Smoking Cessation Reduces Lung Cancer Mortality

Shechar Dworski, BSc

Lung cancer is the most common cause of cancer-related deaths in both men and women, accounting for 34% of cancer-related deaths in men, and 22% in women. Lung cancer survival rates are dismal: the five-year survival rate is 14% for all cases of lung cancer, and the median survival is less than half a year for untreated patients. The lung cancer mortality rate in the United States is approximately 50 in 100,000, 68% of which occur in people over 65 years of age. Lung cancer mortality in the elderly is rising, which may be due to the aging of the population. Between 1968 and 1983, there was an 8.2% annual growth in mortality in white women 54 to 74 years old. The mortality rates in males seemed to reach a plateau in the 1980's, or may even be declining, possibly due to a decrease in the cigarette smoking by men from 67% in the 1950's, to 28% presently in the United States.

Over one half of all cases of lung cancer are reported in people aged 65 and over. Men aged 65 years and over have an incidence of lung cancer three times higher than men age 45 to 64. This trend is thought to be related to increased lifetime exposure to tobacco smoke and other carcinogens. The rate of lung cancer has risen dramatically in the last 70 years, accounting for 18% of all cancer cases in men, and 12% in women.

Occult Blood Test Not So Good For the Elderly?

Clinical Care of Older Cancer Patients is Outdated

Barry Goldlist, MD, FRCPC, FACP

Last year as I was watching the National News on CBC, I was treated to a classical good news, bad news medical scenario by Peter Mansbridge. The first report was the good news; the proportion of deaths each year in Canada caused by cardiovascular disease was declining. The bad news was that the proportion of deaths caused by cancer was increasing. I felt like screaming "Peter, of course. It has to add up to 100% each year, if one goes down another has to go up!" However, in truth it is not just an issue of proportion. The prevalence of cancer is clearly rising in western society, and the reason is very straightforward. Old age is the major risk factor for many types of cancer, and our society is aging.

This has led to a tremendous growth of research concerning cancer in the elderly, and into the fundamental connection between aging and cancer. I am not confident, however, that the clinical care of elderly cancer patients has been influenced by recent advances in geriatric medicine. In the United States, many medical oncology training programs have started to include geriatric modules in their curriculum. I am unaware of this occurring in Canada. Although the wards of cancer hospitals now have a high proportion of frail elderly in their beds, few hospitals have advanced practice nurses with expertise in geriatrics to help in the nursing management of these patients. Geriatric medicine consultations are very uncommon, and even more importantly, formal programs to rehabilitate elderly people after aggressive therapy (surgery, radiation, chemotherapy), do not currently exist. The Health Services Restructuring Commission in Ontario, to its credit, recognized this deficit and mandated the newly formed Toronto Rehabilitation Institute to develop an oncology rehabilitation program. The funding and success of programs such as this might have a great impact on the quality of life of elderly cancer patients in the future.

Colorectal Cancer Rates Declining in Canada

Sheldon Singh, BSc

Colorectal cancer is the second leading cause of cancer death in North America and Western Europe. This disease tends to occur mainly in older individuals. Early-stage disease is curable in more than 80% of patients. Unfortunately, more than 55% of patients present late with evidence of lymphatic or distant metastases. There is now compelling evidence that screening of average risk individuals over 50 can identify disease at a more curable stage thereby allowing for more effective management and subsequent reduction in mortality.

Epidemiology
Cancer of the colon and rectum kills more Canadians than any other cancer with the exception of lung cancer. During their lifetime, women have a 1 in 18 chance of developing colorectal cancer while men a 1 in 16 chance. This year, the disease is expected to affect 16,600 Canadians (with roughly 93% occurring in people over age 50) and claim 6,300 lives (with roughly 95% occurring after age 50). Rates of colorectal cancer in Canada have been declining, particularly among women. This may be due to changes in diet as well as the casual use of screening techniques.

Risk Factors
Age is a major risk factor for developing colorectal cancer. Approximately 75% of colorectal cancers are sporadic and without any identifiable risk factors other than age. Colorectal cancers are rare before 50 and over 90% are diagnosed after 60.

Angiogenesis: Leaching Blood Supply

Rhonda Witte, BSc

Cancer. The word alone is enough to send fear into the hearts of people. It is safe to assume that everyone knows of someone who has been touched by cancer; they know of someone who is living with or has died of the disease. There are also people who have triumphed over the disease--they have fought cancer and won, they are survivors. Over the years, there have been numerous advances in cancer research. A hot topic in cancer research, in recent years, has focused around a process called angiogenesis. Specifically, researchers are trying to understand angiogenesis and use this knowledge to prevent the growth and spread of cancer.

Angiogenesis, also called neovascularization, is the growth of new blood vessels. Normally, the endothelial cells comprising the capillary walls do not divide. However, during pregnancy, menstruation, and wound repair, endothelial cells are stimulated to grow and divide, increasing the number of blood vessels.^1-3 During angiogenesis, endothelial cells must break through the basal lamina around the capillary wall. They do this by releasing proteases, thereby degrading the extracellular matrix. Endothelial cells then migrate toward the stimulatory signal, proliferating and aligning to form new capillaries.⁴ When properly regulated, angiogenesis stops after a short period of time.

Adopting Decision-Making Capacity Leads to Controversy

Michel Silberfeld, MD, MSc, CRCP(C)

Coordinator, Competency Clinic, Department of Psychiatry
Baycrest Centre for Geriatric Care. North York, Ontario

In Ontario, as in some other provinces, there was a push to modernize guardianship and consent legislation, which culminated in new statutes in 1992. The motivations for new legislation came from several directions. The Ontario Mental Incompetency Act was felt to be outdated because it only permitted plenary guardianship. Plenary guardianship gives a person authority over all decision-making, much like a parent has over a small child. Furthermore, incapacity was poorly defined, based primarily on evidence as to the severity of an illness, and a person deemed incapable had to be incapable in all respects. There were no provisions for Powers of Attorney for personal care.

Several policy initiatives came from patient rights advocates. There was a desire to promote patient autonomy. This was accomplished by clarifying the definitions of capacity in statutes. The new definitions permitted the recognition of partial competence whereby a person could be incapable in one respect and yet retain the right of discretion in all others.

Screening Mammography is Underutilized in the Elderly

Valerie Ha, BSc

In the past ten years, public campaigning on behalf of breast cancer has raised awareness to new heights. Despite an increase in the incidence of breast cancer over the past twenty years (most likely due to better detection of disease), we have seen a plateau and even more recently a decline in the mortality rates in both Canada and the United States. This is likely due to our ability to diagnose disease earlier through breast screening and our improvements in treatment.

Breast Screening is indeed a major player in our fight against breast cancer. It is estimated that a significant reduction in breast cancer mortality can be achieved in Ontario if 70% of women between the ages of 50-69 were to participate in a program of early detection.

Breast cancer screening involves participation in biennial mammograms, monthly self-examination and regular breast examination by a trained professional; a regimen that should be followed during the years that the woman is most likely to be affected.