Older People With Cancer: Nearly Half of Cases, Too Little Tailored Care

Cancer is mostly a disease of later life: close to half of all new cancers worldwide (47.5% in 2012) are diagnosed in people aged 65 and over. Yet older people with the same cancer are often less likely to receive standard treatment, the trials behind that treatment rarely reflect them, and geriatric assessment, an approach shown in randomised trials to make treatment safer for them, looks for the problems that standard oncology assessments do not routinely capture.

For many families, cancer arrives alongside other things that come with age: a heart condition, a handful of daily medicines, a fall last winter, a partner who now needs care too. Good cancer care for older people means seeing all of that, not just the tumour and not just the date of birth. The evidence below shows where services already know how to do this, and where age is still standing in for a proper assessment of what a person can and wants to go through.

Nearly half of new cancers are in people over 65, and the share is rising

The clearest global picture of cancer in later life comes from studies that broke down the GLOBOCAN estimates of the International Agency for Research on Cancer (IARC) by age. In 2012, an estimated 6.7 million new cancer cases, 47.5% of all cancers worldwide, were diagnosed in people aged 65 and over. This is not only a rich-country pattern: nearly 48% of those cases occurred in what the study classed as less developed regions^[1].

Within individual countries the concentration in later life is plain. In the United States, the National Cancer Institute reports from SEER registry data that the median age at a cancer diagnosis is 67 years (71 for lung cancer, 68 for prostate, 66 for colorectal and 63 for breast). The incidence rate for all cancers climbs from fewer than 26 cases per 100,000 people in age groups under 20 to more than 1,000 per 100,000 in age groups 60 and over (age-specific rates, SEER 21 registries, 2018-2022)^[4]. In the UK, 37% of all new cancer cases are diagnosed in people aged 75 and over, and incidence rates are highest at ages 85 to 89 (cases diagnosed in 2019 and 2021-2022)^[2].

The oldest group is also growing quickly. An estimated 2.6 million new cancers in 2022, 14% of all cases worldwide (excluding non-melanoma skin cancer), were in people aged 80 and over (GLOBOCAN 2022 estimates)^[5]. In sub-Saharan Africa, where populations are younger, people aged 60 and over still accounted for one-third of all cancers registered in 2008-2012 in four population-based registries covering selected regions of Kenya (Nairobi), South Africa (Eastern Cape), Uganda (Kyadondo County) and Zimbabwe (Harare), almost 9,000 cases^[6].

Projections point the same way. Applying population projections to 2012 rates, and assuming those rates do not change, the authors estimated 14 million new cancers in people aged 65 and over by 2035, almost 60% of the global total, with the number of cases rising by 144% in less developed regions against 54% in more developed regions^[1]. A projection from 2022 rates, again assuming no change in rates, put cases in people aged 80 and over at 7.4 million by 2050, with the largest increases expected in China, India and Africa^[5]. These are projections of case numbers driven by population ageing, not forecasts that any one person's risk is rising; how ageing and growth drive case counts is covered in our article on cancer incidence trends.

With the same cancer, older people are less likely to receive standard treatment

Population registries in several countries show the same pattern: the older the person, the less often they receive the treatment that guidelines describe as standard for their cancer and stage. Some of that difference is appropriate. Treatment that suits a fit 60-year-old may do more harm than good for someone with serious heart disease or advanced frailty, and some people choose a gentler path. The question the data raise is how much of the gap reflects those things, and how much reflects age alone.

Breast cancer in England and Wales is the best-documented case. Among 83,188 women aged 50 and over with early invasive breast cancer (stage 1-3A) diagnosed in 2014-2017, the share who had no breast surgery rose steeply with age for oestrogen-receptor-positive cancers: 5.6% at ages 70-74, 11.0% at 75-79 and 41.9% at 80 and over. For oestrogen-receptor-negative cancers the figures were 3.8%, 3.7% and 12.3%. Crucially, the authors found that the lower rate of surgery for oestrogen-receptor-positive cancer persisted in women with good fitness, and concluded that the reasons should be explored to ensure consistency in treatment decisions^[7]. Registry data alone cannot say how far each decision reflected other illness, a woman's own informed preference, or an assumption about age.

Bowel cancer shows similar gaps. In the Eindhoven Cancer Registry area of the southern Netherlands, 85% of people under 65 with stage III colon cancer diagnosed in 2001-2007 received chemotherapy after surgery, against 68% at ages 65-74 and 17% at 75 and over, with large differences between hospitals. Comorbidity independently lowered the odds of treatment, and in the multivariable analysis older age itself was no longer a significant predictor of poorer survival, whereas receiving adjuvant chemotherapy was the most important predictor of survival^[8]. Because this is observational data, people who were treated may also have been fitter in ways the registry did not record. These data are now old, and practice has changed, but the hospital-to-hospital variation is the telling part: the same age band, very different care depending on where people were treated.

Whether less treatment means worse outcomes is genuinely hard to tell

Observational studies cannot settle whether older people are under-treated or appropriately treated, because the people who do not receive treatment usually differ in ways that also affect survival. Two population studies of stage III colon cancer, from different continents, show why the answer is not simple. Both used routine records and statistical adjustment rather than randomisation.

In the Georgia Comprehensive Cancer Registry in the United States (people diagnosed in 2000-2007), just over one-third of people with stage III colon cancer did not receive adjuvant chemotherapy, and the proportion rose with age. Receiving it was linked to better five-year overall survival, and that survival benefit was seen across age groups; the authors called for efforts to ensure treatment, unless contraindicated, for people up to 84 years of age^[9]. In Osaka Prefecture, Japan (people who had curative surgery in 2010-2014 at 36 cancer care hospitals), 36.8% of people aged 75 and over received adjuvant chemotherapy against 73.3% of those under 75. After weighting for measured differences, chemotherapy was associated with lower all-cause mortality under 75 (hazard ratio 0.56) but showed no clear association at 75 and over (hazard ratio 1.07, 95% confidence interval 0.66-1.74). The authors concluded that the clinical effectiveness of adjuvant chemotherapy in older people appeared limited under current utilisation practices^[10].

Neither study can say that treating more older people would or would not help: both rely on routine data, and frailty and comorbidity are recorded imperfectly. What they show together is that age bands are a blunt instrument. The variation within each band, between hospitals and between countries, is where the evidence points to decisions that could be made better.

Frailty, more than age, predicts who struggles with treatment

A systematic review of 20 observational studies covering 2,916 older people with cancer found a median frailty prevalence of 42% (range 6% to 86% across studies) and a median pre-frailty prevalence of 43% (range 13% to 79%); a median of 32% were classed as fit. Frailty was independently associated with higher all-cause mortality (adjusted five-year hazard ratio 1.87) and with intolerance of cancer treatment (adjusted odds ratio 4.86)^[11]. The wide ranges matter: depending on who is counted and how, a group of 75-year-olds with cancer can be mostly fit or mostly frail. Chronological age on its own tells a clinician little about which.

The gap shows up in survival trends too. Across seven high-income countries in the International Cancer Benchmarking Partnership (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK), age-standardised net survival rose between 1995 and 2014 for almost all of the seven cancers studied, but improvements were larger for people diagnosed before age 75 than for those aged 75 and over, notably for cancers with a poor outlook such as oesophagus, stomach, pancreas and lung. The authors named stage at diagnosis, timely access to effective treatment and comorbidity as likely main drivers of differences in outcomes^[12]. International comparisons are covered in more depth in our article on cancer survival around the world.

Geriatric assessment cut serious side-effects and hospital admissions in randomised trials

Geriatric assessment is a structured look at the things a standard oncology review tends to miss: physical function and falls, memory and thinking, mood, other illnesses, the number of medicines a person takes, nutrition and the support they have at home. Unlike the observational data above, its effects have been tested in randomised trials.

The largest, GAP70+, randomised 40 community oncology practices across the United States. It enrolled 718 people aged 70 and over (mean age 77) with incurable solid tumours or lymphoma, each with at least one impaired geriatric assessment domain, who were starting a new treatment such as chemotherapy. Where oncologists received a tailored geriatric assessment summary with management recommendations, 51% of people had serious (grade 3-5) toxic effects over three months, against 71% in usual care: a relative risk of 0.74 (95% confidence interval 0.64-0.86). Fewer people fell (12% against 21%) and more medicines were stopped^[3].

In Australia, the INTEGERATE trial randomised 154 people aged 70 and over starting chemotherapy, targeted therapy or immunotherapy at three hospitals, in 2014-2018. Comprehensive geriatric assessment integrated into oncology care led to better health-related quality of life over 24 weeks and fewer unplanned hospital admissions (adjusted incidence rate ratio 0.60, 95% confidence interval 0.42-0.87). There was no statistically significant difference in overall survival^[13].

The evidence is not uniform. A 2024 meta-analysis of randomised trials found that the effect of geriatric assessment-guided care on overall quality of life was variable: a potential improvement at three months (Cohen's d 0.27, 95% confidence interval -0.03 to 0.58, moderate certainty) could not be excluded, and larger trials, and trials that required assessment before treatment began, were more likely to report benefit^[14]. The fair summary is that geriatric assessment has repeatedly reduced harms from treatment and unplanned hospital use, without trial evidence that it lengthens life.

All of this rests on a thin evidence base for older people in general, because they are under-represented in the trials that set the standard treatments in the first place; that gap is examined in our article on access to cancer clinical trials.

What the evidence asks of us

The evidence does not say older people should always have more treatment. It says decisions should rest on a proper assessment of the whole person rather than on age, and that services can do this now. Professional bodies have already set out what that looks like.

• Make geriatric assessment routine, with action on what it finds. The American Society of Clinical Oncology's 2023 guideline update, based on a systematic review of 26 publications, recommends geriatric assessment for all people with cancer over 65 to identify vulnerabilities not routinely captured in oncology assessments, and geriatric assessment-guided management for those aged 65 and over receiving systemic therapy who have identified deficits. It names the domains to cover: physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition and social support^[15]. Commissioners and cancer networks can fund the time and geriatric input this needs.
• Measure treatment by age and fitness, not age alone. Breast cancer data for England and Wales show that a lower surgery rate persisted in older women recorded as fit^[7], and Dutch registry data showed wide variation between hospitals^[8]. Audits that report treatment rates by age band, frailty and comorbidity, hospital by hospital, let services see where age is doing the work an assessment should.
• Build the evidence for the people who actually get cancer. With close to half of all cancers worldwide diagnosed at 65 or over, and that share rising, trials that include older and frailer people, and that measure function and quality of life as well as survival, are the only way to replace the uncertainty seen in the observational studies above.
• Plan for growth everywhere, not only in rich countries. Projections show the largest relative rises in cancer cases among older people in less developed regions^[1]. The International Society of Geriatric Oncology's updated priorities set out actions on education, clinical practice, research and partnerships, considered separately for high-income and low- and middle-income countries, in support of universal health coverage for older adults with cancer^[16].

Older people are close to half of everyone diagnosed with cancer, and on current projections will soon be the majority: not a special case. A cancer service that is good for them is, in large part, simply a good cancer service. More evidence across the whole cancer pathway is collected in our cancer research library.

Language: this piece says "people with cancer" and "people living with and after cancer", and describes the illness and its treatment plainly, without combat metaphors. Clinical terms such as "stage", "incidence" and "net survival" are used in the sense the cited source defines them.

Why we're publishing this

Charities, hospices and support groups spend much of their time with older people affected by cancer and the partners and families who care for them. They hear of treatments ruled out, or pushed through, without anyone asking about the things that shape how an older person copes. We are publishing these figures so that organisations can make the case, with the evidence in hand, for care that is fitted to the person rather than to their date of birth, and for research that includes the people who most often get cancer.

How to read this data

The incidence figures are shares and counts of new cases from GLOBOCAN estimates (2012 for people aged 65 and over, 2022 for those aged 80 and over), the US SEER registries and UK registry data; the SEER rates quoted are age-specific, and the Cancer Research UK page does not state the rate type, so only its share of cases is used here. Projections apply population forecasts to fixed rates and describe case numbers, not individual risk.

The treatment figures come from observational registry studies. They show who received treatment, not whether each decision was right: frailty, other illness and personal preference are recorded imperfectly, and the studies themselves say so. The Dutch and US colon cancer data describe people diagnosed in the 2000s and practice has changed since. The geriatric assessment evidence comes from randomised trials, which can show cause and effect, but these trials were run in the United States and Australia in people aged 70 and over starting systemic treatment, and their results may not transfer to every health system. Evidence from low- and middle-income countries is much thinner than from high-income countries; the global incidence estimates are the main exception.

Use this data

Free to cite with attribution to Better Health For Everyone. Charities, campaigners and journalists are welcome to reuse these figures and charts. For the underlying figures as a spreadsheet, get in touch.

Important: This article summarises published research for general information. It is not medical advice and cannot be used to diagnose, treat or predict anything about an individual. If you have concerns about your own or someone else's health, please speak to a qualified health professional.

Sources

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