Oncologists have adopted new ways of caring for older adults with cancer over the past decade and a half.

Cancer treatment for older adults has shifted toward these specialists prescribing newer treatments, primarily immunotherapies, such as immune checkpoint inhibitors, and targeted therapies based on genetic testing results. Another more recent change related to oncologists’ treatment of their older patients is that they have been using geriatric assessments to tailor therapy to the individual and reduce toxicity. That practice grew over the past few years after clinical trials provided the evidence base to support it.

Experts, who spoke with Medscape Medical News, characterized these changes as moving away from a one-size-fits-all approach and recognizing that age isn’t a barrier to the use of the latest treatments demonstrating the greatest efficacy.

How Were Older Patients With Cancer Treated 25 Years Ago?

William Dale, MD, PhD, trained in medicine in the early 2000s and has spent over two decades working at the intersection of oncology and geriatrics. He describes the culture he encountered when he began practicing as one in which age was treated as a clinical variable that was often given more weight than the patient’s physical condition.

“During my training…every patient presentation started by stating the patient’s age,” said Dale, who is a professor in the Department of Supportive Care Medicine and director of the Center for Cancer and Aging at City of Hope Comprehensive Cancer Center in Duarte, California. “Implicit in this was the assumption that age was essential context for making treatment decisions.”

This was especially relevant for patients with cancer as choices about pursuing “aggressive” treatments such as surgery or full-dose, multi-drug chemotherapy, or recommending a “palliative approach” or hospice enrollment were implicitly, and sometimes explicitly, connected with a patient’s age, he explained.

Dale also noted that in some clinics, age cutoffs were codified into institutional practice. Bone marrow biopsies, for example, were tied to age thresholds in many hospitals. Chemotherapy dosing, too, was decreased in older patients, without supporting evidence.

Commenting on the consequences of basing cancer treatment decisions solely on chronological age, he said that older patients who were fit were sometimes undertreated or redirected toward palliative care, whereas those who were frail might receive treatments they could not tolerate.

Dale provided an example from early in his career: a patient in her mid-80s with stage II ovarian cancer who was physically fit, swam half a mile 5 days a week, and yet was nearly steered toward “a little palliative chemo and hospice” simply because of her age. After Dale insisted on standard-of-care treatment, she received it — and lived another 5 years.

‘Staging the Aging’: The Rise of Geriatric Assessment

Dale was among the clinicians who helped push the shift of recognizing that chronological age is a poor proxy for biological or functional age, and that treatment decisions for older patients needed a better framework.

“I helped coin the phrase ‘Staging the Aging’ — similar to staging cancer — to help oncologists understand this concept,” Dale said. He explained that at first, physicians felt they could judge a patient’s level of fitness or frailty through clinical judgment, what was called the ‘eyeball test.’ He also said that measures of performance status, such as Eastern Cooperative Oncology Group performance status or Karnofsky performance status scale, were helpful for some stratification, but proved to be rather poor measures of toxicity risk.

However, we now know that validated, multidomain assessments covering function, mobility, cognition, mood, social support, comorbidity burden, and polypharmacy are more predictive of treatment outcomes than age or performance status alone, Dale said. This work gave rise to geriatric assessment, and ultimately to the Cancer and Aging Research Group Toxicity Tool, developed largely through studies led by the late Arti Hurria, MD, at City of Hope.

In parallel, the clinical infrastructure to deliver this kind of assessment was taking shape. Dale founded the Specialized Oncology Care and Research in Elders (SOCARE) Clinic at the University of Chicago, Chicago, in 2006, creating a model for integrating geriatric principles into oncology practice. When his colleague Supriya Mohile, MD, MS, moved to the University of Rochester, Rochester, New York, she adopted the model there, and Dale later brought it to City of Hope when he joined in 2017.

Mohile explained that when she was building her program, the clinical benefits of formal geriatric assessment in oncology were largely unknown. Oncologists treated older adults based on intuition because there was no level-one evidence to justify adjusting standard protocols based on frailty.

But the evaluation of older patients with cancer has shifted considerably, according to Mohile, who explained that large-scale clinical trials now provide level-one evidence that integrating a geriatric assessment with guided management improves outcomes for older adults with cancer.

The 2021 GAP70+ cluster-randomized trial, which enrolled 718 patients aged 70 years or older with incurable solid tumors or lymphoma, demonstrated that geriatric assessment-guided intervention for older patients with advanced cancer reduced the risk for serious toxic effects from cancer treatment. When community oncologists were provided with a tailored geriatric assessment summary and management recommendations, the proportion of older patients experiencing grade 3-5 adverse events was 51% in the intervention group vs 71% in the usual care group over 3 months. Patients in the geriatric assessment intervention group also experienced fewer falls (12% vs 21%) and had more medications discontinued before starting cancer treatment. Despite a higher proportion of patients in the intervention group receiving reduced-intensity treatment at cycle one, overall survival at 6 months and 1 year was similar between the two groups.

Another randomized trial, GAIN, published in The Lancet Oncology, showed that geriatric assessment-driven intervention can reduce chemotherapy-related toxic effects among older adults with cancer receiving chemotherapy.

“The use of validated geriatric assessment tools increased, but uptake was slow and inconsistent at best. There remained doubts that interventions based on these assessments mattered, and that they were too time-consuming and resource-intensive to be justified,” Dale stated. “The randomized trials changed that.”

The GAP70+ and GAIN trials provided the evidence base that Dale and colleagues needed to develop the 2023 ASCO guidelines, which established geriatric assessment-guided care for older adults starting chemotherapy as the standard of care. The updated ASCO guidelines published in 2025 extended the recommendation to all patients aged 65 years or older receiving systemic therapy who show vulnerabilities. This recommendation holds true across various clinical environments, including resource-constrained settings.

Do Shifts in Geriatric Oncology Vary by Tumor Type?

Dale emphasized that the evolution in how older patients are treated has not been the same across cancer types. He explained that the adoption of geriatric assessment-guided care has been most widespread in solid tumors managed by medical oncologists, with breast cancer leading the way, followed by prostate, colorectal, and lung cancer. Hematologic malignancies, particularly leukemias, have been slower to integrate geriatric assessment-guided interventions.

“Adoption has been more common in NCI-designated cancer centers than in community-based ones, likely due to guideline awareness and resource differences,” Dale added. Dale pointed to a need for wider integration of geriatric assessment in patients with blood cancers, noting that some types of leukemias disproportionately affect older adults, and older patients have historically been considered poor candidates for intensive induction chemotherapy.

How Do Newer Cancer Treatments Affect Older Adults?

Melisa Wong, MD, MAS, AGSF, a thoracic medical oncologist and geriatric oncology researcher at Kaiser Permanente Northern California, identified the increasing use of immunotherapy as a key change in geriatric oncology in the last 15 years. She noted that 15 years ago, the only immune checkpoint inhibitor available was ipilimumab for melanoma. Today, immunotherapy is part of standard treatment for multiple cancer types and stages. Because these agents lack the traditional toxicities of cytotoxic chemotherapy, they are frequently perceived as more tolerable alternatives for frail older adults.

“We sometimes call this the Jimmy Carter Effect,” Dale said. He explained that after the former president was diagnosed with metastatic melanoma with brain metastases at the age of 90, he was started on immunotherapy with a dramatic impact on his tumors. “He famously lived another 10 years to 100, which was unheard of prior to the development of immunotherapy,” Dale added.

When it comes to drug selection, Dale said that age itself should not drive the decision. He explained that the same immunotherapy agents available to younger patients are generally available to older ones, and he would not choose based on age alone. The determining factors, he said, are a patient’s fitness as assessed by a geriatric assessment and the molecular profile of the tumor.

Where Is the Field Headed?

Dale said that the number of dedicated geriatric oncology clinics and programs is increasing nationally and internationally: “There is a proliferation of these types of clinics…including at places such as Wake Forest, Ohio State University, Thomas Jefferson, Dana-Farber, Moffitt, and UCLA. Many are recognized by the Institute for Hospital Innovation and the American Hospital Association as delivering Age-Friendly Care. There are various models — not just one — including consultation models, co-management models, screen-and-refer models, and embedded models.”

At City of Hope, Dale’s team now operates multiple parallel clinics for older adults, including SOCARE, a nurse practitioner-led Aging Wellness clinic for patients starting new therapies, the Aging Blood Cancers clinic for transplant evaluation in patients aged 60 years or older, and a community-based clinic.

Wong and her colleagues have also focused on improving how oncologists communicate with older patients during this process, adapting the Best Case/Worst Case communication tool (originally developed for geriatric surgery) to oncology. The framework trains oncologists to present two treatment options through scenario planning, narrating the best, worst, and most likely case for each while accounting for geriatric assessment data and the patient’s own values.

In a cluster-randomized pilot study, oncologists reported that the tool helped them have more balanced, thorough conversations, and patients said it helped them make decisions based on their own values rather than focusing solely on tumor shrinkage.

“Our communication tool helped oncologists…arrive at recommendations based on patients’ goals and cancer characteristics,” Wong said. “We are also learning more about how older adults experience different cancer treatments as new geriatric oncology research is published each year, so oncologists will have more personalized information to share with patients over time.”

Dale emphasized that approximately 70% of cancer survivors in the US are now older than 65 years, and the number of older adults with cancer is projected to be double by 2050. He sees this as an argument for continued expansion of both clinical models and research infrastructure for geriatric assessment-guided care.

Mohile reported receiving research funds from Gilead Sciences (paid to the institution). Wong reported receiving royalties from UpToDate. Dale reported receiving research funding from the National Institute of Aging, the Rising Tide Foundation, and the Hearst Foundation.

Christos Evangelou, PhD, is a freelance medical writer and science communications consultant.