Advanced age is the most significant risk factor for cancer, with approximately 60% of cases occurring in adults above 65.¹ Yet, despite this epidemiologic reality, older adults remain underrepresented in clinical trials that guide cancer care.² This evidence gap forces clinicians to extrapolate from studies conducted in younger, healthier populations, often leading to both overtreatment and undertreatment. Older adults with cancer face unique vulnerabilities that impact their treatment tolerance and outcomes, including comorbidities, frailty, polypharmacy, and social determinants that compound the physiologic and psychosocial stressors of cancer and its treatment. Addressing these complexities requires a fundamentally different, age-inclusive approach to oncology.
What Are Geriatric Assessments?
National and international guidelines, including those from the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN), recommend a geriatric assessment for all patients with cancer aged 65 and older prior to starting systemic therapy.3,4 These assessments can identify impairments not typically found in routine oncology exams. They evaluate multiple domains, including:
- Physical functioning
- Preexisting conditions
- Cognitive functioning
- Psychological health
- Nutritional needs
- Social support
- Goals and values.
Geriatric assessments also identify barriers to care and needs for supportive services, which can improve a patient's quality of life and even outcomes. Evidence from randomized trials (eg, GAP70+ and GAIN) shows that geriatric assessment-guided care improves communication, reduces chemotherapy toxicity, and aligns treatment decisions with patient goals and values.5,6
Critically, these assessments move beyond predicting treatment toxicity—they serve as a values-elicitation tool. Studies demonstrate that a majority of older adults prioritize maintaining independence, cognition, and quality of life over survival alone, reinforcing the need for goal-concordant, individualized care.⁷
Barriers and Implementation Challenges
Despite the proven benefits of geriatric assessments, their implementation is hindered by complex workflows, time constraints, and workforce shortages,⁸ particularly outside of academic cancer centers. Oncologists face uncertainty in counseling older adults, given the paucity of evidence and the disconnect between trial end points and outcomes that matter most (eg, maintaining function).
Penn Medicine Princeton Health: Building a Scalable Community Model
As part of Penn Medicine, Princeton Health offers a comprehensive community cancer program in Plainsboro, New Jersey. The oncology population is comprised of approximately 70% adults aged 65 and older, with 20% of these aged 80 and older. To better understand the needs and goals of the older adult cancer population and offer personalized care, the team at Princeton Health developed and implemented a structured, scalable geriatric oncology program.
This effort was led by Ramy Sedhom, MD, section chief of Medical Oncology and Palliative Care at Princeton Health and director for the Program in Geriatric Oncology & Supportive Care Innovation at the Penn Center for Cancer Care Innovation (PC3I), and Julianne Ani, MPH, manager of the Geriatric Oncology Program at Princeton Health. With philanthropic investment from the Bristol Myers Squibb Foundation and other generous donors, and with vital support from institutional leaders, the informatics team, oncology providers, and our patient and family advisory council, the Geriatric Oncology Program began its operations in December 2023.
Our team employed a population health approach to ensure age-related cancer disparities are addressed systematically and equitably. Utilizing population-level and patient-level data and electronic health record (EHR)-based tools, we continually evaluated and refined the program to achieve optimal reach, implementation, and outcomes, and established a model for scalability across the Penn system and beyond.
Our program was also designed with a behavioral economics framework to facilitate change within busy clinics. Barriers to geriatric assessments are generally practical ones, including limited training, time, and accountability. To remove these barriers and promote adoption, we integrated the Practical Geriatric Assessment (PGA)³ into workflows and developed new tools for streamlined assignment, communication of findings, documentation, and supportive care referrals.
Program Components
There are 4 main building blocks of our Geriatric Oncology Program (Figure 1):
- Dedicated nurse navigator, social worker, and palliative care providers to facilitate goals of care discussions and to support patients with complex care needs and monitoring over the course of treatment.
- Multidisciplinary team meetings to ensure seamless care coordination for each patient according to their individual needs and goals.
- EHR-based geriatric assessment tools integrated into oncology workflows to ensure older adults undergoing cancer treatment receive a comprehensive evaluation of functional status, cognition, nutritional status, psychological distress, and social support. These assessments are not just one-time evaluations but are incorporated into ongoing multidisciplinary care, allowing for continuous monitoring of the patient's condition, and can be easily scaled to other locations within the Penn Medicine System.
- A novel population health dashboard that enables real-time monitoring of geriatric assessment completion rates, hospitalizations, and advance care planning discussions. The dashboard functions as a quality improvement tool and a clinical decision support system, ensuring that high-risk patients receive targeted interventions in a timely manner (Figure 2).
Geriatric Oncology Pathway
New cancer patients are assessed for mobility issues and, if they have a consultation with medical oncology for systemic therapy, they are automatically assigned a Practical Geriatric Assessment (PGA). Patients can complete the PGA through the patient portal, in the clinic on an iPad, or with a provider during their visit. Those with identified vulnerabilities receive specialized treatment recommendations and are followed by the program's dedicated nurse navigator and social worker. Some patients complete a reassessment after about 6 months to address any ongoing issues on a case-by-case basis (Figure 3).
Program Goals and Results
Geriatric Assessment Completion and Supportive Care Utilization
- Goal 1: Increase geriatric assessment completion and supportive care utilization, ensuring older adults receive individualized care tailored to their unique vulnerabilities.
- Results: From December 2023 to June 2025, we completed 243 geriatric assessments with 236 unique patients. Our team made 549 referrals to supportive care services, with an average of 3.5 services per person (Figure 4).
Identification of High-Risk Patients
- Goal 2: Improve early identification of vulnerable older adults and recommend evidence-based treatment modifications to reduce toxicity and improve tolerance to therapy.
- Results: Among patients who received a geriatric assessment, 78% had functional impairments impacting treatment tolerance, yet there was an average ECOG performance status of 1, which indicates this commonly used performance scale is poorly reflective of vulnerability in older adults. With more precise information, our team was able to identify patients at high risk for severe toxicities and make recommendations for treatment modifications. Additionally, 23% of patients experienced psychosocial distress and 31% had inadequate social support. Despite the high rate of geriatric impairments, 96% received treatment for their cancer. Notably, 75% of patients did not previously have any advance care planning documents in their charts.
Goal-Concordant Care
- Goal 3: Improve integration of advance care planning and supportive care as appropriate to ensure patients' goals and preferences are honored throughout their cancer journeys.
- Results: We found that only 15% of patients completing the PGA prioritized length of life over quality of life. Our team ensured treatment goals were respected and shared with treating oncologists. With integrated palliative care and social work, advance care planning increased by 140%. Among patients who died (58), 83% received hospice services. Hospice length of service increased dramatically from 3 days prior to program inception to 16 days after 18 months.
Research Opportunities
- Goal 4: Increase enrollment of older adult patients with cancer in clinical trials and other research studies.
- Results: We recently opened 2 geriatric-focused clinical therapeutic trials and 1 PGA implementation study. In 2024, we tripled the number of patients aged 65 and older enrolled in research studies compared to the previous year. As the new studies accrue, we expect these numbers to continue to rise dramatically. Additionally, the new Center for Cancer & Aging opened through the PC3I, focused on increasing geriatric oncology research across the Penn system and training the next generation of researchers in the field.
Key Takeaways
- Integration of geriatric assessments enhances care quality. Embedding geriatric assessment into oncology workflows ensures that treatment decisions are personalized and consistent with the patient's goals. Our approach moves beyond traditional oncology care by addressing factors that directly influence treatment tolerance, helping to mitigate toxicity and prevent unnecessary treatment interruptions. Patients who receive geriatric assessments benefit from more tailored interventions, including palliative care and referrals to supportive services, leading to better overall quality of life.
- Population health tracking drives proactive interventions. Our dashboard serves as an essential tool for improving patient outcomes, allowing continuous monitoring of assessment completion, hospitalization rates, and advance care planning. By tracking these metrics, our team can proactively identify high-risk patients, intervene early, and allocate resources efficiently. The dashboard also enables expansion of our program to other locations within our health care system. The ability to visualize real-time data helps guide institutional policies and quality improvement initiatives, ensuring that geriatric oncology remains a key focus of our cancer program.
- Behavioral economics increases advance care planning uptake. One of the key innovations of our program has been the integration of behavioral economics principles to increase advance care planning uptake. By defaulting advance care planning discussions into oncology visits, we significantly increased the number of older adults engaging in conversations about their treatment goals and end-of-life preferences. Many patients, especially older adults, delay these discussions due to uncertainty or discomfort. By making advance care planning a routine part of care rather than an optional discussion, we have normalized these conversations and ensured that patients' voices are heard early in the treatment process. This strategy has reduced the likelihood of aggressive, non-beneficial interventions in later disease stages and improved overall patient satisfaction with their oncology care.
- Institutional commitment sustains and scales innovation. The success of the Geriatric Oncology Program was made possible through strong institutional commitment and cross-departmental collaboration. From the outset, senior leadership at Princeton Health and the Penn Cancer Service Line recognized geriatric oncology as a strategic priority, providing dedicated resources, data infrastructure, and protected staff time to support implementation. This commitment extended beyond funding. Under the leadership of David Dougherty, MD, MBA, deputy director of clinical services of the Abramson Cancer Center, geriatric oncology was embedded into the health system's broader quality and population health goals, ensuring that age-friendly, goal-concordant care became a shared institutional value rather than a niche initiative. Sustained engagement from clinical operations, information technology, nursing, and philanthropy has enabled the program's integration into routine workflows and positioned it as a model for replication across other Penn Medicine sites. This level of leadership endorsement has been critical to maintaining momentum and fostering a culture that views supportive, individualized care for older adults as a marker of excellence in oncology.
A Patient Story: When the System Is Doing Its Best, But Not Its Best Work
When Robert, a 76-year-old with advanced colorectal cancer, began chemotherapy at a community site, his treatment followed every clinical guideline. Yet within months, he had lost 20 pounds, developed neuropathy, and was hospitalized twice for dehydration. No one had realized that Robert lived alone, had mild cognitive impairment, and relied on public transportation for every appointment. His oncologist was compassionate and attentive—but without a system to capture functional decline, social risk, or home environment, the care team never saw the full picture.
Robert's story is not one of neglect; it's a story of good clinicians trapped in inadequate systems. His story illustrates both the promise and the gap in modern cancer care—and the opportunities that innovation can unlock. Despite receiving guideline-concordant therapy, his care lacked the infrastructure to recognize frailty, social isolation, and functional decline until a crisis occurred.
A system designed through the Center for Cancer & Aging could have transformed Robert's experience:
- An embedded geriatric assessment at the start of treatment would have revealed his cognitive and transportation challenges
- A population health dashboard could have flagged his unplanned hospital visits
- Digital monitoring tools or patient-reported outcomes might have captured early weight loss or fatigue
- Behavioral defaults could have prompted earlier palliative and social work engagement
Collaboration with industry partners could extend these solutions further—integrating wearable sensors to detect mobility decline, AI-driven alerts to predict dehydration or toxicity, and home-based supportive care to reduce emergency visits. In this model, Robert's care becomes anticipatory rather than reactive, guided by data and empathy in equal measure. His story underscores that innovation in geriatric oncology is not about more technology or more treatment—it is about smarter systems that see the whole patient, act early, and preserve what matters most: independence, stability, and dignity.
Next Steps: The Center for Cancer & Aging—A Catalyst for Innovation and Impact
The creation of the Center for Cancer & Aging through PC3I represents the next step in transforming how we care for older adults with cancer—moving from isolated success stories to a unified, systemwide model of precision supportive oncology. At its core, the center's mission is to make age-friendly, equitable, and research-integrated care the default for every patient across Penn Medicine. We envision a future where no older adult faces treatment decisions without data that reflect their values, biology, and lived experience—and where every clinician has the tools, time, and support to deliver that care seamlessly.
Goals and strategic priorities at the Center for Cancer & Aging include:
- Generating evidence that matters. Building a research portfolio that closes the evidence gap for older adults through pragmatic clinical trials, real-world data analysis, and implementation science. The center will partner with industry and academic collaborators to design trials that fit the patient, not the other way around—testing interventions that optimize function, reduce time toxicity, and align with patients' priorities.
- Scaling innovation across the system. Using the infrastructure developed at Princeton Health—Epic-embedded geriatric assessments, behavioral nudges, and population dashboards—the center will expand geriatric oncology and supportive care pathways to all Penn community sites. This systemwide adoption will enable a single, interoperable data ecosystem where outcomes can be monitored, compared, and continuously improved.
- Leveraging technology for precision supportive care. Collaborating with PC3I's digital innovation partners, the center will integrate AI-assisted tools, wearable devices, and patient-reported outcomes to detect functional decline and symptom distress in real time. These technologies will not replace human care—they will amplify it—allowing clinicians to intervene earlier and tailor treatment intensity to each individual's resilience and goals.
- Building partnerships that shape the future. Through collaborations with the biopharmaceutical industry, startups, and philanthropic organizations, the center will create a translational pipeline where promising ideas in geroscience, digital health, and behavioral economics can be tested in real-world oncology populations. These partnerships will ensure that innovations developed for older adults are not theoretical but tangible, scalable, and reimbursable.
- Educating and inspiring the next generation. The center will serve as a training ground for clinicians, researchers, and administrators to learn the science and practice of age-inclusive oncology. By embedding education into every innovation, we aim to produce leaders who see aging not as a barrier to cancer care, but as its defining frontier.
Looking Ahead
As the number of adults over age 65 doubles by 2040, cancer care will face one of its greatest demographic shifts—and one of its greatest opportunities. Programs like the one launched at Princeton Health have shown that high-quality, geriatric-informed oncology is not limited to major academic centers. With the right design, leadership, and data infrastructure, community hospitals can deliver care that is scientifically rigorous and deeply personal.
The Center for Cancer & Aging will build on this foundation to unite innovation, implementation, and impact across the Penn system. Our next steps include launching multicenter pragmatic trials focused on time toxicity, functional preservation, and goal-concordant care; collaborating with digital health and AI partners to develop early-warning systems that predict decline before crisis; and expanding patient-reported dashboards that integrate clinical, psychosocial, and functional data into a single, longitudinal view of each patient. By embedding geriatric assessments within oncology workflows and using technology for real-time tracking, we are creating a scalable framework for precision supportive oncology—one that continually learns and improves.
Over the coming year, this model will expand to additional Penn Medicine sites and community partners, strengthening our ability to provide proactive, age-friendly care to every older adult we serve. Each new site will benefit from shared infrastructure, standardized metrics, and a culture that prioritizes what matters most—function, independence, and dignity.
Ultimately, the success of the Princeton program proves what is possible when vision and intent align: a community hospital can pioneer a nationally recognized model that redefines the standard of care for older adults with cancer. With commitment, mission, and deliberate design, this approach can be replicated anywhere—turning every cancer center, regardless of size, into a place where patients not only live longer, but live better.
Ramy Sedhom, MD, is section chief of Medical Oncology and Palliative Care at Princeton Health and director for the Program in Geriatric Oncology & Supportive Care Innovation at the Penn Center for Cancer Care Innovation (PC3I) and Julianne Ani, MPH, manager of the Geriatric Oncology Program at Princeton Health in Plainsboro Township, New Jersey.
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