Geriatric Assessment Before Systemic Cancer Therapy: Clinical Relevance and Evidence-Based Approaches

Abstract

Optimal management of older adults with cancer demands a nuanced approach that integrates comprehensive geriatric assessment (CGA) prior to systemic therapy. This review evaluates current evidence supporting the use of CGA, highlights critical domains assessed, discusses epidemiological trends, and explores clinical implications and guideline-based recommendations. Incorporating geriatric assessment improves therapeutic decision-making, identifies vulnerabilities, predicts treatment-related toxicity, and enhances patient-centered care, thus representing an essential component of modern oncology practice for the aging population.

Introduction

The global burden of cancer in older adults is rapidly increasing, with more than 60% of all new cancer diagnoses and over 70% of cancer-related deaths occurring in individuals aged 65 years or older. The heterogeneity of physiologic reserve, comorbidities, and geriatric syndromes in this demographic necessitates individualized evaluation beyond chronological age. Systemic therapies, including cytotoxic chemotherapy, targeted agents, and immunotherapy, present unique challenges in elderly patients due to age-associated changes in pharmacokinetics, organ function, and increased susceptibility to treatment toxicities. Comprehensive geriatric assessment (CGA) has emerged as a validated, multidimensional tool to inform oncologic decision-making and optimize outcomes in this vulnerable group.

Epidemiology / Disease Burden

The aging global population has led to a pronounced rise in cancer incidence among older adults. According to recent GLOBOCAN data, individuals aged 65 and above comprise the fastest-growing cancer population. This demographic shift imposes a substantial burden on healthcare systems, as older patients often present with complex comorbidities, functional impairments, and social challenges that complicate oncologic management. Studies have shown that elderly patients are underrepresented in clinical trials, resulting in a paucity of evidence to guide therapy in this group. There is a pressing need for evidence-based strategies tailored to the geriatric oncology population.

Pathophysiology

Aging is characterized by progressive decline in physiological function, reduced organ reserve, and an increased prevalence of chronic diseases. These changes impact tumor biology, host response, and treatment tolerance. Age-related alterations in drug metabolism (hepatic and renal), diminished bone marrow reserve, and decreased cardiovascular and pulmonary function increase the risk of systemic therapy toxicity. Furthermore, the interplay between cancer-related inflammation, frailty, and immunosenescence can influence both disease progression and therapeutic outcomes. Understanding these mechanisms underscores the importance of individualized risk assessment in elderly cancer patients.

Risk Factors

Key risk factors influencing outcomes in older adults undergoing systemic cancer therapy include advanced age, frailty, polypharmacy, multimorbidity, cognitive impairment, poor nutritional status, and lack of social support. Geriatric syndromes such as falls, delirium, and incontinence further complicate treatment planning. The presence of these risk factors correlates with increased likelihood of adverse events, hospitalization, and treatment discontinuation, necessitating a thorough pre-therapy evaluation.

Clinical Features

Older cancer patients frequently exhibit atypical clinical presentations, including non-specific symptoms such as fatigue, weight loss, or altered mental status. Functional decline, impaired mobility, and decreased activities of daily living (ADL) are common. Geriatric syndromes may mask or mimic oncologic symptoms, complicating diagnosis and staging. Identifying baseline functional status, cognitive capacity, psychosocial context, and patient preferences is critical to informing shared decision-making and aligning treatment goals.

Diagnosis

Diagnosis in geriatric oncology extends beyond tumor staging, requiring systematic evaluation of physiological, functional, and psychosocial domains. Comprehensive geriatric assessment encompasses validated tools to assess comorbidity (e.g., Charlson Comorbidity Index), cognition (e.g., Mini-Mental State Examination), nutritional status (e.g., Mini Nutritional Assessment), functional status (e.g., Katz ADL, Lawton IADL), polypharmacy, psychological health, and social support. Baseline laboratory studies and organ function tests are essential to evaluate candidacy for systemic therapies. Incorporating frailty screening (e.g., G8, Clinical Frailty Scale) aids in risk stratification.

Treatment & Management

Management strategies for elderly cancer patients must be individualized based on CGA findings, tumor characteristics, patient goals, and life expectancy. CGA informs modifications in systemic therapy regimens, dose adjustments, and supportive care interventions. Early involvement of multidisciplinary teams—including geriatricians, pharmacists, nutritionists, and social workers—can mitigate treatment toxicity and address non-oncologic needs. Symptom management, rehabilitation, and palliative care integration are vital components of a holistic approach. Close monitoring for adverse effects and proactive management of comorbid conditions improve outcomes and quality of life.

Recent Advances / Emerging Therapies

Recent advances include the development of predictive models incorporating CGA variables to estimate chemotherapy toxicity (e.g., CARG, CRASH scores). Biomarker-driven therapies and immunotherapies offer new avenues for treatment but may pose unique risks in the elderly. Ongoing trials are evaluating tailored regimens and de-escalation strategies in fit versus frail older adults. Digital health tools and telemedicine are increasingly utilized for remote monitoring and assessment, expanding access to geriatric expertise in oncology care.

Guideline Recommendations

International guidelines from organizations such as ASCO, ESMO, and NCCN emphasize the routine use of geriatric assessment for patients aged 65 years and older considered for systemic therapy. Recommendations include incorporating CGA into initial evaluation, using assessment findings to guide treatment selection and intensity, and systematically addressing geriatric syndromes. Guidelines advocate for shared decision-making, patient and caregiver education, and ongoing reassessment throughout the cancer care continuum.

Conclusion

Comprehensive geriatric assessment is integral to optimizing systemic cancer therapy in older adults, enabling personalized care that balances efficacy, safety, and patient preferences. As the oncology population ages, routine incorporation of CGA into clinical practice and adherence to guideline recommendations are essential to improving outcomes, minimizing toxicity, and maintaining quality of life. Continued research and innovation in geriatric oncology will further refine assessment strategies and therapeutic approaches for this growing patient population.