In a first for the country, Indian oncologists and geriatricians have issued comprehensive guidelines recommending that every cancer patient aged 60 years and above undergo a structured geriatric assessment before starting cancer treatment, particularly chemotherapy, to identify age-related vulnerabilities that could influence treatment tolerance and outcomes.
Published in the Journal of Geriatric Oncology, the recommendations are India’s first consensus guidelines on geriatric oncology. They were developed by a multidisciplinary task force led by Tata Memorial Hospital, Mumbai, in collaboration with experts from the All-India Institute of Medical Sciences (AIIMS), New Delhi, and several other cancer centres across the country. The recommendations were formulated through a structured review of scientific evidence and a consensus process involving medical oncologists, geriatricians, physiotherapists, occupational therapists, clinical pharmacologists, psycho-oncologists, dietitians, social workers and patient advocates.
Dr Vanita Noronha, lead author of the guideline, professor and medical oncologist at Tata Memorial Hospital, Mumbai, said the recommendations address an important gap in cancer care in India. “Geriatric oncology itself is still under-practised in India and there are very few geriatricians. Most older patients with cancer continue to be evaluated much like younger patients because oncologists have not traditionally been trained to assess them differently,” she said.
What the guidelines recommend
The recommendations call for every cancer patient aged 60 years and above to undergo a comprehensive geriatric assessment, preferably before chemotherapy begins, with a repeat assessment approximately three months later to identify any decline in physical or functional status during treatment.
The guidelines further recommend that, wherever available, older adults with cancer should be registered at dedicated geriatric oncology clinics, where care is delivered by a multidisciplinary team comprising geriatricians, medical oncologists, physiotherapists, occupational therapists, dietitians, clinical pharmacologists, psycho-oncologists or psychologists, and social workers.
The assessment should go well beyond routine cancer evaluation and include physical function, nutritional status, co-existing illnesses, risk of falls, inappropriate medications and polypharmacy, cognition, depression, anxiety, chemotherapy-related toxicity, and social support. Where resources are limited, the expert panel recommends that clinicians should, at a minimum, assess physical function, nutrition, comorbidities and chemotherapy toxicity risk before initiating treatment.
Why the guidelines were needed
The recommendations come at a time when the number of older adults with cancer is steadily increasing. According to the guideline, adults aged 60 years and above already account for more than one-third of patients treated at tertiary cancer centres. Community-based cancer registry data suggest the proportion may be as high as 45 per cent, and it is expected to increase further as India’s population ages.
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Despite this growing burden, most older patients continue to be assessed much like younger adults, with treatment decisions often based on a physician’s clinical judgement or routine performance status scores. Experts say these approaches frequently fail to identify frailty, functional decline and other age-related vulnerabilities that significantly influence treatment tolerance, treatment-related toxicity and overall outcomes.
Looking beyond chronological age
The central message of the guideline is that chronological age alone should never determine cancer treatment. Instead, treatment decisions should be guided by a patient’s biological age, overall health, functional reserve and ability to tolerate therapy.
Dr Noronha, who established the geriatric oncology clinic at Tata Memorial Hospital and later launched a fellowship programme in the specialty, said India needed recommendations tailored to its own patient population rather than relying solely on international guidance. “There are global guidelines from organisations such as the American Society of Clinical Oncology (ASCO) and the International Society of Geriatric Oncology (SIOG), but our patients are different. We found that Indian patients often have lower muscle mass, different literacy levels, different social circumstances and different support systems. These factors influence treatment decisions, so we needed guidelines that are relevant to the Indian context,” she said.
Looking beyond the tumour
Unlike routine cancer evaluations, which primarily focus on the tumour and whether major organs can tolerate treatment, a geriatric assessment provides a much broader understanding of an older patient’s health.
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It evaluates whether a patient is physically, mentally and socially fit enough to undergo treatment by assessing functional ability, nutritional status, existing illnesses such as diabetes or heart disease, memory and cognition, medication burden, risk of falls, depression, anxiety, chemotherapy-related toxicity and the availability of family or social support.
“Older patients with cancer are not simply older versions of younger patients. They have several vulnerabilities that are unrelated to the cancer itself but significantly influence how well they tolerate treatment and how they fare overall,” Dr Noronha said.
“These vulnerabilities include functional ability, cognition, other illnesses, multiple medications, nutrition, social support and mental health. Most patients today are evaluated just like younger patients, so many of these vulnerabilities go unnoticed. As a result, patients may experience greater toxicity from chemotherapy, poorer quality of life and an overall worse treatment experience.”
Screening and follow-up
To make implementation practical, the guideline recommends that clinicians can initially use validated screening tools such as G8, VES-13 or SCOPE-C to identify patients who require a more comprehensive geriatric assessment.
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The authors say routine incorporation of geriatric assessment into cancer care could help personalise treatment, reduce avoidable treatment-related complications, improve quality of life and ensure that older adults receive treatment based on their overall fitness rather than their age alone.
