This review examined leading international geriatric oncology practice guidelines, including the International Association of Geriatric Oncology (SIOG) 2014, SIOG Screening Tools Update 2014, National Comprehensive Cancer Network (NCCN) 2025, American Society of Clinical Oncology (ASCO) 2023, The European Society for Medical Oncology (ESMO)/SIOG 2025, and ASCO Global 2025, to specifically delineate areas of convergence and divergence. This analysis aimed to highlight critical inconsistencies that influence clinical decision-making and propose directions for future research. Particular emphasis is placed on how heterogeneity in assessment strategies and intervention frameworks may influence feasibility, implementation, and patient outcomes across a range of health care system and resource settings. Analysis demonstrated universal agreement that multidomain geriatric assessment (GA) is essential for evaluating functional status, cognition, nutrition, psychological health, social support, polypharmacy, and the risk of treatment-induced morbidities. GA-guided interventions are consistently emphasized to reduce treatment toxicity, improve advanced care planning and quality of life outcomes. However, significant divergence was identified across the recommended tools, screening strategies, age cut-off for GA, recommended clinical interventions and the use of non-cancer specific life expectancy data. Most guidelines cited evidence from high-income countries, limiting generalizability of their recommendations regarding GA to other settings. Few guidelines provide recommendations based on cost-effectiveness analyses or implementation research, nor do they address patient or caregiver perspectives systematically. Awareness of the differences and gaps in existing geriatric oncology guidelines may aid clinicians and policymakers to choose an appropriate GA strategy that is recommended by the guidelines, while accounting for resource constraints, patient characteristics and treatment contexts. Future research should focus on standardizing framework for collecting essential geriatric oncology data to allow pooled data analysis, harmonization of a universally accepted, minimum core set of GA components, the development of consensus-based, resource-stratified intervention models that incorporate patient and caregiver perspectives, and leveraging technology to enhance patient care.
INTRODUCTION:Rising life expectancy has led to an increasing number of older adults diagnosed with cancer, yet this population remains under-represented in clinical research that informs oncologic care. Consequently, treatment decisions for older adults are often made with limited age-specific evidence. This study aimed to understand how older adults navigate decisions not to initiate disease-directed oncologic treatment, in order to inform communication and shared decision making in geriatric oncology. MATERIALS AND METHODS:We conducted a qualitative study using semi structured, in-depth interviews with adults aged 65 years and older who chose not to initiate oncologic treatment following a cancer diagnosis. Fifteen interviews were conducted between September 2023 and May 2025. Interviews were audio recorded, transcribed verbatim, and analyzed using reflexive thematic analysis. RESULTS:Participants aged 65-95 years described a coherent decision-making process centered on avoidance of suffering. Three themes shaped this process: Acceptance of death, expressed in rational, spiritual, or life course terms, framed non-initiation as a meaningful option; personal illness-related experience shaped understanding of treatment implications; and a strong sense of decisional agency guided choices aligned with participants' values and priorities. Together, these elements supported a deliberate choice not to initiate treatment. DISCUSSION:Older adults who decline disease directed oncologic treatment describe a considered, values-based decision-making process rooted in life experience and identity. Conceptualizing non initiation as an active process may support more attuned clinical communication and contribute to discussions of decision quality in aging populations.
INTRODUCTION:As the number of adults aged ≥80 undergoing cancer surgery increases, predicting postoperative outcomes remains difficult. Traditional risk tools often fail to capture psychosocial and subjective health factors, contributing to the so-called "black box effect"-unexplained variation in outcomes despite similar clinical profiles. Emerging evidence suggests that wellbeing, symptom burden, and loneliness may influence recovery and survival, yet these factors are rarely assessed preoperatively. Our primary objective was to examine associations between baseline functional, psychosocial, and symptom-related characteristics and postoperative outcomes in cognitively intact adults aged ≥80 years undergoing elective cancer surgery. A secondary objective was to characterize functional independence and psychosocial health in this patient population. MATERIALS AND METHODS:In this prospective single-center pilot study, 55 patients consented between 2018 and 2021, of whom 51 with a Montreal Cognitive Assessment (MoCA) score > 25 were included. Participants underwent structured preoperative assessments covering cognitive function (MoCA), functional independence (Barthel Index), symptoms (Edmonton Symptom Assessment System [ESAS]), psychosocial factors (Sense of Coherence Scale, loneliness, Social Provision Scale, Self Transcendence Scale, Geriatric Depression Scale), and health-related quality of life (HRQoL) (RAND-12). Clinical data, surgical characteristics, postoperative complications (Clavien-Dindo II-V), length of stay (LOS), and overall survival (OS) were recorded. Multivariable logistic, linear, and Cox regression models were used to examine independent associations between candidate variables and postoperative outcomes. RESULTS:Most patients demonstrated high baseline functioning, low depressive symptoms, and preserved HRQoL. Nonetheless, 24% reported frequent loneliness. Postoperative complications occurred in 45% of patients, and 18% experienced major complications. Lower ESAS wellbeing scores independently predicted postoperative complications (OR 1.32 per point). Longer LOS was associated with complications, surgical approach, and frequent loneliness, the latter corresponding to approximately 60% longer LOS. Five-year OS was 71% for localized disease, 41% for locally advanced disease, and 13% for metastatic disease. In the final Cox model, increasing age, locally advanced disease, and frequent loneliness (HR 3.56) independently predicted reduced OS. DISCUSSION:Poorer self-rated wellbeing and frequent loneliness were independently associated with adverse postoperative outcomes, including complications, prolonged hospital stay, and reduced survival, even in this functionally robust older surgical population. As a pilot study, these findings are hypothesis-generating and require validation in larger, adequately powered cohorts before informing clinical practice.
INTRODUCTION:Frailty assessment is essential in managing the care of older patients with multiple myeloma, as frailty influences treatment tolerability and clinical outcomes. The Simplified Frailty Scale is widely used due to its simplicity; however, its binary classification-non-frail (scores of 0 and 1) vs. frail (scores of 2-5)-may not fully capture the heterogeneity within the frail group. We aimed to refine the Simplified Frailty Scale by further stratifying frail patients into moderate and severe frailty subgroups. MATERIALS AND METHODS:We retrospectively analyzed 313 patients aged ≥70 years with newly diagnosed multiple myeloma (110 in the training cohort and 203 in the validation cohort). RESULTS:Based on overall survival in the training cohort, we identified optimal cutoff scores for moderate (scores of 2 and 3) and severe (scores of 4 and 5) frailty. In the validation cohort, the median overall survival was not reached for non-frail patients, while it was 4.0 years for moderate-frail and 1.2 years for severe-frail patients. Multivariate analysis confirmed the three-class Simplified Frailty Scale classification as an independent prognostic factor (hazard ratio: 2.35). Additionally, the incidence of serious adverse events increased with the frailty level. DISCUSSION:These findings support the clinical utility of the refined Simplified Frailty Scale in predicting prognosis and treatment-related toxicity in older patients with multiple myeloma, especially in real-world settings.
INTRODUCTION:To support the clinical interpretation of individual patients' health-related quality of life, this study aimed to define thresholds for clinical importance (TCIs) for the seven scales of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Elderly-14 (EORTC QLQ-ELD14). MATERIALS AND METHODS:In this prospective, cross-sectional study, older patients (≥70 years) with mixed cancer diagnoses completed the validated EORTC QLQ-ELD14 alongside an anchor questionnaire. These anchors assessed the clinical importance of scale scores relying on three criteria: limitations in daily life, the need for help/care, and the worries of patients and their partner/family. By categorizing patients based on these anchors, receiver operating characteristic (ROC) curve analysis was used to develop TCIs. RESULTS:Data from 251 patients across seven European countries (mean age: 77.2 years; 53.8% female) were analysed. For five of the seven generated TCIs, the EORTC QLQ-ELD14 scales exhibited sensitivity values ranging from 0.75 to 0.91 and specificity values ranging from 0.74 to 0.90 (area under the curve >0.80). The Maintaining Purpose scale showed fair discrimination (area under the curve [AUC] = 0.73). The diagnostic accuracy of the Family Support scale was insufficient to define a meaningful threshold (AUC = 0.60). DISCUSSION:This study provides TCIs for six of the seven EORTC QLQ-ELD14 scales with sufficient diagnostic accuracy. However, the TCI for the Maintaining Purpose scale is not suitable for interpretation at the patient level.
INTRODUCTION:Thirty percent of patients with colorectal cancer (CRC) are aged 75 years or older. Despite advances in cancer treatment, complications may arise, impacting patients' quality of life. Physical exercise has shown benefits for cancer-related health outcomes. However, perioperative exercise recommendations for patients with CRC are often inadequate or poorly understood, limiting their participation. This qualitative study aimed to explore the perceived barriers and facilitators to engagement in physical exercise among older adults with CRC scheduled for elective surgery during the perioperative period. MATERIALS AND METHODS:Patients aged ≥75 years with a diagnosis of CRC awaiting elective surgery were purposively sampled from a tertiary referral hospital in Madrid, Spain. Semi-structured individual telephone interviews were conducted, audio-recorded and transcribed verbatim. Data were analyzed using Braun and Clarke's six-phase thematic analysis. RESULTS:Sixteen participants (7 women, mean age 84.8 ± 6.2 years) were included. Three main themes emerged: (1) CRC diagnosis impacts emotion and nutrition among older adults, who described feelings of discouragement and loss of appetite; (2) Multiple barriers across life domains limit exercise engagement in older adults with CRC, including lack of awareness, pain, and low physical function; and (3) Tailored support and autonomy facilitate exercise participation in older patients with CRC, highlighting a preference for home-based exercise guided by written materials rather than digital formats. DISCUSSION:Older adults with CRC preparing for elective surgery face multiple interrelated barriers and facilitators to engaging in physical exercise. These findings highlight the need for tailored, home-based exercise programs supported by clear written guidance and professional supervision.
INTRODUCTION:The American Society of Clinical Oncology guidelines recommend geriatric assessment (GA)-guided interventions to inform care for older adults with cancer. GA-guided intervention delivery to lower-resourced settings has been limited. We assessed the feasibility of implementing GA-guided supportive care (GAIN-S) via telehealth in a lower-resourced setting. MATERIALS AND METHODS:A quality improvement study was conducted in a low-resourced community oncology practice in the Mojave Desert. Eligible participants were 65+ years with a diagnosis of cancer, newly initiating care at the clinic. At baseline, patients completed: GA, SupportScreen, and the Fulmer SPICES assessment. A geriatric oncology nurse practitioner (GNP) reviewed GA results and implemented GAIN-S via telehealth between April 2020 and January 2023. Key outputs measured included: number of patients who completed GAIN-S; number of referrals to supportive care services and completion rate; and patient satisfaction with telehealth visits. Participants' demographics, distance traveled for care, type of cancer, stage, treatment, and telehealth satisfaction items were summarized using descriptive statistics. To evaluate the implementation process, run charts were utilized. RESULTS:A total of 253 patients (median age 72, 62% non-Hispanic White, 22% lived 60+ miles from the clinic, 40% had stage III or greater, 30% received chemotherapy) completed assessments. Two hundred forty-two had initial visits with the GNP, 197 via tele-video, and 45 via telephone for a total telehealth encounter participation rate of 96%. The GNP reviewed vulnerabilities with 231 patients and generated 483 accepted referrals for supportive care services, of which over 88% of services were completed. The highest numbers of accepted referrals were to pharmacy (177), social work (154), occupational therapy (79), and physical therapy (55). Over 92% of patients were satisfied with telehealth-based GAIN-S for ease of visit, access to care with their provider, and telehealth use. DISCUSSION:Telehealth-based GAIN-S is feasible and acceptable, providing accessible healthcare to older patients with cancer in a lower-resourced community setting. This approach highlights telehealth delivery of GAIN-S in our clinical enterprise and has implications for other such settings.
INTRODUCTION:Treatments for advanced and metastatic cancer can cause fatigue and accelerate the progression to frailty, a condition that increases vulnerabilities to stressors. Time-restricted eating (TRE) entails consuming food within a defined time window every day. TRE may help strengthen circadian rhythms and improve physiology. We present findings from a pilot study assessing the feasibility of TRE, when aligned with the daytime hours, as well as measures of fatigue, frailty, diurnal rhythms, and physiological responsiveness among people living with cancer. MATERIALS AND METHODS:Participants were eligible if they were ≥ 55 years old and had prostate cancer receiving androgen deprivation therapy (ADT) or metastatic breast cancer receiving CDK4/6 inhibitors plus an aromatase inhibitor. All participants met with a licensed dietitian/nutritionist and were provided with personalized nutrition counseling fortnightly for 12 weeks. After baseline assessments, participants were randomized 1:1 to TRE, with a self-selected 10-h eating window, or control. The primary outcomes were retention and adherence. Secondary outcomes included fatigue (FACIT-F fatigue subscale), frailty (Fried's frailty criteria), rest-activity rhythms using actigraphy, 24-h urinary hormone fluctuations (e.g., cortisol, melatonin, epinephrine, norepinephrine; dynamic range assessed as maximum-minimum), and orthostatic blood pressure change. For future hypothesis generation, effect of group was assessed using linear regression; correlations between outcomes were assessed using linear mixed models controlling for relevant confounding factors. RESULTS:Participants (n = 30, 93% male) were 68.8 ± 6.4 years old (range 57.4-81.0 y); 24 were randomized and 20 completed the intervention (83.3% retention). The average eating window was 11.6 ± 2.4 h at baseline (all participants). From weeks 1-12, the average eating window was 9.2 ± 1.4 h for the TRE group and 13.3 ± 1.5 for the control group (t-test, p < 0.001). There were no between-group effects for fatigue, frailty, or rhythm measures (p > 0.05). However, relative amplitude of rest-activity rhythms was associated with less fatigue (b ± SE = -6.3 ± 2.8, p = 0.03). Also, frailty was negatively associated with the dynamic range in urinary norepinephrine (b ± SE = -0.033 ± 0.016, p = 0.06). DISCUSSION:TRE is a feasible nutritional program for older adults living with cancer. A greater dynamic range of several circadian rhythm parameters was associated with better supportive care outcomes, suggesting that entrainment of circadian rhythms may help alleviate fatigue and frailty. A larger, phase II preliminary efficacy study is warranted. TRIAL REGISTRATION:NCT05968144.
INTRODUCTION:Cognitive impairment is common in older adults with cancer but often remains undetected due to time constraints and limited specialized resources in routine oncology care. We evaluated whether a 2-min cognitive screener predicts all-cause mortality in this population and explored whether functional dependence mediates this association. MATERIAL AND METHODS:We conducted a longitudinal study of consecutive patients aged ≥60 years with cancer who were referred for geriatric oncology assessment at a tertiary outpatient cancer center in Brazil. Cognitive status was assessed using the 10-point Cognitive Screener (10-CS), a brief clinical tool that evaluates orientation, memory, and verbal fluency. Cognitive impairment was defined as 10-CS scores ≤5. We used Cox proportional hazards models to examine the association between 10-CS scores and 3-year all-cause mortality, as well as sociodemographic factors, comorbidities, cancer type, metastasis, and sensory deficits. Harrell's C-index was calculated to assess whether adding 10-CS improved mortality discrimination. Mediation analysis incorporated activities of daily living (ADLs) dependence. RESULTS:Among 508 patients (mean age = 78.0 ± 7.1 years; female = 42.5%), 224 (44.1%) had cognitive impairment. Of these, 87 (38.8%) had no previous cognitive impairment documented in their medical records. Three-year mortality was higher among patients with impairment (63.6% vs 37.4%, p < 0.001). After adjustment, cognitive impairment remained strongly associated with mortality (HR = 1.87; 95% CI: 1.38-2.54). Adding 10-CS to the model with sociodemographic, comorbidities, and cancer variables improved mortality discrimination (Harrell's C-index 0.72 vs. 0.68; p = 0.01). The 10-CS stratified mortality across subgroups defined by the absence (40.0% vs. 62.9%; p < 0.001) or presence (25.1% vs. 63.6%; p < 0.001) of previous chart-documented cognitive impairment or dementia. Cognitive impairment was associated with dependence in ADL (adjusted prevalence ratio = 4.01; 95% CI = 2.57-6.25). Disability mediated part of the effect on 3-year all-cause mortality, but 62% remained unexplained, indicating that most of the association was independent of functional decline. DISCUSSION:Cognitive impairment evaluated with the 10-CS predicted 3-year all-cause mortality in older adults with cancer. This brief clinical tool provided valuable prognostic information beyond standard oncology measures and may assist clinicians in identifying high-risk patients whose cognitive impairment might otherwise go unrecognized.
