Management of Multiple Myeloma

Manmeet S. Ahluwalia, MD, Department of Internal Medicine, Fairview Hospital, Cleveland Clinic Health System, Cleveland, OH, USA.
Hamed A. Daw, MD, The Cleveland Clinic Cancer Center, Cleveland, OH, USA.

Multiple myeloma (MM) is a neoplasm of plasma cells that is characterized by tumour cell tropism of the bone marrow and production of monoclonal immunoglobulins (Ig) detectable in serum and/or urine. It often manifests as one or more of lytic bone lesions, monoclonal protein in the blood or urine, disease in the bone marrow, renal failure, anemia, and hypercalcemia. Better understanding of the biology of myeloma has led to the development of agents, such as bortezomib, CC-5013, and thalidomide, that target the myeloma cell and the bone-marrow microenvironment. Ongoing trials promise to define the roles of new agents, mini-allogeneic transplantation, and maintenance therapy.
Key words: bone marrow, biology, transplant, chemotherapy, multiple myeloma.

Prevention, Diagnosis, and Management of Prostate Cancer: An Update

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

Prostate cancer remains the most common malignancy in men. Screening remains controversial due to a lack of evidence from randomized trials that it decreases mortality. Treatment decisions are based on assigning patients to one of three risk groups (low, intermediate, or high) based on stage, tumour grade, and prostate-specific antigen level, and considering remaining patient life expectancy (affected by age and comorbidity). Men with low-risk disease can consider expectant management, surgery, or radiotherapy (either external beam or brachytherapy). In intermediate-risk patients, all options except expectant management are associated with excellent long-term survival. In high-risk patients, combining either radiation or surgery with androgen deprivation has emerged as the best option. There is no role for primary androgen deprivation for most patients.
Key words: prostate cancer, screening, treatment, surgery, radiotherapy.

Pancreatic Cancer-A Review of Current Management Principles

Christine B. Brezden-Masley, MD, PhD, Staff Physician, Department of Medicine, Division of Hematology and Oncology, St. Michael’s Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Monika K. Krzyzanowska, MD, MPH, Staff Physician, Department of Medical Oncology & Hematology, Princess Margaret Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.

Pancreatic cancer is the fourth and fifth leading cause of cancer-related death for men and women, respectively (following lung, colon, and prostate cancers in men; lung, breast, colon, and ovarian cancers in women). Patients usually present with advanced disease, making curative attempts difficult. Surgery is the only curative therapy; however, local disease recurrence with or without spread to distant organs occurs in over 80% of patients. Attempts at better therapeutic modalities are necessary in order to improve outcome in this disease. This review will focus on staging, risk factors, and therapies for resectable, locally advanced, and advanced (metastatic) pancreatic cancer. Novel molecular targeted therapies will also be briefly highlighted.
Key words: pancreatic cancer, chemotherapy, radiation therapy, Whipple procedure, staging.

Diagnosis and Management of Lung Cancer in Older Adults

Natasha B. Leighl, MD, FRCPC, Assistant Professor of Medicine, Division of Medical Oncology, Princess Margaret Hospital/University Health Network; Department of Medicine, University of Toronto, Toronto, ON.

Lung cancer is the leading cause of cancer-related mortality in North America and most commonly affects older patients. Patterns of investigation and treatment in older individuals differ, which may compromise outcome. Older patients should be carefully evaluated, using comprehensive geriatric assessment, to assess for function, functional reserve, comorbidities, polypharmacy, and other issues. Fit patients with few or no comorbidities should be offered standard treatments such as surgical resection for early-stage lung cancer with adjuvant chemotherapy, combined modality treatment (chemotherapy and radiation) for locally advanced disease, and systemic chemotherapy with supportive care for metastatic disease. Frail patients should be reviewed to optimize function and comorbid illnesses, and then considered for other treatment alternatives aimed at minimizing toxicity while still trying to maximize the curative or palliative potential of lung cancer therapy depending upon disease stage.
Key words: lung cancer, aging, chemotherapy, surgery, radiation, treatment.

Treatment Strategies for Breast Cancer

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

Christine B. Brezden-Masley, MD, PhD, Staff Physician, Department of Medicine, St. Michael’s Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Maureen Trudeau, BSc, MA, MD, Acting Regional Vice President, Cancer Services--Clinical; Head, Division of Medical Oncology/Hematology, Sunnybrook & Women’s College Hospital Sunnybrook Campus; Head, Systemic Therapy Program, Toronto Sunnybrook Regional Cancer Centre; Associate Professor, Department of Medicine, University of Toronto, Toronto, ON.

Breast cancer is the most common cause of cancer mortality in women over 65 years of age. Older women with breast cancer are usually understaged and undertreated as a result of factors such as significant patient comorbidities, patient preferences, age-biases, and poor cognition. Furthermore, women over the age of 70 have been excluded from many breast cancer clinical trials, making treatment conclusions difficult. Patients’ characteristics (including age and comorbidities) should be considered when deciding on the final treatment, a decision ideally made by both the treating physician and the patient. This review will discuss current treatment strategies for breast cancer patients, with a focus on the older population.
Key words: breast cancer, older adults, staging, systemic chemotherapy, radiotherapy.

Cancer: the Indiscriminate Killer of Young and Old

Cancer is becoming a more common diagnosis and cause of death each year in Canada. This is being driven by several factors: the aging of the population, the age-related decline in death from cardiovascular disease, and more aggressive attempts to diagnose cancer because treatments are becoming more effective. This has resulted in several geriatric oncology issues coming to the fore:

- Are geriatric principles (multidisciplinary, focus on function) being applied to care of older cancer patients?
- Are older patients getting the appropriate cancer treatments?
- Are older patients properly represented in research trials?

Several years ago, Professor Rory Fisher, an eminent geriatrician at the University of Toronto, responded to deficiencies in palliative care by publishing a guide to palliative care in the older population. In the United States, most oncology residency training programs provide a module on principles of geriatric medicine. Initiatives such as these address the first issue above. One of the most efficient ways to address issues two and three is to have geriatricians involved in cancer research. One of the bright young stars in that field is our own senior editor Dr. Shabbir Alibhai who, with his colleague Dr. S. Gogov, deals with the topic “Prevention, Diagnosis, and Management of Prostate Cancer: An Update.” We have several other articles on this edition’s theme of cancer. In our monthly CME feature, Drs. Christina Brezden-Masley and Maureen Trudeau discuss “Treatment Strategies for Breast Cancer,” while Dr. Natasha Leighl reviews the “Diagnosis and Management of Lung Cancer in Older Adults.” Drs. Manmeet Ahluwalia and Hamed Daw discuss “Multiple Myeloma” in their article, and we also present “Pancreatic Cancer--A Review of Current Management Principles” by Drs. Christine Brezden-Masley and Monika Krzyzanowska.

As well, we have our usual collection of columns and articles of interest. Our ethics column in this issue reflects our theme topic and is entitled “Cancer Diagnosis and Consent to Treatment in the Older Adult” by Drs. Goran Eryavec, Gabriel Chan, and Brian Hoffman. Our biology of aging column is the second part of our series on sudden deafness and covers the topic “Sudden Deafness: Rehabilitation.” The dementia column by Donna Algase is on “Wandering: Clues to Effective Management.” The technology in medicine column, by Elizabeth Richard, continues on the theme of wandering with the brief article “Software Tracks Wandering Patients.” As well, Drs. L. Giangregorio, A. Papaioannou, and J.D. Adachi cover an ever-important area of women’s health in “Osteoporosis: Preventing the Deterioration of Bone.”

Enjoy this issue,
Barry Goldlist

Metastatic Cervical Cancer in Older Patients

K. C. Giede, MD, FRCP, Clinical Fellow in Gynecologic Oncology, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON; Associate Professor of Gynecology and Obstetrics, University of Saskatchewan, Saskatoon, SK.
A. M. Oza, MD, FRCP, Co-Director, Drug Development Program; Co-Chair, NCIC Clinical Trials Group, Princess Margaret Hospital, University Health Network, University of Toronto, Toronto, ON.

The purpose of this article is to review the incidence, prognosis, and management of metastatic cervical cancer in older patients. A literature review was conducted using the key words cervical cancer, elderly, and metastatic disease. There were no studies found specific to metastatic cervical cancer in older patients. The incidence of cervical cancer over the age of 65 remained significant with a greater proportion of older patients presenting with metastatic disease. We found good phase III data on the use of chemotherapy for metastatic cervical cancer. We reviewed data supporting the safe use of chemotherapy and radiotherapy in older patients.
We conclude that older patients are more likely to present with metastatic cervical cancer then their younger counterparts. Standard therapies should not be withheld on the basis of age, though management should focus on palliation.

Key words: cervical cancer, older patients, metastatic.

Radiation Therapy in Older Adults

Loren K. Mell, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Arno J. Mundt, MD, Department of Radiation and Cellular Oncology, University of Chicago and the University of Illinois at Chicago, Chicago, IL, USA.

Radiation therapy (RT) is commonly used in the treatment of older cancer patients. RT may be used as definitive therapy for benign or malignant tumours, as adjuvant therapy with surgery and/or chemotherapy, as palliative therapy when cure is no longer possible, and as alternative to surgery in patients with multiple comorbidities. However, RT is often not given to older patients who might benefit from it, due to biases, misapprehensions about potential toxicity, and social factors particular to this patient population. The preponderance of data suggest that RT is well tolerated in older adults and treatment decisions should be based on prognostic factors irrespective of age. Emerging RT technologies may particularly benefit aged patients by reducing potential toxicities, shortening treatment times, and improving tumour control.

Key words: age, radiation therapy, toxicity, cancer, procedures.

Cervical Cancer in the Older Patient: Diagnosis and Management

Nimesh P. Nagarsheth, MD, Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Medical Center, New York, NY, USA.

Jamal Rahaman, MD, Division of Gynecologic Oncology, Department of Obstetrics,
Gynecology and Reproductive Science, Mount Sinai Medical Center, New York, NY, USA.

The diagnosis and management of cervical cancer in the older patient presents important challenges to the geriatrician and oncologist. Cervical cancer almost never occurs in older patients who have followed screening guidelines and have had a history of normal Pap smears prior to age 70. Early stage disease is best managed by radical surgery. While radical pelvic surgery has been proven safe in selected older patients, the current management of early cervical cancer depends upon the resources available to the geographical location. For locally advanced cervical cancer and early stage patients who are not surgical candidates, radiation therapy with concurrent platinum-based chemotherapy is the standard of care. Radiation therapy and chemotherapy can be safely administered to older patients once allowances are made for age-related physiologic changes. Advanced age should not be used as justification to alter the standard of care for the management of cervical cancer.

Key words: cervical cancer, older adults, chemotherapy, radiation therapy, radical pelvic surgery.

Kaposi’s Sarcoma: Diagnosis and Treatment

Irving E. Salit, MD, Director of Immunodeficiency Clinic, Division of Infectious Diseases, Toronto General Hospital; Associate Professor, University of Toronto, Toronto, ON.

Kaposi’s sarcoma (KS) is a malignancy closely associated with human herpesvirus-8 (HHV-8). KS occurs in immunocompromised subjects—those with HIV infection or after immunosuppressive therapy—but it also occurs without obvious immune deficiency (older men of Mediterranean origin or in central Africans). The incidence of KS in Acquired Immunodeficiency Syndrome (AIDS) has markedly decreased in recent years. Treatment depends on the predisposing condition and the extent of disease. Common management options include no therapy, reversal of immunosuppression, local radiation, and systemic chemotherapy.

Key words: Kaposi’s sarcoma, malignancy, HIV, AIDS, transplant.