Complex Decisions in Oncology: Addressing Overtreatment and Undertreatment in Elderly Cancer Patients
Abstract
Modern medicine, despite its numerous benefits, often places oncologists in complex clinical scenarios. These situations require intricate choices to ensure patients receive optimal treatment. Advanced cancer patients, especially in borderline situations of expected benefit or increased risk of complications, face unique challenges.1 Overtreatment and undertreatment represent the two extremes of the therapeutic spectrum, both of which signify suboptimal management of cancer patients. These concepts vary significantly across different medical disciplines, healthcare providers, and patients, as there is no universally accepted definition.2 Oncologists undertake complex decision-making processes following detailed discussions with patients and their families, aiming to find the optimal balance in the therapeutic strategy. The question arises: Is it appropriate to recommend a new line of treatment for all cancer patients in the same manner, including elderly advanced cancer patients with comorbidities? As a palliative medicine specialist working in a government hospital in a developing country, when I consult with elderly advanced cancer patients who are resistant to the first-line available treatment, a primary concern for both patients and their relatives is whether to initiate a new, costly treatment with potentially unknown or limited efficacy, as recommended by the oncologist. From an ethical perspective, in some cases, the recommended treatment by oncologists may not be appropriate. This can be evaluated by considering the four fundamental principles of ethics: autonomy, beneficence, non-maleficence, and justice.
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12. Piili RP, Lehto JT, Luukkaala T, Hinkka H, Kellokumpu-Lehtinen PL. Does special education in palliative medicine make a difference in end-of-life decision-making?. BMC Palliative Care. 2018 Dec;17:1-1.
13. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA. Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine. 2010 Aug 19;363(8):733-42.
2. DuMontier C, Loh KP, Bain PA, Silliman RA, Hshieh T, Abel GA, Djulbegovic B, Driver JA, Dale W. Defining undertreatment and overtreatment in older adults with cancer: a scoping literature review. Journal of Clinical Oncology. 2020 Aug 1;38(22):2558-69.
3. Mohile S, Dale W, Hurria A. Geriatric oncology research to improve clinical care. Nature reviews Clinical oncology. 2012 Oct;9(10):571-8.
4. Zeng C, Wen W, Morgans AK, Pao W, Shu XO, Zheng W. Disparities by race, age, and sex in the improvement of survival for major cancers: results from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program in the United States, 1990 to 2010. JAMA oncology. 2015 Apr 1;1(1):88-96.
5. Mohile SG, Dale W, Somerfield MR, Schonberg MA, Boyd CM, Burhenn PS, Canin B, Cohen HJ, Holmes HM, Hopkins JO, Janelsins MC. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. Journal of clinical oncology. 2018 Aug 1;36(22):2326-47.
6. Lehtonen M, Heiskanen L, Reinikainen P, Kellokumpu-Lehtinen PL. Both comorbidity and worse performance status are associated with poorer overall survival after external beam radiotherapy for prostate cancer. BMC cancer. 2020 Dec;20:1-8.
7. Wright JD, Doan T, McBride R, Jacobson JS, Hershman DL. Variability in chemotherapy delivery for elderly women with advanced stage ovarian cancer and its impact on survival. British journal of cancer. 2008 Apr;98(7):1197-203.
8. Sarfati D. Review of methods used to measure comorbidity in cancer populations: no gold standard exists. Journal of clinical epidemiology. 2012 Sep 1;65(9):924-33.
9. Clarke G, Johnston S, Corrie P, Kuhn I, Barclay S. Withdrawal of anticancer therapy in advanced disease: a systematic literature review. BMC cancer. 2015 Dec;15:1-9.
10. Passaro A, Spitaleri G, Gyawali B, de Marinis F. Immunotherapy in non–small-cell lung cancer patients with performance status 2: clinical decision making with scant evidence. Journal of Clinical Oncology. 2019 Aug 1;37(22):1863-7.
11. Sanoff HK, Chang Y, Lund JL, O'Neil BH, Dusetzina SB. Sorafenib effectiveness in advanced hepatocellular carcinoma. The oncologist. 2016 Sep 1;21(9):1113-20.
12. Piili RP, Lehto JT, Luukkaala T, Hinkka H, Kellokumpu-Lehtinen PL. Does special education in palliative medicine make a difference in end-of-life decision-making?. BMC Palliative Care. 2018 Dec;17:1-1.
13. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA. Early palliative care for patients with metastatic non–small-cell lung cancer. New England Journal of Medicine. 2010 Aug 19;363(8):733-42.
| Files | ||
| Issue | Vol 17 No 1 (2025) | |
| Section | commentary | |
| Keywords | ||
| Oncology Overtreatment Undertreatment | ||
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How to Cite
1.
Ziaei SG, Tahmasebi M. Complex Decisions in Oncology: Addressing Overtreatment and Undertreatment in Elderly Cancer Patients. Basic Clin Cancer Res. 2026;17(1):241-243.
