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.

Julie Lemieux, MD, MSc, FRCPC, Adjunct Professor, Department of Medicine, Université Laval, Centre des maladies du sein Deschênes-Fabia, Centre d’hématologie et d’immunologie clinique, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.
Louise Provencher, MD, MA, FRCSC, Associate professor, Department of Surgery, Université Laval, Centre des maladies du sein Deschênes-Fabia, Unité de recherche en santé des populations, Hôpital St-Sacrement du Centre Hospitalier affilié de l’Université Laval, Québec, QC.

A large proportion of breast cancers in older women have positive hormone receptors. Therefore, these women are eligible to receive adjuvant endocrine therapy to decrease their chance of cancer recurrence. Over the last few years, a new class of endocrine therapy, aromatase inhibitors (AIs), has challenged the place of tamoxifen as the gold standard adjuvant endocrine agent. We will discuss randomized clinical trials comparing tamoxifen to AIs in terms of efficacy and side effects.
Key words: breast cancer, tamoxifen, aromatase inhibitors, side effects, quality of life.

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

Christine B. Brezden-Masley, MD, PhD, Staff Physician, Department of Medicine, St. Michael’s Hospital; Assistant Professor, Department of Medicine, University of Toronto, Toronto, ON.
Maureen Trudeau, BSc, MA, MD, Acting Regional Vice President, Cancer Services--Clinical; Head, Division of Medical Oncology/Hematology, Sunnybrook & Women’s College Hospital Sunnybrook Campus; Head, Systemic Therapy Program, Toronto Sunnybrook Regional Cancer Centre; Associate Professor, Department of Medicine, University of Toronto, Toronto, ON.

Breast cancer is the most common cause of cancer mortality in women over 65 years of age. Older women with breast cancer are usually understaged and undertreated as a result of factors such as significant patient comorbidities, patient preferences, age-biases, and poor cognition. Furthermore, women over the age of 70 have been excluded from many breast cancer clinical trials, making treatment conclusions difficult. Patients’ characteristics (including age and comorbidities) should be considered when deciding on the final treatment, a decision ideally made by both the treating physician and the patient. This review will discuss current treatment strategies for breast cancer patients, with a focus on the older population.
Key words: breast cancer, older adults, staging, systemic chemotherapy, radiotherapy.

Anne-Chantal Braud, Institut Paoli Calmettes, Marseille, France,
Martine Extermann, MD, H. Lee Moffitt Cancer Center and Research Institute and the University of South Florida, Tampa, FL,USA.

Half of breast cancers occur in patients older than 65 and 25% in patients aged 75 or older. Prevention and early diagnosis are a societal but also an individual issue in this population. Good guidelines for screening and prevention are available for patients up to 70, but few data are available for older patients. The present article reviews these data in an effort to provide some guidance to geriatricians and primary physicians about screening and prevention of breast cancer in their older patients. Age alone should not be used to determine when to screen; rather, life expectancy estimates can help decision-making. Patients with a life expectancy of 10 years or more are likely to benefit from mammography screening. Very few data are available for tamoxifen prevention in women older than 70. There is a need for further randomized controlled trials to clarify a host of outstanding issues in improving the prevention and the care of breast cancer in older people.
Key words: older women, breast cancer, mammography, prevention.

A recent study has suggested that Raloxifene may be more effective in preventing breast cancer in women with higher levels of estradiol. It has previously been shown that the risk for breast cancer increases with increased levels of endogenous estradiol. Scientists hypothesized that raloxifene, which competes with estradiol for binding to estrogen receptors in breast tissue, might have a greater effect on breast cancer risk in women with relatively high estradiol levels. They analyzed data from the Multiple Outcomes of Raloxifene Evaluation (MORE) trial, conducted in 7,290 women (80 or younger) with osteoporosis. Serum estradiol concentrations were measured by a central lab. They found that in the placebo group, women with estradiol levels greater than 10 pmol/L (2.7 pg/mL) had a 6.8-fold higher rate of breast cancer than did women with undetectable estradiol levels. Women with estradiol levels greater than 10 pmol/L in the raloxifene group had a rate of breast cancer that was 76% lower when compared to that of women in the placebo group with similar levels of estradiol. In contrast, women with undetectable levels of estradiol had similar breast cancer risk whether or not they were treated with raloxifene. If confirmed, this suggests that measuring estradiol and treating women with high estradiol levels could substantially reduce the rate of breast cancer among postmenopausal women.

Source

1. Cummings SR, Duong T, Kenyon E, et al. Serum estradiol level and risk of breast cancer during treatment with raloxifene. JAMA. 2002;287:216-20.

Is there a Role for Primary and Secondary Prevention Strategies?

Ruth E Heisey, MD, CCFP, FCFP
Assistant Professor,
University of Toronto,
Family physician and Clinical Associate,
Department of Surgical Oncology,
Sunnybrook and Women's Health Science Centre, and
Princess Margaret Hospital Site,
University Health Network,
Toronto, ON.

H Lavina A Lickley, MD, PhD, FRCSC, FACS
Professor of Surgery and Physiology,
University of Toronto,
Surgeon (special interest in Breast Disease),
Women's College Campus of Sunnybrook and Women's College Health Science Centre,
Toronto, ON.

"Old age is like everything else. To make a success of it, you've got to start young."¹ Fred Astaire

Breast cancer is the most common cause of cancer death in women over the age of 65.² Between the ages of 30 and 80 years, the annual incidence of breast cancer rises from 1:5900 to 1:290.^3,4 It has been estimated that by the year 2030, almost two-thirds of women with a diagnosis of breast cancer will be 65 years of age or older.⁵

The incidence of breast cancer among Canadian women has been rising steadily over the past decade, probably due in part to improved detection with mammographic examinations.

Marilyn Schneider, Ph.D.
Executive Director,
Canadian Breast Cancer Research Initiative

Breast cancer is, in large part, a disease of aging in women. It is a disease of genes gone awry. Although a small proportion of women are born with an inherited mutant BRCA1 or BRCA2 gene that immediately puts them at very high risk for breast cancer, these inherited mutations account for only 5-10% of breast cancer cases. In most breast cancers, the woman accumulates sporadic gene mutations throughout her lifetime, and when appropriate combinations of these mutations accumulate in the woman's breast cell, she has the beginning of a breast cancer tumour.

One out of every 9.5 Canadian women is now expected to develop breast cancer sometime in her lifetime. This, however, is the lifetime risk, and this risk is known to increase with age. What is more relevant to an older woman is the probability that she will develop breast cancer over the next decade. A 60-year-old woman's probability of getting breast cancer before age 70 is 2.9% or 1 in 34; a 70-year-old woman's probability is 3.2% or 1 in 31.¹ Breast cancer is primarily a disease of older women, with only 22% of breast cancer cases occurring in women under age 50, 45% occurring in women aged 50-69, and 32% occurring in women aged 70 and over.²

On the one hand, the incidence of breast cancer has risen slowly but steadily over the past three decades, particularly for those women aged 50-69 and over the age of 70.

Olya Lechky

Two Toronto hospitals--The Princess Margaret and Mount Sinai--have the distinction of being on the cutting edge in the early detection of breast cancer.

These two pre-eminent institutions in the study, diagnosis and treatment of breast cancer are the first centres in North America to have installed full field digital mammography systems. At a recent press conference, experts hailed General Electric's Senographe 2000D as the single biggest breakthrough in mammography during the past 30 years. This claim is based on over 8,000 clinical studies performed on five prototype machines during the past decade. "Digital mammography represents a milestone in the diagnosis of breast disease and it will soon replace conventional mammography all over the world," said Dr. Patrice Brett, professor of radiology at the University of Toronto.

While conventional film mammography has been of great benefit in the screening and diagnosis of breast disease, the technique has always had inherent limitations, said Dr. Karina Bukhanov, head of the division of breast imaging, joint department of breast imaging, University Health Network and Mount Sinai Hospital. "Digital mammography will bring breast cancer diagnosis into the digital age, enabling all the benefits of modern computer technology and software to be applied to the fight against cancer," she said.

In digital mammography an electronic detector replaces the traditional film screen.

Lilia Malkin, BSc

Breast cancer has the dubious distinction of being the most frequently diagnosed neoplasm and the second leading cause of cancer deaths in Canadian women today. Since the incidence of breast cancer increases with age, its appropriate diagnosis, management, and prevention are highly important in the geriatric population.

Epidemiology
A widely quoted statistic is that one in nine Canadian women will develop breast cancer in her lifetime, while one in twenty-five will die from it. The National Cancer Institute of Canada (NCIC) estimates that 18,700 Canadian women will be diagnosed with breast cancer and that 5,400 will succumb to it in 1999. In Ontario alone, more than 7,000 new cases are reported and approximately 2,000 women die each year. Although breast cancer affects men as well as women, male patients make up less than one percent of all cases. In 1994, when nearly 16,000 Canadians were diagnosed with breast cancer, only 97 of them were male.

Breast cancer remains a significant contributor to morbidity and mortality in the female geriatric population. More than 50% of breast cancer patients are older than 65 at diagnosis. According to NCIC's 1999 estimates, 6,000 of the new breast cancer cases will occur in Canadian women aged 70 and over.