Abstract

The incidence of cancer among older adults continues to rise, presenting unique challenges in oncological care. Comprehensive geriatric assessment (CGA) has emerged as a pivotal tool in evaluating the multidimensional health status of elderly cancer patients. It encompasses domains such as functional status, comorbidities, cognition, psychological health, nutrition, social support, and polypharmacy. Evidence suggests that CGA can identify previously unrecognized health deficits, stratify patients by risk, and inform tailored interventions that enhance quality of life and reduce treatment-related morbidity. Implementation of geriatric assessment into oncology practice can foster a more understanding of patient needs, promote shared decision-making and optimize resource allocation, and transform cancer management by aligning therapeutic strategies with the patient’s overall health profile, values, and goals. CGA guides individualized cancer treatment decisions, predicting treatment tolerance, and improving clinical outcomes.

Keywords:Geriatric Assessment; Frail; Cancer; Challenges; Immunization

Abbreviations:GA: geriatric assessment; CGA: comprehensive geriatric assessment; GAM: geriatric assessment and management; ACP: advance care planning; SIOG: International Society of Geriatric Oncology

Introduction

Geriatric assessment (GA) is defined as a multi-dimensional, interdisciplinary diagnostic process designed specifically for older adults to evaluate the medical, psychological, functional capability and socioenvironmental factors of a frail or chronically ill older person to develop a coordinated, integrated care plan for treatment [1]. GA is a cost-effective approach that prevents inadequate treatment and minimizes the inappropriate use of costly oncologic therapies. By minimizing adverse events, it reduces overall healthcare expenditures and enhances access to better quality care. However, its implementation in clinical practice is still limited [2].

The American Society of Clinical Oncology (ASCO) and the International Society of Geriatric Oncology (SIOG) guidelines for practical assessment and management of vulnerabilities in older patients receiving chemotherapy recommend evaluating the following health-related domains during GA: functional status, comorbidities, cognitive function, mental health status, fatigue, social functioning and support, nutritional status, mobility, presence of geriatric syndromes [1], and medications [3]. Each of these domains is assessed using specific tools and questionnaires [1].

Comprehensive domain coverage is prioritized over the use of multiple tools within each domain. The selection of assessment tools should be guided by the available local resources and clinical expertise [3]. Geriatric assessment also provides a valuable opportunity to identify older adults who have not received recommended vaccinations [4]. Patients older than 60 years account for 60% of tetanus cases and over 90% of influenza-related deaths. Additionally, the morbidity of pneumonia and zoster markedly increases after 65 years of age [4].

Which patients to assess?

According to the ESMO/SIOG Cancer in the Elderly Working Group, the following patients should be considered for geriatric assessment:

1. Individuals aged 70 years and older, (65 years when feasible), who are considered for cancer-directed therapies, particularly systemic treatment. The physiological reserves and treatment tolerance start to diminish above this age cutoff playing a role in treatment choice. However, patients younger than 70 years can be extremely frail, whereas very old people can still be fit [2].

2. Assessment should ideally be performed prior to the commencement of the treatment plan and again before its finalization, when feasible.

3. If comprehensive geriatric assessment and management (GAM) cannot be implemented for all patients, validated screening tools should be employed to identify individuals most likely to benefit from a full GAM evaluation.

4. GAM models provided to cancer patients should be adapted to align with the available local resources, clinical settings, and staffing capacity.

5. Assess chemotherapy-related toxicity in older adults with cancer, utilizing established tools such as the Cancer and Aging Research Group (CARG) score or the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) (3).

Models to deliver geriatric assessment and management (GAM) in clinical practice

The appropriate GAM models delivered to elderly cancer patients are.

The Traditional Gold Standard Model of Care

It consists of a comprehensive multidisciplinary clinic conducted at a single time point and location. During this single visit, patients receive GA from either a geriatrician or geriatric oncologist, oncologic treatment planning from the primary oncologist and a range of supportive care services, including dietitians, pharmacists, physical/occupational therapists, and social workers. This model reduces the need for multiple clinic visits and facilitates continuous follow-up to address evolving needs throughout the treatment journey. However, its implementation is typically restricted to centers with substantial resources and specialized personnel [3]. Several alternative models have emerged to deliver GAM guided by the available local resources and clinical expertise [3].

High Resource Setting (Geriatric Oncologist or Geriatrician and Oncologist are Available)

A two-step consultative model where an oncologist initiates a geriatric screening tool [e.g. Geriatric 8, Vulnerable Elders Survey-13, Senior Adult Supplement Screening Questionnaire (SAOP3)] then patients at higher risk are referred to geriatrician or geriatric oncologist for evaluation where a traditional or shared-care model can be implemented [3].

Moderate Resource Setting (Geriatrician and Oncologist Are Available)

In the shared-care model, patients are co-managed by separate visits to a geriatrician and an oncologist, possibly at different times. The geriatrician conducts the GA, while the oncologist carried out the oncologic assessment. An interdisciplinary team, including referrals to additional support services, collaborates to develop a comprehensive care plan. This model places a higher burden on patients and caregivers due to multiple visits [3].

Low or More Limited Resource (Oncologist is Available),

Geriatric screening tools may be utilized solely to facilitate selected management decisions (e.g. cancer-directed treatment versus specific non-oncologic intervention).

In any of the models, innovative strategies such as telehealth or video-assisted GA should be considered [3].

Practice Recommendations for Subsequent Management of Geriatric Conditions:

General Recommendations [4]

i. Do not prescribe a medication without conducting a drug regimen review.

ii. Avoid premature diagnosis of dementia in older adults presenting with altered mental status and/or symptoms of confusion. Always evaluate delirium or delirium superimposed on dementia using a brief, sensitive, validated assessment tool before confirming a diagnosis.

iii. Avoid prescribing appetite stimulants or high-calorie supplements for the treatment of anorexia or cachexia in older adults; instead, enhance social engagement, discontinue medications that may suppress appetite, offer visually appealing and palatable meals, provide feeding assistance when needed, and clarify the patient’s personal goals and expectations.

Immunization recommendations [4]

i. Administer annual influenza vaccination.

ii. Pneumococcal vaccination: the 13-valent pneumococcal conjugate vaccine (Prevnar 13) is administered at 65 years of age followed by the 23-valent pneumococcal polysaccharide vaccine (Pneumovax 23) one year later.

iii. Herpes zoster vaccination: two doses of recombinant herpes zoster vaccine (Shingrix) are administered two to six months apart for immunocompetent adults 50 years or older.

iv. Tetanus, diphtheria, and pertussis vaccination: a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine is administered in individuals over 65 years, and the tetanus and diphtheria toxoids (Td) booster vaccine every 10 years thereafter.

Post-Assessment

Following the completion of the assessment, the problem list should be revised to include any newly identified geriatric syndromes. Care plans should be adjusted to reflect the patient’s individual goals, preferences, and evolving clinical needs [4].

Advance care planning (ACP)

ACP is a vital component of the comprehensive geriatric assessment (CGA), particularly for older adults experiencing frailty, chronic illness, or cognitive decline. It is about patient goals and decisions for future medical care, including preferences for preventive care and decisions regarding life-sustaining treatments as their health evolves. GA offers an opportunity to discuss medical care goals priorities such as prolonging life, maintaining independence, preventing illness, relieving suffering, and maximizing time with family and friends. Understanding these goals should inform specific treatment plans. ACP becomes especially critical in the context of dementia, where partial decision-making capacity may still be present. Several evidencebased tools are available to support and engage older adults in shared decision making [4].

Challenges in delivering geriatric assessment (GA) for older adults with cancer [2]

Implementing GA for older adults with cancer can present multiple challenges. These include patient-specific factors—such as physical, cognitive, or psychosocial limitations. Additionally, effective collaboration between the oncology team and the GA team can be complex.

Time Demands of Comprehensive GA (CGA): conducting a full CGA typically requires a significant time investment, ranging from 30 to 120 minutes on average. This duration can pose logistical challenges in busy clinical settings, especially when resources are limited.

Variability in assessment models: A range of screening instruments has been developed to support GA in oncology, including the Groningen Frailty Indicator, the G8 screening tool, and the Vulnerable Elders Survey. These tools, along with their respective cutoff values, are detailed on resources such as the SIOG website, the Senior Adult Oncology Guideline, and the Consulter platform of the Hartford Institute for Geriatric Nursing (http:// consultgerirn.org). While SIOG has issued guidance on the use of screening instruments, it does not endorse any single screening instrument.

Resource Limitations of GA: Given that approximately 60% to 70% of newly diagnosed cancer patients are older adults, the demand for CGA far exceeds current capacity. Due to limited resources—such as time, trained personnel, and infrastructure-it may not be feasible to provide a full GA for every older patient. Prioritization strategies or targeted screening tools may be necessary to identify those who would benefit most from a detailed evaluation.

Importance of Assessment Location for Older Adults: the setting in which assessments are conducted plays a critical role in ensuring accessibility and comfort for older adults. Many elderly individuals experience vision and/or hearing impairments, along with physical or cognitive limitations. Travel to multiple or unfamiliar locations for evaluation can impose unnecessary hardship, potentially affecting the accuracy and completeness of the assessment. Whenever possible, assessment should be conducted in environments that are familiar, accessible, and tailored to the specific needs of older patients.

Scheduling Consideration for Elderly Patients with Caregiver Support: early morning appointments may pose significant challenge for elderly patients who rely on caregivers for assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs)-such as dressing, mobility, and transportation. Therefore, scheduling appointments later in the morning or early afternoon may better accommodate both the patient’s needs and the caregiver’s logistics [2].

Conclusion

Geriatric assessment (GA) is not just a diagnostic tool. It delivers effective, and individualized cancer care to older adults. GA enables clinicians to tailor oncologic treatment to the individual’s physiological reserve and personal goals. Incorporating GA into oncology practice promotes better quality of life. Despite its proven benefits, widespread implementation remains limited due to resource constraints and variability in clinical settings. However, emerging models-including telehealth and tiered screening approaches-offer promising pathways to expand access.

References

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3. Loh KP, Liposits G, Arora SP, Neuendorff NR, Gomes F, et al. (2024) Adequate assessment yields appropriate care-the role of geriatric assessment and management in older adults with cancer: a position paper from the ESMO/SIOG Cancer in the Elderly Working Group. ESMO Open 9(8): 103657.
4. Paul E Tatum Iii, Shaida Talebreza, Jeanette S Ross (2018) Geriatric assessment: an office-based approach. American Family Physician 97(12): 776-784.