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.

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.

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.

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.

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.

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.

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

J. A. Maroun, MD, Medical Oncologist, Integrated Cancer Program, The Ottawa Hospital; Professor of Medicine, University of Ottawa, Ottawa, ON.

Colorectal cancer is one of the most common cancers in Canada. In the last decade, there has been significant progress in the management of this disease. Improved understanding of the pathophysiology of colorectal cancer has resulted in the development of more prevention and screening strategies. Adjuvant therapy in high-risk patients has led to an increase in cure rates. For years, 5-fluorouracil was the only drug available for metastatic disease; now, new and effective drugs have been developed, with opportunities for effective second- and third-line therapies as well as new combinations. This has led to an increase in the median survival of patients from six months to over 20 months. Ongoing research with new agents—in particular, biologically targeted drugs—will undoubtedly lead to further improvement in the outcome of this disease.

Key words: colorectal cancer, 5-fluorouracil, colonoscopy, chemotherapy, radiation.

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.

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.

Tara Morrison, MD and James R. Perry, MD, Crolla Family Brain Tumour Research Unit, Division of Neurology, Sunnybrook and Women's College Health Sciences Centre; University of Toronto, Toronto, ON.

Primary brain tumours are most commonly diagnosed in elderly individuals and the incidence of these uniformly fatal malignancies is on the rise. Recent studies have shown that the most common of these tumours, the glioblastoma multiforme, is genetically different in elderly compared to younger patients. Current research studies exploiting the genetic differences of these tumours as anti-cancer targets hold promise for the immediate future. At present the focus of brain tumour treatment is excellent supportive care. Radiation treatment and chemotherapy are being actively revisited to maximize quality of life. In addition, complications such as venous thromboembolism, seizures and therapy-induced adverse effects have received much attention and are reviewed in this article.
Key words: brain neoplasms, glioblastoma multiforme, palliative care, chemotherapy.