Geriatric oncology is becoming increasingly important as population aging represents one of the most significant demographic transformations of the twenty-first century. According to the United Nations, the number of individuals aged 65 years and older is expected to more than double over the coming decades, driven by increased life expectancy and declining fertility rates (1). As populations age, chronic non-communicable diseases are becoming the predominant cause of morbidity and mortality worldwide, making geriatric oncology an increasingly important field in modern cancer care (1,2). Because aging is the strongest risk factor for most malignancies, the growing number of older adults is expected to substantially increase the global burden of cancer, particularly in low and middle-income countries, where health systems often lack adequate geriatric oncology infrastructure (3).
More than 60% of newly diagnosed cancers and approximately 70% of cancer-related deaths occur in individuals aged 65 years or older. Despite this epidemiological reality, older adults remain consistently underrepresented in clinical trials, resulting in limited evidence to guide therapeutic decisions for this highly heterogeneous population. Chronological age alone poorly reflects biological reserve, functional capacity, or treatment tolerance, making individualized assessment essential in geriatric oncology (3,4).
Cancer in older adults presents unique diagnostic challenges. Symptoms are frequently attributed to physiological ageing or pre-existing chronic diseases, leading to delayed diagnosis and more advanced disease at presentation (3). In addition, older patients are less likely to undergo screening procedures or receive comprehensive diagnostic workups because of frailty, multimorbidity, disability, cognitive impairment, or perceived limited life expectancy (4,5). Consequently, underdiagnosis and undertreatment remain common, contributing to poorer outcomes and increased mortality (5,6). Conversely, overtreatment may also occur when treatment decisions rely exclusively on chronological age without considering functional reserve or patient goals (4,7).
The management of older patients with cancer is one of the central challenges in modern geriatric oncology. Beyond tumor stage and molecular characteristics, treatment decisions should integrate functional status, multimorbidity, polypharmacy, nutritional status, cognition, psychological health, social support, life expectancy, and patient preferences. Frailty has emerged as one of the strongest predictors of chemotherapy toxicity, postoperative complications, treatment discontinuation, institutionalization, and mortality (6,7). Systematic reviews indicate that more than half of older adults with cancer exhibit pre-frailty or frailty, reinforcing the importance of routine frailty assessment before initiating oncologic therapy (4,7).
Several validated screening instruments — including the Geriatric-8 (G8), Vulnerable Elders Survey-13 (VES-13), Clinical Frailty Scale (CFS), and Fried Frailty Phenotype — can rapidly identify vulnerable patients who should undergo a Comprehensive Geriatric Assessment (CGA). Furthermore, prognostic tools such as the ePrognosis platform allow estimation of life expectancy based on validated mortality prediction models, supporting individualized treatment decisions by balancing expected survival, competing risks of death, and the potential benefits and harms of cancer therapy. These prognostic estimates are particularly valuable when considering invasive procedures, chemotherapy, immunotherapy, radiotherapy, or cancer screening in very old adults with multiple comorbidities (7).
Special consideration should be given to patients with dementia and other neurocognitive disorders. Dementia is increasingly prevalent in ageing populations and frequently coexists with cancer. Cognitive impairment may compromise informed consent, adherence to treatment, recognition of adverse events, and communication of symptoms (3,4). Furthermore, individuals with dementia often present with more advanced-stage malignancies and experience lower rates of guideline-concordant treatment. Decision-making in this population requires careful assessment of disease severity, functional trajectory, caregiver availability, life expectancy, and the individual’s previously expressed values and goals of care. Incorporating caregivers into shared decision-making is essential to optimize both treatment outcomes and quality of life (3,4,5).
Comprehensive Geriatric Assessment (CGA) has become the cornerstone of modern geriatric oncology. CGA is a multidimensional, interdisciplinary process that evaluate functional capacity, cognition, mood, nutrition, mobility, comorbidity, medication use, social support, and geriatric syndromes. Several studies have demonstrated that CGA identifies vulnerabilities not detected during routine oncologic evaluation. It predicts treatment toxicity and mortality, improves treatment selection, reduces unnecessary interventions, and facilitates individualized supportive care (3,4). Current ASCO guidelines recommend that all patients aged 65 years and older receiving systemic cancer therapy undergo geriatric assessment, with identified impairments guiding targeted interventions throughout the cancer care continuum (2). Within geriatric oncology, the benefits of CGA extend beyond treatment selection. Findings obtained during assessment support the implementation of prehabilitation strategies—including nutritional optimization, physical exercise, medication review, cognitive stimulation, psychological support, and management of comorbidities before cancer treatment begins. Throughout therapy, periodic geriatric reassessment enables early recognition of functional decline, treatment-related toxicity, delirium, malnutrition, falls, and caregiver burden, allowing timely interventions that improve treatment completion, preserve independence, and enhance quality of life. Rehabilitation following surgery, chemotherapy, or radiotherapy similarly plays a fundamental role in restoring physical function and maintaining autonomy among older cancer survivors (6,7,8).
The Brazilian scenario reflects the global epidemiological transition but presents additional challenges. Brazil is experiencing one of the fastest ageing processes worldwide while simultaneously facing increasing cancer incidence and marked regional inequalities in healthcare access. The coexistence of population ageing, limited availability of geriatricians, delayed cancer diagnosis, socioeconomic disparities, and unequal access to specialized oncology services creates substantial barriers to optimal care. Although CGA is recommended by international guidelines, its implementation remains limited in many Brazilian institutions because of workforce shortages, time constraints, and resource limitations (8). Nevertheless, expanding multidisciplinary geriatric oncology programs represents a critical opportunity to improve treatment personalization, reduce avoidable complications, and promote healthy ageing among Brazilian older adults with cancer (8,9).
In this context, integrating CGA, frailty evaluation, prognostic tools such as ePrognosis, and multidisciplinary prehabilitation and rehabilitation into routine oncologic practice represents a fundamental strategy for optimizing therapeutic decision-making (7,8). Rather than focusing exclusively on chronological age or tumor characteristics, modern geriatric oncology aims to deliver individualized, evidence-based, and value concordant care that maximizes survival while preserving functional independence, cognition, quality of life, and dignity throughout the cancer journey (9).
Written By Silmara Moura, MD, Geriatrician
REFERENCES
1. United Nations. World Population Prospects 2024. New York: United Nations; 2024.
2. Soto-Perez-de-Celis E, et al. Geriatric Assessment: ASCO Global Guideline. JCO Glob Oncol. 2025.
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6. Soto-Perez-de-Celis E, et al. Global geriatric oncology: achievements and challenges. J Geriatr Oncol. 2017;8(5):374-86.
7. ePrognosis. UCSF Division of Geriatrics. Available from: https://eprognosis.ucsf.edu
8. Melo RC, et al. Prevalence of Frailty in Brazilian Older Adults: A Systematic Review and Meta-analysis. J Nutr Health Aging. 2020;24(7):708-16.
9. Oliveira MRF, et al. Implications of comprehensive geriatric assessment on quality of life in older adults with cancer: an integrative review. Rev Bras Geriatr Gerontol. 2021;24(1):e200297.