Pauline T. Truong, MDCM, FRCPC, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Rohit Pai, BSc, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Ivo A. Olivotto, MD, FRCPC, Radiation Therapy Program, Vancouver Island Centre, British Columbia Cancer Agency and the University of British Columbia, Victoria, BC.

Breast conserving surgery (BCS) and postoperative radiation therapy (RT) achieve local control and survival equal to mastectomy in women with early stage breast cancer. The incidence of breast cancer increases with age and the number of older women in Canada continues to rise, but the under-representation of older women in BCS trials limits the evidence on which to base optimal therapy decisions. This article reviews breast conservation in older women, with a focus on the necessity of radiation therapy. Multiple randomized trials with and without age subgroup analyses demonstrate that RT after BCS should be considered standard therapy. A low-risk subset in whom radiation therapy may be omitted without compromising local control has not been defined. In women with early breast cancer, age alone should not preclude treatment that optimizes local control. Efforts to include representative samples of older breast cancer subjects in modern clinical trials with endpoints that include cancer control, survival, function, and quality of life are needed.

Key words: age, breast conserving surgery, breast cancer, breast conservation, radiotherapy.

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.

Barbara-Ann Millar MB ChB, FRCR, Clinical Fellow, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON.

Normand Laperriere MD, FRCPC, Associate Professor, Department of Radiation Oncology, Princess Margaret Hospital/University Health Network, University of Toronto, Toronto, ON

Radiation therapy is commonly used in the management of intracranial malignancies. Although the effects on the developing brain have been extensively documented, the impact of this treatment modality on the older brain requires further investigation. The effect of radiation treatment, the intracranial lesion, and associated comorbidities and medications all influence the individual’s overall outcome. This review looks at the pathophysiology of radiation injury within the brain and its impact on cerebral irradiation in older patients.

Key words: radiotherapy, older brain, tumour, neurocognitive effects.

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.

Amit Morris, BSc, School of Medicine, Queen's University, Kingston, ON; Department of Psychiatry, Sleep and Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Colin M. Shapiro, MBBCh, PhD, FRCP(C), Department of Psychiatry, Sleep and
Alertness Clinic, Toronto Western Hospital, University of Toronto, Toronto, ON.

Insomnia is very common among older adults and may have serious consequences. The assessment of insomnia can be challenging, given the number of possible causes and the fact that insomnia is often not a presenting complaint. Inquiring about patients’ sleep and performing a thorough evaluation of any concerns will allow a rational and targeted approach to treatment.

Key words: insomnia, sleep, older adults, aging, diagnosis.

Roger Y. Wong, BMSc, MD, FRCPC, Division of Geriatric Medicine, University of British Columbia, Vancouver Hospital & Health Sciences Centre, Vancouver, BC.

Palpitations are common in ambulatory older people and have a variety of causes. The correlation of palpitations and cardiac arrhythmias is poor. Basic assessment, which includes history taking, physical examination, 12-lead electrocardiogram (ECG), and laboratory data, is necessary but may not be sufficient to diagnose the underlying problem. Ambulatory ECG monitoring can be helpful, depending on the frequency of the palpitations. Continuous-loop event monitors are cost-effective in diagnosing palpitations, and the optimal duration of monitoring is two weeks. The overall clinical outcomes of patients with palpitations are favourable, with low mortality but high recurrence risk.

Key words: palpitations, arrhythmias, assessment, cardiac, older adults.

Anna T. Monias, MD, Erickson Retirement Communities, Oak Crest Village, Parkville, MD.

Kenneth S. Boockvar, MD, MS, Assistant Professor, Brookdale Department of Geriatrics and Adult Development, Mount Sinai School of Medicine; Investigator, Program of Research on Serious Physical and Mental Illness, Bronx Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, New York, NY.

Acute illness often presents atypically in long-term care patients. Atypical presentation refers to the lack of one or more symptoms or signs that usually indicate acute illness. Due to underlying medical illness, nursing home patients with acute infection, metabolic disorders, and even surgical emergencies frequently present with delirium, malaise, or weakness. Nursing assistants are often the first to recognize these non-specific indicators. It is imperative that researchers include assessments by nursing assistants when developing and validating tools to recognize early but atypical indicators of disease.

Key words: long-term care facility, atypical presentation, delirium, nursing assistants, non-specific symptoms.

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

Peter Pommerville, BA, MD, FRCS(C), Director of Research, Can-med Clinical Research, Inc.; Consulting Urologist, Vancouver Island Health Authority,
Vancouver, BC.

Abstract:Sildenafil was introduced in Canada in 1998 as the first effective oral therapy for erectile dysfunction (ED). Since its release, sidenafil has been proven to be an effective and safe treatment for ED in older patients with multiple medical problems. In the last year, two new PDE5 inhibitors have been approved for ED treatment: vardenafil and tadalafil. There are subtle differences between the three phosphodiesterase type 5 (PDE5) inhibitors with respect to efficacy, dosing instructions, and adverse event profiles. All three PDE5 inhibitors have exhibited efficacy and safety in the cardiac patient as long as he is not reliant upon the regular use of nitroglycerine. This article reviews the similarities and differences between the three PDE5 inhibitors, and refers to patient attitudes in Canada towards sexual activity and its treatment with these agents, as discussed in the Canadian Sexual Satisfaction Survey (CSSS).

Key words: Erectile dysfunction, phosphodiesterase inhibitor, sildenafil, vardenafil, tadalafil

Introduction
Physicians in Canada are treating an increasingly aging population, and coupled with this is an increase in the incidence of specific diseases that may arise as a result of the breakdown of biological mechanisms (e.

David F. Mobley, MD, Department of Urology, Memorial City Hospital, Houston, TX, USA.
Neil Baum, MD, Associate Clinical Professor of Urology, Tulane Medical School, New Orleans, LA, USA.

Abstract
Benign Prostatic Hyperplasia (BPH) is a pervasive condition associated with the aging process. Causes of BPH include stimulation of the alpha receptors located in the prostate gland and bladder neck, or an increase in epithelial cell proliferation, resulting in enlargement of the prostate gland and subsequent passive compression of the urethra. Medical treatment consists of alpha-blockers or 5-alpha-reductase inhibition. This article will review the evaluation and the medical treatment for patients with mild to moderate BPH and provide suggestions for urologic referral.

Key words: BPH, prostate, alpha blockers, 5-alpha-reductase inhibitors, PSA.