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.

Cherdchai Nopmaneejumruslers, MD, Senior Clinical and Research Fellow, Division of Respirology, University of Toronto, Toronto, ON.
Charles K.N. Chan, MD, FRCPC, FCCP, FACP, Head, Division of Respirology, University Health Network, Mount Sinai Hospital, Sunnybrook & Women's College Health Sciences Centre, University of Toronto, Toronto, ON.

A diagnostic dilemma of a solitary pulmonary nodule (SPN) is a common clinical problem in the older population. Most pulmonary nodules are discovered incidentally on chest radiographs. Signs and symptoms are rarely present until the disease has become advanced and unresectable. Therefore, a timely and accurate diagnosis of the etiology of an SPN in early stage is essential to provide an excellent prognosis following surgical resection. Based on the best evidence, the algorithm presented in this article was made to provide the clinician with a clinical management pathway of the solitary lung nodule in older adults.
Key words: solitary pulmonary nodule, lung cancer, PET scan, diagnostic workup, VATS.

Yaron Shargall, MD and Michael R. Johnston, MD, FRCSC, Division of Thoracic Surgery, Department of Surgery, University of Toronto; Division of Thoracic Surgery and Department of Surgical Oncology, Toronto General and Princess Margaret Hospitals, Toronto, ON.

Introduction
Lung cancer is the leading cause of cancer death in Canada and the Western world. In the year 2001, it is estimated that 21,200 people in Canada will be diagnosed with lung cancer, and approximately 18,500 people will die as a result.¹ Despite extensive research and clinical efforts, the survival rate has not changed appreciably over the past 30 years and remains poor, with an overall five-year survival of about 13%.² Lung cancer is predominantly a disease of the elderly, since more than 60% of all lung cancer cases occur in people older than 60 years.³ There is overwhelming experimental and epidemiological data to support the contention that cigarette smoking is the primary risk factor for the development of lung cancer. Of all lung cancers in Canada, 85% are directly attributable to smoking, and another 3% may be caused by second-hand smoking.⁴ In this article, we summarize the current status of lung cancer screening and treatment, with special emphasis on the elderly population.

Screening for Lung Cancer
Lung cancer screening studies have not clearly demonstrated a reduction in mortality.

Shechar Dworski, BSc

Lung cancer is the most common cause of cancer-related deaths in both men and women, accounting for 34% of cancer-related deaths in men, and 22% in women. Lung cancer survival rates are dismal: the five-year survival rate is 14% for all cases of lung cancer, and the median survival is less than half a year for untreated patients. The lung cancer mortality rate in the United States is approximately 50 in 100,000, 68% of which occur in people over 65 years of age. Lung cancer mortality in the elderly is rising, which may be due to the aging of the population. Between 1968 and 1983, there was an 8.2% annual growth in mortality in white women 54 to 74 years old. The mortality rates in males seemed to reach a plateau in the 1980's, or may even be declining, possibly due to a decrease in the cigarette smoking by men from 67% in the 1950's, to 28% presently in the United States.

Over one half of all cases of lung cancer are reported in people aged 65 and over. Men aged 65 years and over have an incidence of lung cancer three times higher than men age 45 to 64. This trend is thought to be related to increased lifetime exposure to tobacco smoke and other carcinogens. The rate of lung cancer has risen dramatically in the last 70 years, accounting for 18% of all cancer cases in men, and 12% in women.