Discussion

This analysis involved 52 respondents, including 13 residents (25%) and 39 consultants (75%) in RO, with diverse expertise covering various cancer subtypes. Most of the respondents reported a lack of awareness regarding guidelines for older cancer patients, and 98·1% expressed the need for enhanced training in geriatric oncology. The preferred training methods included case studies discussions, workshops, constitution of cancer type-specific interest groups and easy access to international geriatric oncology guidelines.

Our findings indicate that a minority of respondents had received training in geriatrics. This aligns with the outcomes of a cross-sectional online survey distributed across 45 cancer centres in Australia, New Zealand and Singapore, revealing that 91·8% of respondents had not undergone any formal or informal instruction related to geriatric oncology during their radiation oncology training. ^{Reference Morris, Thiruthaneeswaran, Lehman, Hasselburg and Turner19} Our findings, in conjunction with literature, highlight that the lack of training in geriatrics is common among RO regardless of the country of practice.

Approximately half of the survey participants mentioned that age significantly impacts clinical decision-making. Unfortunately, this trend aligns with findings from a comprehensive scoping review, emphasizing the prevalent use of patient age, either explicitly or implicitly and consciously or unconsciously, as a determinant in guiding clinical decisions in cancer care. ^{Reference Tranvag, Norheim and Ottersen20} Additionally, there is evidence that healthcare professionals have negative biases toward older women with breast cancer resulting in less optimal care. Neal et al performed a study that used the Implicit Association Test to assess healthcare professionals’ biases toward older women, revealing a moderate negative implicit association with older women (M = 0·52, p < 0·001). These biases may influence treatment decisions, leading to assumptions that older patients are less capable of decision-making or prefer less aggressive treatments. ^{Reference Neal, Morgan, Kenny, Ormerod and Reed21} The findings published in the literature along with the results from our survey emphasize the need for objective assessments to counteract age-based assumptions and ensure personalized, evidence-based treatment for older cancer patients.

Regarding the utilization of frailty screening tools within the context of RT, approximately one-third of our study respondents reported their implementation. Despite no specific data being available regarding the use of frailty screening tools within the scope of RT, an international survey addressing frailty assessment in cancer patients revealed a 37% utilization rate among European respondents. In this international survey, reasons cited for the non-utilization of screening tools included lack of awareness, time constraints and a perceived lack of associated benefits. ^{Reference Banna, Cantale and Haydock22}

The relationship between frailty and RT, as well as its potential role as a predictor of radiotoxicity and other clinical outcomes, remains inadequately understood. A cohort study found that frailty or vulnerability, as assessed by the G-8, VES-13, or Fried phenotype, was linked to higher rates of radiotoxicity, with areas under the curve of 0·86, 0·79, and 0·61, respectively. ^{Reference Runzer-Colmenares, Urrunaga-Pastor, Aguirre, Reategui-Rivera, Parodi and Taype-Rondan23} A different prospective study investigating the Edmonton Frail Scale as a predictor of radiotoxicity in older patients found no significant statistical correlation. ^{Reference Keenan, O’Brien, Ryan, Dunne and McArdle24} Data from head and neck cancer patients indicate that frailty, assessed using the CGA, Groningen Frailty Indicator, and G-8, as well as limitations in geriatric domains, were not linked to acute radiation-induced toxicity. ^{Reference Bras, de Vries and Festen25} In patients with early-stage non-squamous cell lung cancer undergoing stereotactic RT, the modified frailty index (mFI) was associated with a reduced 3-year overall survival compared to those considered fit (37·3 vs 74·7%; p = 0·003). However, the higher mortality rate appeared to be primarily attributed to factors unrelated to lung cancer. ^{Reference Franco, Chen and Chipidza26} Another study found that in this patient group, frailty, as assessed by the mFI, was a significant predictor of decreased overall survival (HR = 1·98, 95% CI 1·02–3·85, p = 0·04). ^{Reference Raghavan, Shaverdian, Chan, Chu and Lee27} Data from a Greek RT department indicate that, among patients aged 75 or older receiving curative or palliative RT, a VES-13 score greater than 3 was linked to a 2·12-fold higher likelihood of an incomplete RT course, with this likelihood increasing to 3·34 times higher when the score exceeded 7· ^{Reference Spyropoulou, Pallis, Leotsinidis and Kardamakis28} In urological cancer patients undergoing initial surgery or radiotherapy, those classified as frail based on the CGA had a higher risk of cancer-related hospitalizations compared to their fit counterparts (OR = 6·79, 95% CI 1·42–32·51). ^{Reference Monfardini, Morlino and Valdagni29} These findings underscore the critical importance of assessing frailty status in older adults proposed for RT, as it may facilitate the identification of individuals at increased risk for adverse outcomes. Furthermore, such assessments could enable the development of personalized treatment strategies, in this manner optimizing the potential benefits of RT for each older patient.

In the context of interpreting the domains evaluated within RT, our findings indicate that social aspects are the most frequently assessed, with cognition following closely. Notably, while pertinent data specific to the geriatric assessment domains within radiation oncology are not presently available, recent insights derived from a survey conducted by the ASCO reveal that cognitive assessment prominently ranks among the top five domains evaluated in the geriatric assessment of older adults with cancer. In accordance with these results, the assessment of functional status and falls predominates among the frequently employed tools in geriatric assessment. Additionally, other tools were utilized, involving evaluations of weight loss, comorbidities, life expectancy, chemotherapy toxicity, mood, and noncancer mortality risk. ^{Reference Dale, Williams and A30}

The observed increase in older cancer patients attending RT departments, acknowledged by the majority of respondents, aligns with published projections. Over the next two decades, Europe is predicted to witness a notable increase in the number of new cancer cases annually, reaching 4·5 million, with 65% and 50% of patients aged over 65 and 75, respectively. By 2050, the typical cancer patient in Europe is expected to be 70 years of age or older, reflecting the significant demographic change. ^{Reference Baumann, Ebert, Kurth, Bacchus and Overgaard31}

Furthermore, most participants emphasized the critical need for further training in geriatric oncology. Comprehensive training is imperative for healthcare professionals, as it is crucial for them to recognize that chronological age inadequately predicts tolerance and outcomes in older adults with cancer, emphasizing the need for treatment decisions to reflect this understanding. ^{Reference O’Donovan and Leech5} Expanding on this imperative, Morris et al. contribute valuable insights by providing an extensive compilation of global educational courses and strategies tailored to meet the upcoming training needs. ^{Reference Morris, Thiruthaneeswaran, Lehman, Hasselburg and Turner12}

The authors would like to highlight that this study has several limitations. The number of respondents falls short of the minimum threshold of 139 required to achieve a 95% confidence level with a 5% margin of error. Another limitation of this study is the use of closed-ended questions, which limited participants’ ability to elaborate on their responses. Including open-ended text boxes would have provided valuable data. Nevertheless, this pilot study underscores the necessity for further training in geriatric oncology and the importance of having dedicated geriatricians working alongside RO.