Geriatric Oncology

As Singapore’s population continues to age coupled with rising cancer incidence, there is a growing need for cancer care tailored to elderly patients. Geriatric patients are diverse, with varying lifestyles, socioeconomic backgrounds, levels of social support, and multiple co-morbidities. When treating this group for cancer, an accurate patient profile is needed to determine the best course of treatment.

Geriatric oncology addresses this challenge by providing specialised care that caters to the complexities of ageing such as frailty, comorbidities and functional decline.

To better support our elderly population with specialised and personalised care, the National Cancer Centre Singapore’s Geriatric Oncology Clinical Service and Research Programme (NCCS GO) offers a dedicated platform where oncology and geriatric medicine converge. NCCS GO supports clinicians in evaluating older adults beyond the cancer diagnosis—integrating medical, functional and psychosocial factors into a personalised treatment plan. This personalised approach is supported by the use of a comprehensive geriatric assessment (GA) to understand the needs of elderly patients and ensure they receive appropriate, effective and compassionate treatment.

What are the common cancers diagnosed in older adults?

According to the Singapore Cancer Registry 2022 Annual Report, older individuals continue to make up the majority of cancer cases. Between 2018 and 2022, 45.3% of male cancer patients and 35.3% of female cancer patients in Singapore were aged above 70 at the time of diagnosis. Cancer is increasingly being diagnosed in older adults, with the median age of diagnosis at 68.8 years for males and 64.2 years for females between 2018 to 2022. The most commonly diagnosed cancers in elderly adults include cancers of the lung, colorectal region, breast, prostate and bladder.

• Colorectal cancer: Symptoms may be vague or attributed to other gastrointestinal conditions, and screening rates tend to be lower in older age groups, often resulting in delayed diagnosis. 
• Lung cancer: Frequently diagnosed in long-term smokers, older patients may present with reduced lung function or co-existing cardiovascular and metabolic conditions, which can affect diagnosis and treatment. 
• Genitourinary cancers: Prostate cancer is particularly common among older men and may progress slowly, though it still requires regular monitoring and personalised management. Bladder cancer is also more prevalent in this age group, especially among those with a history of smoking. 
• Breast cancer: Risk increases with age, particularly after menopause. Delayed presentation or underestimation of risk can affect outcomes. 

Older patients may also present with multiple chronic conditions such as diabetes and hypertension or functional impairments, which may impact how the cancer grows or spreads, treatment decisions and recovery. A comprehensive, personalised approach is essential in the management of cancer in the elderly to empower them and improve their quality of life.

Geriatric Assessment (GA)

How does the geriatric assessment (GA) improve cancer care for the elderly?

As part of the GO treatment process at NCCS, cancer patients over the age of 70 years undergo a comprehensive geriatric assessment (GA) to ensure that care is tailored to the unique needs of elderly patients. The GA improves care for the elderly by:

• Providing a holistic overview of an elderly patient's health, beyond the cancer diagnosis
• Helping to identify vulnerabilities and supports shared decision-making 
• Assisting to create personalised care plans that prioritise both survival and quality of life 

What GA entails

• Pre-screening questionnaire
  A short, 3-minute questionnaire is sent via a text message before the patient’s first visit to NCCS to screen for issues in mobility, nutrition and general health. 
• In-person assessment with a trained GO coordinator during the patient’s first clinic visit
  This hour-long assessment covers key domains such as: 
  • Functional status (ability to manage daily activities) 
  • Mobility and risk of falls 
  • Cognitive function (e.g. memory, confusion) 
  • Mental health (e.g. depression, anxiety) 
  • Nutrition (e.g. unintentional weight loss)
  • Social support 
  • Comorbidities and medication use 
  • Chemotherapy tolerance and potential treatment toxicity 

This assessment helps clinicians understand the patient beyond their cancer diagnosis and is essential in creating a care plan that is unique to the medical and personal needs of the individual. For example, based on the assessment, clinicians can decide whether it is suitable to reduce the medication or chemotherapy dosage for the patient without adversely impacting their health.

How are patients categorised following the geriatric assessment and how does this guide treatment planning?

After undergoing the assessment, patients are broadly categorised into three categories:

• Fit: These individuals have good functional status and few health issues. They are usually suitable for standard cancer treatments, such as surgery or chemotherapy. 
• Vulnerable: Patients in this group may have some limitations or mild health conditions. These patients require further assessment and are reviewed at regular meetings by the NCCS GO team. With supportive interventions, they may become fit for treatment or may need modified regimens. 
• Frail: Frail patients have significant physical or cognitive impairments, making them less able to tolerate aggressive treatment. For this group, they are recommended to avoid treatment, which may not prolong or improve their quality of life, and care often focuses on symptom management and maintaining quality of life. 

This categorisation ensures that treatment decisions are aligned with the patient’s health status and values, avoiding unnecessary side effects or hospitalisations.

Multidisciplinary Treatment Approach at NCCS GO Programme

The NCCS GO team is made up of a multidisciplinary medical team. This team-based approach ensures that all aspects of the patient’s health are considered and managed collaboratively.

The multidisciplinary team includes:

• Medical Oncologists 
• Geriatricians 
• Nurses 
• Dietitians 
• Rehabilitation Physicians and Physiotherapists 
• Pharmacists 
• Psychologists 
• Palliative Care Specialists

Each member contributes specialised knowledge to create a comprehensive and cohesive care plan for every patient. The multidisciplinary team’s expertise helps detect medical, psychosocial and functional issues that may not be identified during routine evaluations and the team will recommend holistic interventions to support the patient’s overall well-being. For example, the NCCS GO team may recommend holistic interventions by the primary treating oncologist which may include changes to medication regimes and referrals to medical social workers, dieticians, physiotherapists as needed.

1. How does open communication and being involved in cancer care decisions empower the elderly?
   Older patients often have different goals when it comes to cancer treatment. While some may prioritise life extension, others may value independence, symptom control or simply the ability to spend quality time with family. Open and respectful communication is therefore central to GO.
   
   Clinicians work closely with patients and their families to explain treatment options, expected outcomes and potential risks, ensuring that care decisions are made collaboratively and transparently.
   
   Advance care planning discussions are also routinely offered to patients and caregivers, enabling individuals to express their values and preferences, and ensure care remains aligned with what matters most to them. 
   
   
2. How does personalised geriatric oncology care enhance outcomes?
   The NCCS GO programme incorporates geriatric assessments into cancer care for better patient outcomes. These include improved treatment tolerance, reduced complications, shorter hospital stays and better quality of life.
   
   This one-stop multidisciplinary approach at NCCS provides patients with convenient and comprehensive care, reflecting the NCCS GO’s commitment to support the elderly to age and live well, even with cancer.
   
   A recent study also showed that patients who received the GA had a better quality of life, fewer hospital admissions and lower medication dosage.