In March 2012, Macmillan Cancer Support, one of the UK’s biggest cancer charities, launched their ‘Age Old Excuse’ campaign. This campaign called for older people with cancer to be offered treatment on the basis of their physical fitness rather than their age. In the UK, 155,000 people aged 70 years or more are diagnosed with cancer every year. This number represents 50% of all cancer diagnoses and it is likely to rise as the population ages. The challenge of treating older adults diagnosed with cancer is not unique to the UK, and the European Organisation for the Research and Treatment of Cancer has convened an ‘elderly task force’ to look at key questions.

Poor cancer survival rates in older adults may be partly explained by under-treatment. Some older patients may decline or choose to receive less aggressive treatment. Clinical reasons for offering less intensive treatment include frailty and comorbidity that would render patients less likely to tolerate treatments such as surgery, chemotherapy and radiotherapy. However, chronological age alone is a poor proxy for treatment tolerance. Macmillan Cancer Support’s campaign called for older patients to be offered treatment on the basis of their fitness and not their chronological age, and this is welcome as a stimulus for action. However, developing robust measures of so-called biological age and incorporating them into clinical practice presents several challenges.

Biological age is probably best determined by some form of comprehensive geriatric assessment, which might include measurements of comorbidities, functional status, cognition, nutrition, psychological state and social support. Although several scales are available to measure each of these domains, there is little consensus on which to use for this patient group, or even which domains to include. 

However, cancer-specific tools may be needed because it is not certain that assessments of global health status developed in the inpatient or community geriatric population will accurately predict relevant outcomes in older patients with cancer. Formal assessments might help to identify those older patients whose life expectancy is limited by their pre-existing frailty, but few data validate the use of a comprehensive geriatric assessment in this way. 

Robust validation would require prospective studies. It would be premature, therefore, to make treatment recommendations (in particular withholding treatment) on the basis of such tools at this time. Even if a standard assessment could be agreed on and validated against clinically relevant outcomes, delivery remains a challenge. A comprehensive assessment may take as long as an hour to complete and would involve input from several members of the geriatric multidisciplinary team. Furthermore, one important reason for conducting an assessment is to identify reversible health problems that, if dealt with, might render the patient fit enough for treatment. If such assessments are to be conducted, systems should be in place for accessible, timely onward referral to relevant specialist or multidisciplinary services.

Assessment tools are not a panacea; they will not solve the problems of delayed diagnosis, limited evidence base for treatment, and (in some areas) prevailing attitudes about the value of treating cancer in older patients. Nonetheless, the survival and experience of older adults diagnosed with cancer would probably be improved by developing more formal assessments of fitness and delivering optimum cancer care to older patients who can tolerate it. It is important to overcome the challenges even though this will require investment in the development of assessment tools, training, and service infrastructure.