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.

Cutaneous Melanoma, Part Two: Management of Patients with Biopsy-Proven Melanoma

Patricia K. Long, FNP-C, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
David W. Ollila, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.

Proper management of patients with biopsy-proven melanoma is vitally important. Patients with melanoma in situ, invasive melanoma <1 mm thick, and invasive melanoma >1 mm thick should have surgical resection margins of 5 mm, 1 cm, and 2 cm, respectively. All patients with melanomas >1 mm should be offered a sentinel node procedure, the most important prognostic variable in this group of patients. All patients with metastatic melanoma in the sentinel node should undergo a complete therapeutic lymphadenectomy.
Key words: melanoma, margin of resection, sentinel node biopsy.

Oral Cavity Cancer in the Older Population

Richard J. Payne, MD, MSc, FRCSC, BComm Fellow, Head & Neck Oncology, Department of Otolaryngology--Head & Neck Surgery, University of Toronto, ON.
Jamil Asaria, MD, BSc, Resident, Department of Otolaryngology--Head & Neck Surgery, University of Toronto, Toronto, ON.
Jeremy L. Freeman, MD, FRCSC, FACS, Professor of Otolaryngology--Head & Neck Surgery; Temmy Latner/Dynacare Chair in Head & Neck Oncology, Otolaryngologist-in-Chief, Mount Sinai Hospital, Toronto, ON.

The oral cavity is a frequent site of head and neck cancer. The population most commonly afflicted with cancer of the oral cavity is older adults. Tobacco and alcohol are often implicated as associated preventable factors for oral cavity cancer--when used in combination their effects are synergistic. Malignant lesions may present as a persistent ulceration, mass, or red or white irritations in the oral cavity. They tend to be painful and cause difficulty with chewing. It is not uncommon for patients to complain of a neck mass. Investigation of suspicious lesions mandates a biopsy. Diagnostic imaging involving CT and MRI are important components of staging the primary tumour, and determining the extent of loco-regional and distant metastases. The treatment of early cancers is primarily surgical, while the treatment of advanced disease involves a multimodal approach incorporating a combination of surgery, radiation, and chemotherapy. However, the situation of each patient is unique, especially in the older adult, and other factors such as comorbidities often dictate the specific treatment approach.
Key Words: oral cancer, head and neck cancer, cancer in the older adult, oral malignancies.

Second Malignant Neoplasms

Miguel N. Burnier Jr., MD, PhD, FRCSC, Chairman, Ophthalmology, McGill University, Montreal, QC.
Vinicius S. Saraiva, MD, PhD, Fellow, Ocular Oncology & Pathology, McGill University, Montreal, QC.

Second malignant neoplasms (SMN) are nonmetastatic malignancies occurring in patients previously diagnosed with another malignant neoplasm. This clinical entity is becoming increasingly more frequent with the aging of the overall population and better diagnosis and treatment of cancers. Although a reasonable percentage of cases may be explained by genetic, iatrogenic, and/or shared environmental exposure, it is estimated that the majority of cases are sporadic. Recognizing the possibility of SMNs is essential for appropriate and timely diagnosis and treatment, but even more important for the development of preventive strategies.
Key words: oncology, second malignant neoplasms, ophthalmology, eye tumours.

Detection and Diagnosis of Cutaneous Melanoma

Patricia K. Long, FNP-C, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
David W. Ollila, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.

The incidence of melanoma continues to rise. The clinician needs to be familiar with characteristics of lesions more likely to be melanoma and be able to apply the “ABCDE” criteria. Additional imaging techniques such as digital photography and dermoscopy aid the clinician in deciding which nevi require biopsy. The techniques for biopsying cutaneous lesions vary, and clinicians need to be familiar with the various techniques. Once a cutaneous melanoma is diagnosed, the most important histologic feature of the primary is Breslow thickness.
Key words: melanoma, pigmented nevi, digital imaging, dermoscopy.

Everyone’s Guide to Cancer Supportive Care: A Comprehensive Handbook for Patients and their Families

Authors: Ernest Rosenbaum, MD, Isadora Rosenbaum, MA
Publisher: Andrews McMeel (September 1, 2005)

Reviewer: Lesley McKarney, PhD, Editorial Director, Geriatrics & Aging

A diagnosis of cancer brings with it many questions and a need for clear, understandable answers for both patients and their families. There is a multitude of information about cancer available at bookstores, on the Internet, and on television. It can be overwhelming and insufficient because not all the answers are available--from anywhere--and when they are available, they are not always accurate.

Author Ernest Rosenbaum, MD, FACP, a clinical professor of medicine at the University of California, San Francisco, is himself a survivor of esophageal cancer. Together with his wife Isadora and almost 80 medical advisors and contributing authors, all of whom serve as top specialists in their respective fields of cancer treatment and research, the Rosenbaums have assembled Everyone’s Guide to Cancer Supportive Care, a comprehensive assimilation of information relative to the disease of cancer written for patients and caregivers. It includes accurate but palatable descriptions of physiological changes and methods of psychological coping, and encourages patients to be more involved in their care. As correctly observed in the preface by Dr. I. Craig Hendersen, “…our modern medical system allows too little time for the doctor to provide everything the patient needs to live with and overcome this disease.”

The book serves as a companion read to Everyone’s Guide to Cancer Therapy: How Cancer Is Diagnosed, Treated, and Managed Day to Day. While the latter deals with issues surrounding the diagnosis and treatment of cancer, Cancer Supportive Care is designed to guide patients towards an organized program of comprehensive rehabilitation by examining psychosocial aspects (e.g., loneliness and stress), nutrition, exercise, sexuality, nursing, hospital issues, community services, medical economics, and end-of-life care.

A hefty reference running at 468 pages, Everyone’s Guide to Cancer Supportive Care is divided into six sections. The first section attends to what typically happens when a patient first learns about the diagnosis and what treatments are available, as well as treatment side effects and options for pain control. There are helpful chapters describing surgery, radiation therapy, bone marrow transplantation, chemotherapy, alternative and complementary therapies, and clinical trials, though the lengthy description of targeted therapy of cancer is far too advanced for the layperson. The two chapters on side effects of cancer therapy include information on the consequences of such (e.g., severe neutropenia, for example, can lead to delays in or termination of chemotherapy), advice on how the patient and/or doctor can reduce the impact of side effects, and what is tolerable. The chapter on pain control attempts to dispel the myths surrounding opioid use.

The second section coaches patients on regaining control of their confidence and self-esteem. Titled “The Role of the Mind,” it discusses coping strategies for stress and depression--natural responses to news that a person has cancer--and whether or not a patient’s attitude has an impact on medical outcome. In particular, this section has chapters discussing the value of religion, spirituality, and creative expression in helping patients confront and deal with their illness.
Perhaps the most valuable section of the book for the patient, section three focuses on the care of the body. In addition to emphasizing the importance of a well-nourished patient and achieving a balanced diet, this section also instructs on nutrition for symptom management and control, particularly as it relates to the type of treatment or cancer. Which foods least irritate the bowels of patients who have undergone a colonectomy or colostomy? How do you bypass the problem of difficulty swallowing, mucositis, and dry mouth in head and neck cancer cases? What can be done for loss of appetite due to chemotherapy or morphine-induced constipation? And so on. These are also dealt with to some extent in the chapters on modified diets, recipes for the chemotherapy patient, multivitamins, and complementary medications. Rehabilitation and fitness exercises (with illustrations), insomnia, and sexuality are also covered.

Section four includes supportive and social services for life and death issues, such as in-hospital routines, in-home support groups, home nursing, hospice care, grief, and recovery. Section five covers the sensitive topics of when to consider an advance directive, preparing a will, and arranging a funeral or memorial service. The last chapter, “Choosing Life,” reinforces the major messages throughout the book and reminds patients of the relevance of their will to live and the interaction of body, mind, and health.

Finally, the book finishes with a list of supportive care resources including Internet resources, support groups, and relevant literature.

This is an impressive resource for all those wanting to learn about cancer and its consequences. In truth, I have only one criticism to make of this book: the reference in the title to it being Everyone’s Guide is somewhat misleading. The book requires (or assumes) postsecondary education of its readers, or at least grade 10 comprehension--an all too common mistake made in medical literature. A physician would be wise to consider the patient’s and family’s abilities to read and understand the content before recommending such a detailed and possibly intimidating book.

Despite this, physicians and other health care providers will certainly appreciate this comprehensive and well-written overview of cancer supportive care as a teaching tool, and it is a valuable addition to the library of any cancer clinic.

Cancer Screening: Applying the Evidence to Adults beyond Age 70

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

Shabbir M.H. Alibhai, MD, MSc, FRCPC, Department of Medicine, University Health Network; Department of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.

More than one-half of new cancers and over 70% of cancer deaths in industrialized nations occur in adults age 65 or older. Systematic screening has been associated with reductions in cancer-related mortality for a variety of cancers, including breast, cervical, and colorectal cancer. While increasing numbers of older adults are living beyond 70, few guidelines address cancer screening in this group of older adults. In this article, evidence-based guidelines are reviewed for cancer screening in adults and limitations of screening studies with respect to older adults are discussed. A framework for deciding when to stop cancer screening in older adults is presented based on estimating remaining life expectancy, which incorporates age, comorbidity, and functional status.
Key words: cancer screening, aged, mass screening, overdiagnosis, cancer mortality.

Malignant Photo Damage

Joseph F. Coffey, BSc, MD, Currently PGY4 Dermatology, University of Alberta, Edmonton, AB.
Gordon E. Searles, OD, MD, MSc, FRCPC, Assistant Clinical Professor; Program Director, University of Alberta, Edmonton, AB.

Accumulation of sun exposure is an important factor resulting in aging of the skin and development of cutaneous malignancy. Unfortunately, most people think of suntanning as a healthy, natural process, and damaging effects of the sun are not experienced until 15-20 years after the initial damage has been done. By the time we see patients in our clinic, the majority of our older clientele has extensive, irreversible photo damage and precursors of skin cancer. It is difficult to treat many of these patients as multiple lesions are frequently present, and patients are sometimes unwilling to initiate sun-protective measures, are not ideal surgical candidates, and may not comply with treatments suggested by the dermatologist due to financial burden. We emphasize the critical role of sun exposure as a cause of skin aging, benign stigmata of aging, and development of skin cancers. Treatment options including topical therapies, oral medications, surgery, and new-age technologies are discussed.
Key words: photo-aging, therapy, skin cancer, dermatoheliosis, melanoma.

Mending the Rift: DNA Repair and Aging

David A. Goukassian, MD, PhD, Department of Dermatology, Boston University School of Medicine, Boston, MA, USA.

One important goal in the field of DNA repair is to use current knowledge of DNA damage and repair mechanisms in normal young and adult cells and animal models in the chemoprevention and chemotherapeutics of DNA damage-related diseases. However, such a translation into a true in vivo setting can prove difficult. No doubt, the scope of human in vivo studies is currently restricted by the complexity of this setting and by the relatively limited availability of safe and effective in vivo chemopreventive and chemotherapeutic substances, as well as tremendous ethical responsibility. This article’s focus is on human and human skin organ-culture studies and outlines possible future directions for the field of photobiology in “translational” applications.
Key words: aging, DNA repair, UV, skin tumour, T-oligos.

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.