Robin McLeod, MD, Division of General Surgery, Mount Sinai Hospital, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, ON.
Selina Schmocker, Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.
Erin Kennedy, MD, PhD, Division of General Surgery, University Health Network, University of Toronto; Department of Health Policy, Management and Evaluation, University of Toronto; Zane Cohen Digestive Diseases Clinical Research Centre; Toronto General Research Institute, University Health Network, Toronto, ON.

Colorectal cancer is the third most common cancer worldwide, and more than half of those newly diagnosed with colon cancer are over the age of 70 years. Despite the large proportion of patients over the age of 70 diagnosed with colon cancer annually, this age group is significantly underrepresented in clinical trials and, therefore, there is little high-quality evidence on which to base treatment decisions or treatment guidelines. This article reviews the management of primary colon cancer in older adults, including screening, presentation and diagnosis, treatment, and follow-up in this population.
Key words: colon cancer, colorectal cancer, screening, tumour, older adults.

The incidence of colorectal cancer increases with age, with approximately 60% of patients in the US (and similar numbers in Canada) older than 65 years at diagnosis and 40% over the age of 75. As highlighted by McLeod et al in this issue, the management of older patients with colorectal cancer is challenging. The prevailing difficulty is the lack of randomized trial data to support and guide treatment decisions. Pivotal trials establishing the standard of care for this disease have tended to enroll younger patients. For example, the median age of patients enrolled in phase III studies of systemic chemotherapy for metastatic colorectal cancer is commonly 60-64 years,1,2 with fewer than 20% of patients being 70 years and older. In the large colorectal screening studies, older patients are again under-represented, with only 15-17% of randomized patients being 70 years or older.3, 4 Similarly, elderly patients are less likely to be enrolled in surgical trials than younger patients.5 With this absence of prospective data, evidence regarding safety and efficacy of interventions in older patients with colorectal cancer has come mainly from subgroup analyses or meta-analyses of large randomized clinical trials, both in the adjuvant and metastatic disease settings. These analyses suggest that older patients gain similar benefit from chemotherapy as do younger patients, with little difference in the rates of severe toxicity.6 This should be reassuring to clinicians.  The relation between age and outcomes from colorectal cancer surgery is more complex, however. Poorer outcomes in terms of postoperative morbidity and mortality are reported with increasing age, but these are confounded by presentation with more advanced disease stage, a greater frequency of emergency surgery and fewer curative surgeries compared to younger patients.7 All of these analyses suffer from selection bias with patients in these studies generally being fit and of good performance status. Data from randomized studies will ultimately help optimize management of older patients with colorectal cancer. However, careful consideration should be given to the design of these studies.  A growing appreciation of the heterogeneity of this patient population has led to a better understanding and use of geriatric specific assessments. These assessments which evaluate functional status, comorbid medical conditions, cognitive function, psychological state, and social supports may have value in predicting postoperative complications following surgery and may help better predict tolerance to systemic therapies. Incorporation of these assessments into both the clinical trial setting and daily clinical practice is encouraged but challenging due to time constraints in busy practices. Identifying elder-specific clinical predictors of tolerability to various interventions will ultimately lead to a more tailored approach for these patients. The essential principles of managing colon cancer in the elderly are the same as in younger patients, however, as the authors state, an individualized approach is necessary. Frameworks for determining a patient’s remaining life-expectancy, risks of toxicities and operative complications, and quality of life issues must be developed and should ultimately underlie these individualized decisions. No competing financial interests declared. References: 1.    Goldberg RM, Sargent DJ, Morton RF et al. A randomized controlled trial of fluorouracil plus leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated metastatic colorectal cancer. J Clin Oncol 2004; 22: 23-30. 2.    Seymour MT, Maughan TS, Ledermann JA et al. Different strategies of sequential and combination chemotherapy for patients with poor prognosis advanced colorectal cancer (MRC FOCUS): a randomised controlled trial. Lancet 2007; 370: 143-152. 3.    Hardcastle JD, Chamberlain JO, Robinson MH et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 1996; 348: 1472-1477. 4.    Mandel JS, Bond JH, Church TR et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. Minnesota Colon Cancer Control Study. N Engl J Med 1993; 328: 1365-1371. 5.    Stewart JH, Bertoni AG, Staten JL et al. Participation in surgical oncology clinical trials: gender-, race/ethnicity-, and age-based disparities. Ann Surg Oncol 2007; 14: 3328-3334. 6.    Kumar A, Soares HP, Balducci L, Djulbegovic B. Treatment tolerance and efficacy in geriatric oncology: a systematic review of phase III randomized trials conducted by five National Cancer Institute-sponsored cooperative groups. J Clin Oncol 2007; 25: 1272-1276. 7.    Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group. Lancet 2000; 356: 968-974.

Kristen L. Currie, MA, CCRP, Department of Surgical Oncology, Division of Urology, Princess Margaret Hospital, University Health Network (UHN), Toronto, ON.
Sheri Stillman, RD, Clinical Nutrition, Allied Health, Princess Margaret Hospital, UHN, Toronto, ON.
Susan Haines, RD, Clinical Nutrition, Allied Health, Princess Margaret Hospital, UHN, Toronto, ON.
John Trachtenberg, MD, FRCSC, FACS, Department of Surgical Oncology, Division of Urology, Princess Margaret Hospital, UHN, Toronto, ON.

Older adults represent the highest percentage of new cancer diagnoses each year. This, combined with the increasing age of the population, underscores the importance of identifying methods for risk reduction. The World Cancer Research Fund, together with the American Institute for Cancer Research, has published recommendations for cancer prevention through diet and physical activity. These guidelines should be considered when counselling patients in cancer prevention. In this article, colorectal, breast, and prostate cancers are highlighted, and nutritional recommendations for these cancers are presented.
Key words: nutrition, prevention, colorectal cancer, breast cancer, prostate cancer.

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.

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.

Sheldon Singh, BSc

Colorectal cancer is the second leading cause of cancer death in North America and Western Europe. This disease tends to occur mainly in older individuals. Early-stage disease is curable in more than 80% of patients. Unfortunately, more than 55% of patients present late with evidence of lymphatic or distant metastases. There is now compelling evidence that screening of average risk individuals over 50 can identify disease at a more curable stage thereby allowing for more effective management and subsequent reduction in mortality.

Epidemiology
Cancer of the colon and rectum kills more Canadians than any other cancer with the exception of lung cancer. During their lifetime, women have a 1 in 18 chance of developing colorectal cancer while men a 1 in 16 chance. This year, the disease is expected to affect 16,600 Canadians (with roughly 93% occurring in people over age 50) and claim 6,300 lives (with roughly 95% occurring after age 50). Rates of colorectal cancer in Canada have been declining, particularly among women. This may be due to changes in diet as well as the casual use of screening techniques.

Risk Factors
Age is a major risk factor for developing colorectal cancer. Approximately 75% of colorectal cancers are sporadic and without any identifiable risk factors other than age. Colorectal cancers are rare before 50 and over 90% are diagnosed after 60.