The aging population is rapidly growing, with the number of older adults rising steadily each year. In the 1980s, experts predicted a rise in the number of older patients with cancer, yet we were unprepared. The shortage of oncologists, along with many experienced clinicians retiring early, has left us struggling to meet the demand. Additionally, medical education in geriatrics and oncology has not kept up.
Thankfully, a small group of dedicated researchers and clinicians recognized the challenge early on and started educational programs, formed networks, and pushed research to develop Geriatric Oncology. Although it is not yet an official subspecialty, the changing demographics mean that all adult oncologists are, in effect, geriatric oncologists.1 We are now at a crucial crossroads in the field, where important decisions must be made. With so many factors at play, including government policies, Medicare and Medicaid funding, limited research resources, and rising care costs, it’s essential to focus our efforts where they will have the most impact.
“Ensuring that older patients with cancer receive appropriate, evidence-based treatment requires ongoing research, enhanced clinician education, and sustained advocacy efforts.”— STUART M. LICHTMAN, MD, FASCO
Tweet this quote
Geriatric oncology is a rapidly evolving field, driven by the increasing number of older adults diagnosed with cancer. As the global population ages, the demand for specialized cancer care tailored to the unique physiologic and functional needs of older patients has become more critical. Over the past 40 years, significant strides have been made in understanding and optimizing cancer treatment for elderly patients. However, despite advancements, many challenges remain. They include the integration of geriatric assessments, the refinement of treatment strategies, and the need for increased clinical trial participation among older adults.1,2
A Retrospective Glance
The history of geriatric oncology dates back to the 1980s, when oncologists and geriatricians recognized the growing burden of cancer in aging populations. During this time, it became evident that older patients with cancer had distinct needs, requiring a more comprehensive approach to treatment planning.
By the 1990s, principles of geriatric medicine were integrated into oncology through the development and application of the comprehensive geriatric assessment (CGA). This multidisciplinary assessment allowed for a more thorough evaluation of an older patient’s functional status, comorbidities, cognitive function, and social support systems. It was also recognized that in the 2000s, clinical trials began incorporating older patients using CGA-based studies, leading to more precise and individualized treatment plans.
During the 2010s, these assessments became instrumental in predicting treatment toxicity and outcomes, ultimately enhancing clinical decision-making. More recently, advances in immunotherapy, chimeric antigen receptor T-cell therapy, antibody-drug conjugates, and other targeted treatments have reshaped the therapeutic possibilities for older adults, offering more favorable risk-benefit profiles than traditional cytotoxic chemotherapy.
Milestones in Geriatric Oncology
Several key milestones have marked the progress of geriatric oncology. The U.S. National Institute on Aging first recognized cancer and aging as a critical issue in the 1980s, leading to the organization of dedicated research initiatives. In 1994, international meetings on geriatric oncology were initiated under the leadership of Dr. Lodovico Balducci, laying the foundation for global collaboration in this field. A year later, the Cancer and Leukemia Group B, a major cooperative research group in the United States, established a dedicated committee for cancer in older patients, reflecting a growing commitment to addressing the unique challenges faced by this demographic.3
The formation of the International Society of Geriatric Oncology (SIOG) in 2000 further solidified efforts to promote research and education in the field. By 2006, the Cancer and Aging Research Group (CARG) was established in the United States, spearheaded by Dr. Arti Hurria, whose contributions significantly shaped the landscape of geriatric oncology research before her untimely passing in 2018.
In 2011, CARG published a pivotal study in the Journal of Clinical Oncology identifying predictors of chemotherapy toxicity in older adults4—an achievement that has since been validated in multiple studies. More recently, in 2015 and 2017, ASCO released statements emphasizing the need for more research and clinical trial participation among older adults, urging modifications to eligibility criteria to facilitate their inclusion.3,5-7 In the past few years, multiple randomized studies have demonstrated the benefit of some geriatric assessments in terms of reduced toxicity and improved quality of life.7 Clinical trial results should be reported comprehensively to allow correct interpretation and enable the results to be transferable to practice.8
Geriatric Assessments: Challenging but Imperative
Despite these advancements, the implementation of geriatric assessments remains a significant challenge in routine oncology practice. Many clinicians find themselves uncertain about which assessment tools to use, how to interpret the results, and whether conducting these evaluations is feasible within the constraints of a busy practice.
Although a full CGA provides the most comprehensive insights, it is not always necessary for every patient. Instead, simplified tools such as the Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), the G8 screening tool, and the Timed Up and Go test offer practical, time-efficient alternatives that can still yield valuable information. Clinicians should be encouraged to incorporate these assessments into their practice gradually, selecting tools that align with their specific practice setting and patient population. The practical geriatric assessment published by ASCO is an excellent starting point.1
Incorporating geriatric assessments into clinical trials is also imperative to ensure accurate interpretation of treatment outcomes in older adults. Unfortunately, barriers such as funding limitations, insufficient physician education, and inadequate ancillary support have hindered the widespread adoption of these assessments. Many components of geriatric assessments, however, can be self-administered by patients or completed with caregiver assistance, making their implementation more feasible in both research and clinical settings. ASCO’s practical geriatric assessment provides a structured framework for evaluating older patients, though some adaptation may be necessary to accommodate the realities of busy oncology clinics.1
Pharmaceutical Support and Organizational Collaboration
Another major roadblock in geriatric oncology is the limited support from the pharmaceutical industry. Even though older patients represent the majority of individuals receiving cancer treatment, geriatric-specific oncology research remains underfunded. This lack of investment translates to inadequate data on the efficacy and safety of new treatments in older adults, ultimately compromising their access to optimal therapies.
Additionally, traditional clinical trial endpoints such as overall survival may not fully capture the priorities of older patients, who often value quality of life, functional independence, and reduced treatment toxicity as much as—if not more than—prolonged survival. Clinical trials should integrate patient-reported outcomes to better align research objectives with patient preferences and needs.9 Government support for clinical trials is now unpredictable, and the future of the National Institutes of Health and the National Cancer Institute is uncertain.
Furthermore, collaboration across various oncology organizations is crucial to advancing the field. Instead of working in silos, research groups should streamline their efforts, foster data-sharing, and coordinate recruitment strategies to improve clinical trial participation among older adults. In the United States, cooperative groups such as the Alliance, NRG Oncology, and ECOG-ACRIN should work together more cohesively to maximize research efficiency and reduce redundancy. A unified approach will accelerate scientific progress and enhance research findings to real-world clinical practice.
Looking Ahead
The future of geriatric oncology will be shaped by the continued integration of personalized medicine, targeted therapies, and interdisciplinary collaboration. Advances in molecular profiling and genomic analysis will enable more precise treatment selection, and improved geriatric assessment tools will help tailor interventions to individual patient needs. Additionally, the contributions of nurses, patient advocates, and allied health professionals will remain crucial components in optimizing the care of older adults with cancer.
Although geriatric oncology has made substantial progress over the past 40 years, significant work remains to be done. Ensuring that older patients with cancer receive appropriate, evidence-based treatment requires ongoing research, enhanced clinician education, and sustained advocacy efforts. By working together, the oncology community can continue to refine assessment strategies, expand treatment options, and ultimately improve outcomes for this growing patient population. This large, vulnerable patient population needs to be the focus of our endeavors. They deserve nothing less.
DISCLOSURE: Dr. Lichtman reported no conflicts of interest.
REFERENCES
- Dale W, Klepin HD, Williams GR, et al: Practical assessment and management of vulnerabilities in older patients receiving systemic cancer therapy: ASCO guideline update. J Clin Oncol 41:4293-4312, 2023.
- Mohile SG, Dale W, Somerfield MR, et al: Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 36:2326-2347, 2018.
- Alliance Cancer in the Older Adult Committee; Adjei A, Buckner JC, Cathcart-Rake E, et al: Arti Hurria, MD: A tribute to her shining legacy in the Alliance for Clinical Trials in Oncology. J Geriatr Oncol 11:179-183, 2020.
- Hurria A, Togawa K, Mohile SG, et al: Predicting chemotherapy toxicity in older adults with cancer: A prospective multicenter study. J Clin Oncol 29:3457-3465, 2011.
- Hurria A, Levit LA, Dale W, et al: Improving the evidence base for treating older adults with cancer: American Society of Clinical Oncology statement. J Clin Oncol 33:3826-3833, 2015.
- Kim ES, Bruinooge SS, Roberts S, et al: Broadening eligibility criteria to make clinical trials more representative: American Society of Clinical Oncology and Friends of Cancer Research joint research statement. J Clin Oncol 35:3737-3744, 2017.
- Mohile SG, Mohamed MR, Xu H, et al: Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): A cluster-randomised study. Lancet 398:1894-1904, 2021.
- Lichtman SM: Missed opportunities in geriatric oncology research. Oncologist 28:373-375, 2023.
- Colbert JA, Potters L: Overcoming barriers to make patient-reported outcome collection the standard of care in oncology. JAMA Oncol 11:233-234, 2025.
Dr. Lichtman is Attending Physician (retired) at Memorial Sloan Kettering Cancer Center, Commack, New York; Professor of Medicine at Weill Cornell Medical College, New York; a consultant for Wilmot Cancer Institute Geriatric Oncology Research, University of Rochester; and Past President of the International Society of Geriatric Oncology (SIOG). Dr. Lichtman is also Guest Editor of the Geriatrics for the Oncologist column in The ASCO Post.
