposure to petroleum industry chemicals, and being over the age of 55 years. Another risk factor includes the appearance of white patches or spots in the mouth, known as leukoplakia;[2] in about ? of the cases this develops into cancer. Diagnosis Symptoms: Throat Cancer usually begins with symptoms that seem harmless enough, like an enlarged lymph node on the outside of the neck, a sore throat or a hoarse sounding voice. However, in the case of throat cancer, these conditions may persist and become chronic. There may be a lump or a sore in the throat or neck that does not heal or go away. There may be difficult or painful swallowing. Speaking may become difficult. There may be a persistent earache. Other possible but less common symptoms include some numbness or paralysis of the face muscles. Presenting symptoms include: Mass in the neck Neck pain Bleeding from the mouth Sinus congestion, especially with nasopharyngeal carcinoma Bad breath Sometimes a sore tongue Painless ulcer or sores in the mouth that do not heal. White, red or dark patches in the mouth that will not go away. Ear-ache. Unusual bleeding or numbness in the mouth. A lump in your lip, mouth or gums. Enlarged lymph glands in the neck. If the cancer affects the tongue it may cause some slurring of speech. A hoarse voice, which persists for more than six weeks. A sore throat which persists for more than six weeks difficulty swallowing food, change in diet or weight loss, any neck lumps which persists for more than three weeks. A mouth ulcer that does not heal Treatment: General considerations: Improvements in diagnosis and local management, as well as targeted therapy, have led to improvements in quality of life and survival for head and neck cancer patients since 1992[42] After a histologic diagnosis has been established and tumor extent determined, the selection of appropriate treatment for a specific cancer depends on a complex array of variables, including tumor site, relative morbidity of various treatment options, patient performance and nutritional status, concomitant health problems, social and logistic factors, previous primary tumors, and patient preference. Treatment planning generally requires a multidisciplinary approach involving specialist surgeons and medical and radiation oncologists. Several generalizations are useful in therapeutic decision making, but variations on these themes are numerous. Surgical resection and radiation therapy are the mainstays of treatment for most head and neck cancers and remain the standard of care in most cases. For small primary cancers without regional metastases (stage I or II), wide surgical excision alone or curative radiation therapy alone is used. More extensive primary tumors, or those with regional metastases (stage III or IV), planned combinations of pre- or postoperative radiation and complete surgical excision are generally used. Survival and recurrence risk has been roughly equivalent between surgical and radiation-based approaches, with a head-to-head comparison in only one randomized study[citation needed]. More recently, as historical survival and control rates are recognized as less than satisfactory, there has been an emphasis on the use of various induction or concomitant chemotherapy regimens. Patients with head and neck cancer can be categorized into three clinical groups: those with localized disease, those with locally or regionally advanced disease, and those with recurrent and/or metastatic disease. Comorbidities (medical problems in addition to the diagnosed cancer) associated with tobacco and alcohol abuse can affect treatment outcome and the tolerability of aggressive treatment in a given patient. Many different treatments and therapies are used in the treatment of throat cancer. The type of treatment and therapies used are largely determined by the location of the cancer in the throat area and also the extent to which the cancer has spread at time of diagnosis. Patients’ also have the right to decide whether or not they wish to consent to a particular treatment. For example, some may decide to not undergo radiation therapy which has serious side effects if it means they will be extending their lives by only a few months or so. Others may feel that the extra time is worth it and wish to pursue the treatments.
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