Volume 1, Issue 1
Article Type: Review Article

From vulnerability to vitality: Addressing frailty in geriatric oncology practice

Ioanna Tsatsou, RN, Msc, PhD¹*; Maria Angelaki, RN, Health Psychologist, Msc, PhD²

¹One Day Clinic and Oncology-Hematology Department, Hellenic Airforce General Hospital, Greece.
²Psychologist, Psychiatric Department, Hellenic Airforce General Hospital, Greece.

Received: May 20, 2025
Accepted: Jun 09, 2025
Published Online: Jun 16, 2025
Journal: Annals of Pediatrics and Neonatal Care
Copyright: Tsatsou I et al. © All rights are reserved

Citation: Tsatsou I, Angelaki M. From vulnerability to vitality: Addressing frailty in geriatric oncology practice. Ann Gerontol Geriatr Res. 2025; 1(1): 1008.

Introduction

Cancer continues to be a primary contributor to illness and death globally, with projections indicating a significant increase in its burden in the forthcoming decades [1]. Notably, the inci- dence of cancer increases significantly with age, and a growing proportion of patients diagnosed with cancer are older adults. This demographic shift necessitates a greater understanding of the unique challenges faced by the elderly cancer population. Cancer represents a considerable health risk for the elderly, constituting a significant percentage of cancer patients aged 65 and older. With increasing life expectancy and an aging popula- tion, the occurrence of cancer among older adults is anticipated to rise further. Age serves as a primary risk factor for most prev- alent cancers, with both incidence and prevalence escalating as individuals age. Research indicates that the rates of incidence and mortality for various cancers among the elderly and very old populations are increasing globally, with most cancer types reaching their peak between the ages of 75 and 90, followed by a notable decline [2,3].

Geriatric oncology is a distinct area of medicine dedicated to the diagnosis, treatment, and management of cancer among elderly patients. As the global population ages, the incidence of cancer among the elderly is rising, making this area increas- ingly important. Older patients often present unique challenges due to age-related physiological changes, multiple comorbidi- ties, and varying levels of functional and cognitive ability. Geri- atric oncology aims to provide personalized care by integrating oncologic treatment with comprehensive geriatric assessment to optimize outcomes, minimize treatment-related toxicity, and maintain quality of life. This multidisciplinary approach ensures that therapeutic decisions align not only with cancer prognosis but also with the patient’s overall health status and personal preferences [3,4].

Frailty, a multidimensional syndrome, is defined as a clinical state of increased vulnerability resulting from age-associated decline across multiple physiological systems [6], has emerged as a critical factor in the management of older adults with can- cer. It is distinct from chronological age and more accurately predicts adverse outcomes including treatment toxicity, post- operative complications, and mortality [7].

In oncology, frailty has emerged as a critical factor affecting treatment outcomes and quality of life, especially among older adults [8]. The co-occurrence of cancer and frailty intensifies the burden of illness, not only physiologically but also psycho- logically and socially. Understanding the consequences of frailty in cancer patients is essential for holistic care and improved outcomes [9].

Despite its importance, frailty is often under recognized in oncology, leading to suboptimal treatment planning and poorer outcomes [10]. Traditional performance status scales such as the Eastern Cooperative Oncology Group (ECOG) [11] or Karnof- sky Performance Status (KPS) [12] do not adequately capture the complexity of frailty [13]. Therefore, incorporating compre- hensive frailty assessment into cancer care is essential for guid- ing therapeutic decisions and delivering personalized treatment [10].

Cancer and its treatments significantly impact physical func- tion, leading to functional decline and loss of independence. The physiological stress of malignancy, compounded by aggres- sive interventions such as surgery, chemotherapy, and radio- therapy, can precipitate or exacerbate frailty. Specific cancer- related factors contributing to functional impairment include tumor burden, paraneoplastic syndromes, cancer cachexia, fa- tigue, and neuropathy [14].

Then, cancer cachexia is a multifaceted metabolic disorder marked by unintentional weight loss, muscle depletion, and widespread inflammation, which significantly impairs function- al capacity [15]. Additionally, treatment-induced side effects such as chemotherapy-related fatigue, peripheral neuropathy, and cognitive dysfunction further impair physical and cogni- tive function. These effects are often more pronounced in older adults due to pre-existing comorbidities, polypharmacy, and di- minished physiological reserves [16].

Moreover, functional decline in cancer patients is not merely a consequence of aging or treatment but reflects interplay of biological, psychological, and social factors. Depression, anxi- ety, social isolation, and economic hardship can also contribute to decreased functionality [15,17]. Recognizing and addressing these multifactorial contributors is essential in comprehensive cancer care. This review aims to analyze the current understand- ing of frailty in older cancer patients, explore assessment tools and management strategies, and highlight the implications for clinical practice and future research.

Frailty

Definition and pathophysiology

Frailty is a multidimensional syndrome characterized by re- duced strength, endurance, and physiological function, increas- ing an individual’s vulnerability to external stressors. It is a dis tinct clinical entity from comorbidity and disability, although there is significant overlap [18,19].

Two predominant models define frailty: the phenotype model proposed by Fried et al. [20], and the cumulative defi- cit model developed by Rockwood and Mitnitski [21]. The Fried phenotype is characterized by five criteria: unintentional weight loss, self-reported fatigue, diminished grip strength, reduced walking speed, and low levels of physical activity. An individual meeting three or more of these criteria is considered frail [20]. The cumulative deficit model conceptualizes frailty as the accu- mulation of health deficits, resulting in a frailty index based on the proportion of potential deficits present [21].

The pathophysiology of frailty involves multiple systems, including musculoskeletal, neuroendocrine, and immune path- ways. Chronic inflammation, sarcopenia (loss of muscle mass and strength), hormonal dysregulation, oxidative stress, and mitochondrial dysfunction contribute to the frailty phenotype. These pathophysiological changes reduce the body’s ability to maintain homeostasis in the face of physiological stress, such as cancer or its treatments [22].

Assessment

Accurate assessment of frailty is essential to identify patients at risk and tailor treatment accordingly. Several tools have been developed, each with specific strengths and limitations [23].

The Fried Frailty Criteria are widely used in research but may be impractical in busy clinical settings due to the need for physi- cal performance measurements [20]. The Clinical Frailty Scale (CFS), a 9-point scale based on clinical judgment, is simple, quick, and increasingly used in clinical practice [24].

The Edmonton Frail Scale is another comprehensive tool that includes assessments of cognition, mood, functional per- formance, and social support [25]. The Comprehensive Geriat- ric Assessment (CGA) remains the gold standard for evaluating frailty. It includes domains such as physical health, functional status, cognition, nutrition, social support, and psychological well-being. Although time-consuming, CGA provides a holistic understanding of the patient’s health status and can guide mul- tidisciplinary interventions [26].

Frailty affects a significant proportion of older adults with cancer. Up to 50% of older cancer patients exhibit some degree of frailty. Frailty impacts tolerance to chemotherapy, increases postoperative complications, and affects survival rates. Howev- er, beyond these clinical implications, frailty has profound psy- chological and social repercussions that can further complicate cancer care [27].

Frailty assessment is particularly relevant in oncology, where treatment decisions often involve weighing potential benefits against risks of toxicity. Multiple studies have demonstrated that frailty is a strong predictor of chemotherapy toxicity, surgi- cal complications, hospitalizations, and mortality in cancer pa- tients [10].

Geriatric assessment has been endorsed by major oncology societies, including the American Society of Clinical Oncology (ASCO) [28,29] and the International Society of Geriatric On- cology (SIOG) [30], as an essential component of care for older adults with cancer. Tools such as the Cancer and Aging Research Group (CARG) score [31,32] and the Chemotherapy Risk Assess- ment Scale for High-Age Patients (CRASH) score [33] have been developed to predict chemotherapy toxicity in older adults.

However, the implementation of frailty assessment in routine oncology practice remains inconsistent due to barriers such as time constraints, lack of training, and limited resources. There remains a global deficiency in the awareness and application of frailty screening tools, which may vary based on geographical location, national income, and educational levels. Increasing awareness among healthcare professionals, simplified screening tools, integrated electronic health records, and interdisciplinary collaboration may facilitate broader adoption [34].

Management strategies

Management of frailty in cancer patients requires a compre- hensive and individualized approach. The goals are to optimize function, enhance treatment tolerance, and improve quality of life [35]. Prehabilitation, which focuses on improving a patient’s functional capacity prior to treatment, has demonstrated po- tential in enhancing outcomes. This may include structured ex- ercise programs focusing on strength, balance, and endurance; nutritional support to improve caloric and protein intake and psychological support to address anxiety or depression prior to treatment initiation [36].

Rehabilitation should be viewed as a continuous process that begins with diagnosis and extends through survivorship or palli- ative care. Tailored physiotherapy programs can aid in restoring mobility and managing fatigue [37]. Occupational therapy may assist patients in maintaining independence in daily living ac- tivities, while speech and cognitive therapy may be essential for those affected by head and neck cancers or chemobrain [38].

Nutritional interventions are critical, particularly in patients with cancer cachexia or sarcopenia. Regular nutritional screen- ing, dietary counseling, and use of oral nutritional supplements can support muscle mass, enhance immunity, and reduce treat- ment-related complications. Anti-inflammatory and high-pro- tein diets, along with agents like omega-3 fatty acids, may also play a role [39]. Also, pharmacologic optimization is another cornerstone of frailty management. Regular medication reviews can reduce polypharmacy and avoid potentially inappropriate medications [40].

Psychosocial support is essential and should address depres- sion, anxiety, and caregiver burden. Social work consultations can facilitate access to community resources, home care servic- es, and financial assistance [41]. Multidisciplinary care involving oncologists, geriatricians, physiotherapists, dietitians, pharma- cists, psychologists, and social workers ensures that all aspects of a patient’s health and well-being are addressed holistically. Personalized care plans should be dynamic and responsive to changes in health status over time [29].

Psychological and social consequences

Psychological and social consequences of frailty are deeply interconnected. For example, social isolation can lead to de- pression, while depression can reduce motivation to engage so- cially, creating a vicious cycle. This interplay complicates treat- ment planning and underscores the need for multidisciplinary interventions that address both psychological well-being and social support systems [42].

Frailty significantly increases the risk of depression and anxi- ety in cancer patients. The reduced physical capacity and de- pendence associated with frailty often lead to feelings of help- lessness and hopelessness. A study by Loh et al. (2016) found that frail cancer patients had higher levels of depressive symptoms compared to their non-frail counterparts. The psychologi- cal stress of managing cancer, compounded by frailty-related limitations, exacerbates emotional distress [43].

There is growing evidence that frailty is associated with cog- nitive impairment, which may be worsened in the context of cancer and its treatment. Cognitive decline in frail cancer pa- tients can lead to difficulties in understanding treatment plans, decision-making, and maintaining independence. The phenom- enon of chemobrain or cancer-related cognitive impairment is more pronounced in frail individuals due to their diminished physiological reserve [20,44].

Frail cancer patients often experience a loss of autonomy, which can erode their self-efficacy. This psychological burden affects treatment adherence and coping strategies. The inability to perform daily tasks or participate in meaningful activities can lead to diminished self-worth and an increased sense of bur- den. This perceived loss of control over their health and life tra- jectory is a major source of psychological distress [45].

Additionally, frailty often leads to mobility limitations, which restrict social engagement inducing social isolation. Cancer pa- tients who are frail are less likely to attend social gatherings or participate in community activities, leading to social withdrawal and isolation [46,47]. Social isolation has been linked to worse mental health outcomes and lower survival rates in cancer pa- tients [17].

Frailty increases the need for caregiving, which can place significant strain on families. This strain can alter family dynam- ics, sometimes leading to conflict or emotional fatigue among caregivers. The stress of caregiving is often compounded by the emotional toll of watching a loved one struggle with both can- cer and frailty. This dynamic can contribute to feelings of guilt, resentment, or helplessness within the family unit [46,48].

Finally, frail cancer patients may be more likely to experience job loss if not retired, financial strain, and reduced access to healthcare resources. They may also face challenges in navigat- ing healthcare systems, especially if they lack a strong support network. The economic burden of managing cancer and frailty can exacerbate social inequities and limit treatment options [49].

Implications for clinical practice

Integrating frailty assessment into oncology practice can improve patient outcomes by guiding individualized treatment planning. It supports shared decision-making by aligning thera- peutic goals with the patient’s values and functional status [35]. routine use of Comprehensive Geriatric Assessment (CGA) in oncology settings can help identify frailty and its associated risks early. CGA includes assessments of physical health, cogni- tion, psychological state, and social circumstances, providing a holistic view of the patient’s condition [30].

Risk stratification based on frailty can inform decisions re- garding the intensity of therapy, the need for supportive care measures, and appropriate follow-up strategies. It also helps identify patients who may benefit from geriatric interventions or palliative care services. Ethically, assessing frailty ensures that vulnerable patients are not subjected to harmful or futile treatments and promotes equity in care delivery [50].

Psychosocial Interventions such as counseling, cognitive- behavioral therapy, and support groups can mitigate the psy- chological consequences of frailty [51]. Tailoring these interventions to accommodate physical limitations is essential. For example, telemedicine may be a viable option for frail patients with mobility issues [52]. Also, access to social workers, com- munity health programs, and caregiver support groups can alle- viate the social burden of frailty. Programs that promote social engagement through volunteer visits or online platforms can help reduce isolation and improve quality of life [53].

Lastly, integrating palliative care early in the treatment pro- cess allows for symptom management, psychosocial support, and advance care planning. This approach is particularly ben- eficial for frail patients, as it emphasizes comfort, dignity, and patient-centered goals [54].

There is a need for standardized, validated, and easy-to-use frailty screening tools tailored for oncology settings. Future research should focus on identifying biomarkers of frailty, le- veraging digital health technologies, and integrating artificial intelligence to enhance frailty prediction and management. Randomized controlled trials evaluating the impact of frailty- targeted interventions on cancer outcomes are warranted. Ad- ditionally, policies and guidelines should promote routine frailty assessment as part of comprehensive cancer care.

Conclusion

Frailty significantly amplifies the physiological, psychological and social challenges faced by cancer patients. Functional de- cline, depression, anxiety, cognitive impairment and social iso- lation are among the many consequences that can compromise treatment outcomes and quality of life. Addressing these chal- lenges requires a multidisciplinary approach that incorporates geriatric assessment, mental health support, and social care planning. As the population ages and the prevalence of frailty increases, especially in oncology, recognizing and mitigating these consequences will be crucial for improving holistic cancer care. By recognizing and addressing frailty through individual- ized, multidisciplinary strategies healthcare professionals can personalize treatment, reduce adverse outcomes, and improve the quality of life for cancer patients. Ongoing research and sys- temic implementation of frailty informed care are essential to advance the field of geriatric oncology.

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