Malignant Melanoma among Older Adults

Wey Leong, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.
Alexandra M. Easson, MSc, MD, Department of Surgical Oncology, Princess Margaret Hospital and Mount Sinai Hospital, University of Toronto, ON.
Michael Reedijk, PhD, MD, Department of Surgical Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, ON.

Melanoma must be considered in the differential diagnosis of any skin lesion in older adults. With the incidence of melanoma increasing in general and even more so among older people, more older adults are being diagnosed with melanoma than in the past. Among older adults, melanomas display more aggressive histological features with worse prognosis and treatment outcomes than among younger individuals. Furthermore, older individuals have fewer surgical and medical treatment options because of age-associated comorbidities. This article reviews the epidemiology and management of melanoma with emphasis on the older adult population.
Key words: older adults, melanoma, aged, cancer, skin neoplasm.

Distress—the Sixth Vital Sign in Cancer Care: Implications for Treating Older Adults Undergoing Chemotherapy

Barry D. Bultz, PhD, Director, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, AB.
Bejoy C. Thomas, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board, Calgary, AB.
Douglas A. Stewart, MD, FRCPC, Divisions of Medical Oncology and Hematology, Departments of Oncology and Medicine, Tom Baker Cancer Centre and University of Calgary, Calgary, AB.
Linda E. Carlson, PhD, Department of Psychosocial Resources, Tom Baker Cancer Centre, Alberta Cancer Board; Department of Oncology, University of Calgary, Calgary, Alberta, Canada

Cancer is perceived as an illness that most frequently affects the older adult population, yet there is a dearth of research on the psychosocial aspects of cancer affecting this cohort. The effect of chemotherapy on the psychosocial sequelae in this group is moderately researched. This article discusses emotional distress across the trajectory of cancer care in the older adult population. It also identifies key milestones, times when distress is likely to peak, and the psychological, physiological, and social symptoms of distress. The benefits of psychosocial interventions are also discussed.
Key words: older adult, cancer, chemotherapy, emotional distress, 6th vital sign.

Assessing Cancer-Related Fatigue: Conceptualization Challenges and Implications for Research and Clinical Services

Pascal Jean-Pierre, PhD, Department of Radiation Oncology, Department of Family Medicine, University of Rochester Medical Center, Rochester, New York, USA.
Gary Morrow, PhD, MS, Department of Radiation Oncology, Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA.

Fatigue due to cancer and its treatments is a highly prevalent and debilitating symptom experienced by many patients. This symptom is often present prior to a pathologically confirmed diagnosis of cancer and can be experienced both during and for considerable periods after treatment. Oncology professionals are becoming more cognizant of the impact of cancer-related fatigue on key aspects of patients’ psychosocial performance, cognitive functioning, and overall quality of life. This paper discusses the importance of cancer-related fatigue, the challenges involved in assessing this debilitating symptom among cancer patients, and the influence of researchers’ conceptualization of this symptom on the characteristics of the measures developed to assess it. Strategies to facilitate differential diagnosis of cancer-related fatigue are also presented and discussed.
Key words: cancer-related fatigue, assessment, measurement dimension, older adults, quality of life.

Identifying and Treating Depression among Older Adults with Cancer

Scott M. Sellick, PhD, CPsych, Associate Research Scientist & Director of Supportive Care, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON.

Approximately 25% of persons with cancer report symptoms that meet the diagnostic criteria for the most prevalent mood disorders, including major depression, dysthymic minor depression, and adjustment disorder with depressed mood. This is two to four times the incidence found among the general population. To simply consider depression as “normal” precludes the possibility that some very good things can happen when patients are properly diagnosed and referred to a psychosocial program to be seen by a psychiatrist, psychologist, or social worker. Asking about a patient’s general mood or spirits needs to become as routine as asking about pain. While screening instruments can be very helpful, single questions are equally useful for identifying patients with this unmet need. Otherwise, patients remain feeling helpless or that their condition is hopeless, and this can easily spiral into despair and significantly worsened depression.
Key words: cancer, depression, psychosocial, supportive care, coping.

Fever in Older Cancer Patients: A Medical Emergency

Deepali Kumar MD, MSc, FRCP(C), Consultant, Infectious Diseases, Immunocompromised Host Service, University Health Network; Assistant Professor, University of Toronto, Toronto, ON.

The incidence of cancer continues to increase, and many persons receiving treatment for cancer are older adults. Fever in older adults with cancer can be an emergency. Any patient with fever and neutropenia should be given antibiotics as soon as possible. In addition to the immune senescence associated with aging, individuals with cancer have immunodeficiencies specific to their underlying malignancy, and these predispose them to specific infections. Older adults are also at higher risk of the complications of chemotherapy, including infections. Prompt evaluation and judicious management of the febrile cancer patient can reduce morbidity and mortality. The following review considers an approach to the etiologies and evaluation of fever in cancer including the infectious and noninfectious causes.
Key words: fever, cancer, older adults, antibiotics, neutropenia.

Further Reflections on Cancer, Old Age, and the Meaning of Life

It’s been over five years since I last wrote an editorial for Geriatrics & Aging.¹ Many things have changed in the world of geriatric oncology yet much remains the same. Cancer remains the number two killer among men and women. The top cancer killers have not changed--lung, colorectal, breast, and prostate. And more than half of all cancers strike people age 65 or older, with over two-thirds of all cancer deaths in the same age group. Although the incidence continues to climb (especially for lung cancer), in the last two years there has been a small but important victory in the battle against cancer--the mortality rate from cancer has dropped slightly. And, on a more personal level, I’m still very active in research in this field, in both prostate cancer and hematological malignancies.

There is a growing recognition of the importance of cancer among older people. This goes beyond the staggering numbers of the demographic imperative and the stark incidence and mortality statistics. It strikes at deeper chords: Should older people be screened for cancer? (If so, which cancers? What manoeuvres? How much will this cost? Who should pay?) Why aren’t we enrolling more older people with cancer into clinical trials? (Between 5-15% of cancer patients in clinical trials are older adults, a ratio far lower than actual numbers would suggest.) How should we best treat older people with cancer? (Do we use the same protocols or are older people special, needing modified protocols and/or more colony-stimulating factors? Is aggressive treatment worth it, and who should decide worth, using what yardstick?) Important and difficult questions linger. While some things are becoming clearer (e.g., rational treatment of older people with lymphoma, metastatic colorectal cancer, or estrogen receptor-positive nodal breast cancer), far more questions than answers remain and new questions emerge all the time.

Regular readers know that cancer is one of our regular themes, which we have featured every single year since we began publishing Geriatrics & Aging. The reasons for this are too obvious to need explication. In this issue, our CME article, “Fever in Older Adults with Cancer,” is written by Dr. Deepali Kumar, an infectious diseases specialist with a focus on oncology-related infections. She reviews key considerations and principles when dealing with an older febrile cancer patient. Many younger and older cancer patients complain of fatigue, either during active cancer therapy or years later. A tremendous amount of research is being done in this area (including some of my own) to unravel the causes and treatments of this condition, and Drs. Jean-Pierre and Morrow review the assessment of such patients for us. Another important intersection between cancer and overall health is in the realm of mental health, specifically depression. Depressive symptoms are common among persons suffering from a variety of cancers. Yet depression remains underdiagnosed and undertreated in this vulnerable group. Dr. Sellick from the Thunder Bay Regional Cancer Centre tries to dispel this notion and tackle this important area. Outside of our theme, we have articles on postural and postprandial hypotension, sleep disturbances in dementia, the role of the TB skin test in long-term care, exercise in patients with Parkinson’s Disease, and the ever-popular topic of skin ulcers. As always, we hope you enjoy the issue.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C)

Reference

1. Alibhai SMH. Cancer, old age, and the meaning of life. Geriatrics & Aging 2001;4:5.

Update on Endocrine Therapy for Postmenopausal Women in Early Breast Cancer

Julie Lemieux, MD, MSc, FRCPC, Adjunct Professor, Department of Medicine, Université Laval, Centre des maladies du sein Deschênes-Fabia, Centre d’hématologie et d’immunologie clinique, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.
Louise Provencher, MD, MA, FRCSC, Associate professor, Department of Surgery, Université Laval, Centre des maladies du sein Deschênes-Fabia, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.

A large proportion of breast cancers in older women have positive hormone receptors. Therefore, these women are eligible to receive adjuvant endocrine therapy to decrease their chance of cancer recurrence. Over the last few years, a new class of endocrine therapy, aromatase inhibitors (AIs), has challenged the place of tamoxifen as the gold standard adjuvant endocrine agent. We will discuss randomized clinical trials comparing tamoxifen to AIs in terms of efficacy and side effects.
Key words: breast cancer, tamoxifen, aromatase inhibitors, side effects, quality of life.

Living with Ovarian Cancer: Perspectives of Older Women

Margaret Fitch, RN, PhD, Head, Oncology Nursing and Supportive Care; Director, Psychosocial and Behavioural Research Unit,Toronto Sunnybrook Regional Cancer Centre, Toronto, ON.

Ovarian cancer has more than a physical impact.There are also emotional, psychosocial, spiritual, and practical consequences for those women diagnosed with the disease. These women face many challenges— lives are changed irrevocably with the diagnosis, and life becomes a series of transitions. In caring for women with ovarian cancer, health care providers must be sensitive to myriad concerns these patients may have and try to understand the issues from the perspective of those experiencing them.
Structures and processes need to be established within care facilities that allow patients to have regular comprehensive assessment, good symptom management, effective communication, and individually tailored support.The availability of timely and relevant referral to other experts when needed is of key importance at moments of care transition.
Keywords: supportive care, ovarian cancer, older women, psychosocial concerns, emotion.

Diagnosis and Management of Benign Breast Disease in Older Women

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Nehmat Houssami, MBBS, MPH, MEd, FASBP, FAFPHM, PhD, Screening & Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia.
J. Michael Dixon, MBChB,MD, FRCS, FRCSEd, FRCP, Edinburgh Breast Unit,Western General Hospital, Edinburgh, Scotland.

The incidence of breast cancer increases with advancing age, and the relative frequency of benign breast disease (BBD) decreases. Therefore, all breast symptoms or abnormalities should be assessed with triple testing (clinical examination, imaging, +/-percutaneous needle biopsy if a localized lesion is identified) to establish a diagnosis.The spectrum of BBD changes substantially from about age 45 onwards.We review some of the benign conditions that occur in older women, such as cysts and duct ectasia, and describe clinical features and management.We also discuss specific BBDs that may be encountered more frequently and in a much older population of women than was previously identified, a consequence of both increased incidence of BBD due to past use of hormone replacement therapy and improved detection.
Key words: benign breast disease, triple test, breast neoplasms, breast cyst, duct ectasia.

Epidemiology of Colorectal Cancer and Aging

Maida J. Sewitch, PhD, Assistant Professor, Department of Medicine, McGill University, and the Divisions of Gastroenterology and Clinical Epidemiology, The Research Institute of the McGill University Health Centre, Montreal, QC.
Caroline Fournier MSc, Research Associate, Division of Clinical Epidemiology, The Research Institute of the McGill University Health Centre, Montreal, QC.

Colorectal cancer (CRC) is a commonly diagnosed cancer and a leading cause of cancer deaths in Canada and the industrialized world. According to cancer registries, incidence varies by age, geographical location, site, and time. CRC screening reduces both CRC incidence through removal of premalignant polyps and CRC deaths through early detection and treatment. Health Canada considers CRC an ideal target for mass screening of individuals 50 years of age and older. This article reviews the epidemiology of CRC and the reasoning behind the development of screening guidelines for persons 50 years of age and older. Various Canadian and U.S. guidelines are detailed. Routine screening of average-risk individuals is advocated. Finally, the review highlights trends in patient utilization of CRC screening as well as the role of screening in an aging population.
Keywords: aging, colorectal cancer, epidemiology, screening, adenomatous polyps.