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.

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.

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.

Two studies, recently published in the New England Journal of Medicine, have suggested a role for radiation therapy in the treatment of restenosis. Every year, thousands of patients undergo balloon angioplasty to open clogged arteries. In 60% of these cases, physicians also insert a stent to keep the artery propped open. Unfortunately, in 35% of cases, restenosis occurs and the patient has to undergo another angioplasty or a bypass operation. Both studies investigated the use of placing radioactive materials into the arteries for a short period of time, and then removing them. Where the studies differ is in the type of radiation that is used. In the first study, the researchers used beta radiation, considered safer because it does not penetrate past the body of the patient. In the second study, gamma radiation was used, and health-care workers had to be shielded.

In the study of beta radiation, 181 patients were treated who had undergone angioplasty for the first time. Once the blockage had been cleared, a radioactive coil was inserted into the artery and was subsequently removed, after a few minutes. Patients were given heart scans six months later and it was found that restenosis had occurred in only 29% of patients who had received the lowest dose of radiation, and in 15% of those who had received a dose that was two times as high.

In the second study, patients had already undergone a previous angioplasty procedure. In 131 patients, after undergoing a new angioplasty, a tiny ribbon containing gamma radiation was inserted and was removed after 20 minutes. In another 121 patients, the procedure was replicated with an identical looking ribbon that contained no radiation. At 6 months post-procedure, 28% of the patients in the radiation treatment group had restenosis, as compared to 44% in the comparison group. Unfortunately, several months after the procedure, 5% of radiation patients developed dangerous blood clots, as compared to only 1% in the control group.

The technique would mean that many patients could be spared bypass surgery or repeated angioplasties, but is obviously associated with several caveats. Further studies with larger numbers of patients are required before any definitive conclusions can be made regarding the effectiveness of the technique. In addition, the possible development of cancers, as a side effect of the radiation treatment in these patients, is of major concern.

Sources

1. Verin, V et al. Endoluminal Beta-Radiation Therapy for the Prevention of Coronary Restenosis after Balloon Angioplasty. NEJM 2001;344:243.
2. Leon, MB et al. Localized Intracoronary Gamma-Radiation Therapy to Inhibit the Recurrence of Restenosis after Stenting. NEJM 2001;344:250.