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.

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.

Joel B. Epstein, DMD, MSD, FRCD(C), University of Illinois, College of Dentistry, Department of Oral Medicine and Diagnostic Sciences and Chicago Cancer Center, and Advocate Illinois Masonic Medical Center, Chicago, Il.

Harvey Wigdor, DDS, MS, University of Illinois, College of Dentistry, Department of Oral
Medicine and Diagnostic Sciences and Chicago Cancer Center, and Advocate Illinois
Masonic Medical Center, Chicago, Il.

Oropharyngeal cancer is a disease of adults and has a higher risk of occurrence with increasing age. In addition, oral complications of cancer therapy are more frequent and may be more severe in older patients. The prevention and treatment of oral complications of cancer therapy, with an emphasis on older adults, are reviewed in this report.

Key words: oropharyngeal, cancer, palliation, radiation, side effects.

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.

E. Rand Simpson, MD, Associate Professor of Ophthalmology, University of Toronto; Director, Ocular Oncology, Princess Margaret Hospital, Toronto, ON.
Larry Ulanski II, MD, Ocular Oncology Fellow, University of Toronto, Princess Margaret Hospital, Toronto, ON.

Ocular malignancies in the elderly are often difficult to diagnose and manage. The five main cancers found in association with the eye are basal, squamous and sebaceous cell carcinomas, uveal melanoma and malignant cancers to the orbit. These include malignancies from breast, lung, GI, prostate and myelogenous proliferations. This article briefly reviews the most common forms of ocular cancer and brings the general practitioner up to date on the most current data from the Collaborative Ocular Melanoma Study (COMS). We use clinical photos to demonstrate specific clinical signs of cancerous disease. By maintaining a high level of suspicion when treating patients with acute visual symptoms, unnecessary morbidity and mortality may be avoided.
Key words: ophthalmology, cancer, radiotherapy, malignancy.

D'Arcy Little, MD, CCFP, Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Fellow in Care of Elderly at Baycrest Centre, Toronto, ON.

Prevalence of Smoking in the Elderly
Smoking is one of the major causes of morbidity and mortality in Canada. In fact, it has been called the leading preventable cause of death in North America.¹ This is because smoking is a known risk factor for four of the leading causes of death in the industrialized world--coronary heart disease, cancer, lung disease and stroke--and because it contributes to many other causes of morbidity.² While the current prevalence of smoking in Canadians aged 15 years and older declined by 10.3% between 1985 and 1999, the numbers remain high for both men and women (26.8% and 22.9%, respectively, in 1999).³ In those aged 65 and older, current smoking prevalence decreased by 8.9% over the same time period. However, it is estimated that 11.6% of seniors continue to smoke. The prevalence of smoking is highest in the Atlantic provinces and Quebec, and lowest in Saskatchewan and Ontario.⁴

Impact of Smoking on Health of the Elderly

Mortality
The health-related impact of smoking in the elderly is manifold. The increase in mortality has already been mentioned.

June M. Chan, ScD, Assistant Adjunct Professor, Departments of Epidemiology & Biostatistics and Urology, University of California, San Francisco, CA, USA.

Prostate cancer is the most commonly diagnosed cancer and is second only to lung as the most fatal cancer among men in the United States. It is the ninth most common cancer in the world, with higher rates predominating in North America, Europe and Australia, and lower rates reported in Hong Kong, Japan, India and China. The main non-modifiable risk factors include age, race and family history.

The incidence of prostate cancer increases exponentially with age, with men age 75-79 experiencing an incidence rate more than 100-times greater than that of men age 45-49 (age-specific prostate cancer incidence rate for men age 75-79 = 1400/100,000 person-years; for men age 45-49 = 11/100,000 person-years).¹

African Americans have the highest recorded age-standardized rates in the world, estimated at 137 cases per 100,000 persons in 1997 according to Surveillance, Epidemiology, and End Results (SEER) data.² In contrast, the rate among Caucasians in the U.S. was 101/100,000. Europeans tended to have rates in the range of 20-50 cases/100,000.

Stefan Glück^1,2 MD, PhD and Christine Friedenreich³ PhD
¹Professor, Dept. Oncology, Medicine and Pharmacology & Therapeutics Faculty of Medicine, University of Calgary, Calgary, AB.
²Senior Leader, Clinical Research Program Medical Oncologist, Tom Baker Cancer Centre, Calgary, AB.
³Research Scientist, Division of Epidemiology, Prevention and Screening, Alberta Cancer Board, Calgary, AB.

Introduction
In 1996, the most recent year for which complete statistics for Canadian cancer incidence are available, a total of 118 new cases of breast cancer were diagnosed in men.¹ This incidence rate is approximately 0.7% of the 16,551 cases diagnosed in women.¹ This proportion of male to female breast cancers is typical of western populations, although exceptionally high proportions of male to female breast cancers have been found in countries such as Egypt and Zambia, with studies reporting 6% and 15%, respectively.^2,3

In many aspects, the disease has a similar clinical course in both genders. However, because male breast cancer is so rare, it has been very difficult to accumulate knowledge through research, especially through large prospective trials. Many aspects of the diagnosis and treatment of male breast cancer remain controversial and even in the future, clinical research will be difficult.

Peter G. Rossos MD, FRCP(C)
Elaine Yeung MD
Division of Gastroenterology, University Health Network
University of Toronto, Toronto, ON.

Introduction
Colorectal cancer (CRC) is the third most common cause of cancer and second leading cause of cancer death in Canada. It is estimated that there were 17,200 new cases and 6,400 deaths from colorectal cancer in Canada in 2001. When both women and men are considered together, colorectal cancer is the second most frequent cause of death from cancer among Canadians.¹ Most CRC occurs in average risk individuals for whom there are no accepted guidelines for screening.² Higher risk categories include those who have a family history of CRC, a personal history of CRC, colonic adenomas or inflammatory bowel disease, and the familial syndromes including familial adenomatous polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC).³ This discussion will focus on average risk older adults, who comprise almost all CRC cases in patients 65 years of age or older.

Epidemiologic Considerations
Although age-standardized incidence and mortality rates have been declining for CRC since 1985, the number of new cases has continued to rise steadily and significantly among both men and women as a result of the growth and aging of the population. Recent data from the National Cancer Institute of Canada is displayed in Figures 1 and 2.