For a quarter century, Irene Stark had stood by the operating table as a nurse, watching over patients in triumph and tragedy alike.
"I'd been there 25 years, and I've seen the good and the bad," she said.
So when her doctor came in to talk to the 82-year-old Arizona woman in June 2006 about her own need for surgery to excise her cancer, she understood just how risky the procedure would be.
But once she understood the scope of her prognosis, she decided it was time to give up the fight.
Tangled within the crucial blood vessels leading to her heart, Stark had a tumor about half the size of a deck of playing cards.
"The day he told me I had cancer, I had chest X-rays done," she said. "And when I saw the size of the lesions and so forth, I looked at him and I smiled — and I said, 'Well, I guess the party's over.'"
"I think he was hurt more than I was."
From that point forward, Stark refused conventional treatment, opting instead to enjoy the remaining days of her life as best she could.
"When they told me that I had the cancer, they asked me if I wanted an oncologist," Stark said. "I said no — and they were surprised. I said I would rather leave it to a higher power."
More than 1.4 million Americans are expected to be diagnosed with cancer this year. And while most will look to the ever-improving arsenal of medical interventions to battle the disease, many will opt to forgo or end treatment.
Some, like Stark, will choose not to have treatment soon after their diagnosis. Others will make a choice similar to that made by Tammy Faye Messner, who chose to opt out of a particularly aggressive course of therapy after enduring its grueling side effects for years.
Messner, the former wife of disgraced televangelist Jim Baker, died Saturday after a more than a decadelong bout with colon cancer that had recently spread to her lungs. She was 65.
In May she announced in a note on her Web site that she had decided to cease her treatment regimen. The ravages of the disease were readily apparent when a frail Messner, reportedly weighing less than 70 pounds, appeared on CNN's "Larry King Live" earlier this month.
"I think there are several reasons why people stop treatment," said naturopathic doctor Timothy Birdsall, vice president of integrative medicine for the Cancer Treatment Centers of America.
Among them are the side effects of some of the more aggressive cancer therapies — side effects that Birdsall describes as "horrific."
"They tell me, 'I don't want to live like this. I would rather die than put up with these side effects,'" he said.
But as difficult as the decision to give up treatment can be for patients, it also takes a toll on doctors.
"It is so hard, at least for me. It's not like there's a certain set of treatments you can do. You can always come up with one more thing to try," said Dr. David Korones, associate professor of oncology at the University of Rochester Medical Center.
"But then you really have to balance how much good that's really going to do for the patient," he said. "I don't know the details of Tammy Faye Messner's illness, but the fact that she'd been treated a few times and then it came back, I can really understand her reaching her limit."
Unlike Messner, Stark decided from the start that she would not go forward with treatment. Part of this, she said, had to do with the experience of watching her sister die of lung cancer years ago.
"[She] was sick every time she had the medication, the chemotherapy. … She said, 'Look at the way I've suffered so much. And I'm still going to die.'"
"And she did. So I kept that in my mind, and I swore to God that I would never have that done."
Instead, Stark opted for end-of-life care, also known as hospice care. The goal is to make her as comfortable as possible in her last months of life. She gets help through different treatments, such as a breathing machine that helps her lungs get more oxygen. But her doctors are no longer aiming to cure her cancer.
"I'm still able to do things — not go out nightclubbing, you know what I mean? But, I'm here in the house," she said.
Hospice care can also provide family and loved ones with the chance to say goodbye.
"The other part of what hospice does is to include the family in the care of the patient," said Dr. Marcin Chwistek, an attending physician in oncology with the pain and palliative care program at Fox Chase Cancer Center.
For Stark's family, the decision was challenging to accept.
"My kids were very upset," she said. "My kids wanted me to have treatment and I said, 'No, it's my body, my choice and this is where it's going to go.'"
"And they knew there was no way. … There was no way they were going to change my mind. I'm not a changeable person. If they like it, fine. If they don't, that's just too bad."
And Stark is still alive, more than a year after her diagnosis.
"I said God will help me, and he has," she said. "It has been over a year. What more could I ask for? … I'm still laughing. I think that's what's important. It's the way you take it. You have to accept it for what it is."