Cancer Chemotherapy in the Older Cancer Patient

Lodovico Balducci, MD, Professor of Oncology and Medicine, University of South Florida College of Medicine and H. Lee Moffitt Cancer Center and Research Institute; Director, Division of Geriatric Oncology, Department of Interdisciplinary Oncology; Tampa, FL, USA.

The need for physicians to manage cancer in older patients is increasingly common. Cytotoxic chemotherapy for lymphoma, cancers of the breast, of the colorectum, and of the lung may be as effective in older individuals as in younger adults provided that patient selection is individualized on the basis of life expectancy and functional reserve rather than chronologic ages; the doses of chemotherapy are adjusted to the Glomerular Filtration Rate (GFR); prophylactic filgrastim or pegfilgrastim are utilized to prevent neutropenic infections; and hemoglobin is maintained at 120gm/l.
Keywords: Cancer, aging, older adult, chemotherapy, toxicity.

Cancer Diagnosis and Consent to Treatment in the Older Adult

Goran Eryavec, MD, FRCP, Medical Director, Geriatric Psychiatry and Memory Clinic, North York General Hospital; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, ON.
Gabriel Chan, MD, FRCP, Medical Director, Geriatric Medicine, North York General Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Brian Hoffman, MD, FRCP, Chief of Psychiatry, North York General Hospital; Associate Professor, Department of Psychiatry, University of Toronto, Toronto, ON.

Discussing a diagnosis of cancer and obtaining consent to treat older patients can be difficult and challenging. Older cancer patients are often frail, and may have depression or cognitive impairment that brings into question their ability to cope with the diagnosis and their capacity to consent to treatment. Family members may be distressed and fearful of how the patient will cope with the cancer diagnosis. Physicians can be pressured to withhold the diagnosis. The evolution of informed consent, informed decision making, and shared decision making is reviewed along with consent and capacity to consent or refuse treatment legislation in Ontario. We present a case study illustrating these issues and discuss how physicians can cope with the complex clinical, legal, and ethical issues involved.
Key words: informed consent, capacity, older adult, cancer.

Oropharyngeal Cancer and Oral Complications of Cancer Therapy: Considerations in Older Patients

Joel B. Epstein, DMD, MSD, FRCD(C), University of Illinois, College of Dentistry, Department of Oral Medicine and Diagnostic Sciences and Chicago Cancer Center, and Advocate Illinois Masonic Medical Center, Chicago, Il.

Harvey Wigdor, DDS, MS, University of Illinois, College of Dentistry, Department of Oral
Medicine and Diagnostic Sciences and Chicago Cancer Center, and Advocate Illinois
Masonic Medical Center, Chicago, Il.

Oropharyngeal cancer is a disease of adults and has a higher risk of occurrence with increasing age. In addition, oral complications of cancer therapy are more frequent and may be more severe in older patients. The prevention and treatment of oral complications of cancer therapy, with an emphasis on older adults, are reviewed in this report.

Key words: oropharyngeal, cancer, palliation, radiation, side effects.

Update in Oncology

Manmeet S. Ahluwalia, MD, Department of Internal Medicine, Fairview Hospital, Cleveland Clinic Health System, Cleveland, OH.

Hamed A. Daw, MD, The Cleveland Clinic Cancer Center, Cleveland, OH.

This Update in Oncology reports on seven papers published in 2003 that provided evidence that could alter the standard of care. For example, letrozole use is now recommended after standard tamoxifen therapy for postmenopausal women with breast cancer. Another study showed the benefit of platinum-based chemotherapy in invasive bladder cancer. Finasteride was found to delay prostate cancer while aspirin was of value in preventing adenomas of the colon and hence is expected to help prevent colorectal cancer. Usefulness of sentinel node biopsy as a safe and accurate screening method in small breast cancer was confirmed. Finally, neoadjuvant chemotherapy and radical cystectomy improve survival in locally advanced bladder cancer.

Key words: cancer, chemotherapy, metastasis, neoadjuvant, adenoma.

Primary Bone and Soft Tissue Tumours in the Geriatric Population

Michelle A. Ghert, MD, Clinical Fellow in Musculoskeletal Oncology, University of Toronto, ON, Mount Sinai Hospital, Toronto, ON. and Peter C. Ferguson, MD, MSc, FRCSC, Assistant Professor of Surgery, University of Toronto, Division of Orthopaedic Surgery, Mount Sinai Hospital, Department of Surgical Oncology, Princess Margaret
Hospital, Toronto, ON.

Primary bone and soft tissue tumours are rare in the general population. While bone malignancies in the geriatric age group are most often due to metastases or multiple myeloma, primary tumours can occur. These are treated with surgical resection and occasionally chemotherapy. Soft tissue sarcomas are more common and are usually treated with a combination of radiation and surgery. The outcome of treatment for bone sarcomas is poorer in the geriatric age group, but this is not true of soft tissue sarcomas. Patients with both primary bone and soft tissue malignancies should be referred to regional cancer centres for management.

Key words: sarcoma, surgery, radiotherapy, chemotherapy, cancer

Introduction
Musculoskeletal complaints are common in the geriatric population, but rarely are these complaints attributable to malignancies.

Ocular Malignancies in the Elderly

E. Rand Simpson, MD, Associate Professor of Ophthalmology, University of Toronto; Director, Ocular Oncology, Princess Margaret Hospital, Toronto, ON.
Larry Ulanski II, MD, Ocular Oncology Fellow, University of Toronto, Princess Margaret Hospital, Toronto, ON.

Ocular malignancies in the elderly are often difficult to diagnose and manage. The five main cancers found in association with the eye are basal, squamous and sebaceous cell carcinomas, uveal melanoma and malignant cancers to the orbit. These include malignancies from breast, lung, GI, prostate and myelogenous proliferations. This article briefly reviews the most common forms of ocular cancer and brings the general practitioner up to date on the most current data from the Collaborative Ocular Melanoma Study (COMS). We use clinical photos to demonstrate specific clinical signs of cancerous disease. By maintaining a high level of suspicion when treating patients with acute visual symptoms, unnecessary morbidity and mortality may be avoided.
Key words: ophthalmology, cancer, radiotherapy, malignancy.