Globally, the proportion of patients diagnosed with cancer over the age of 65 is expected to increase due to population aging and advances in medical technology, and Korea is expected to enter the ultra-elderly society by 2025 [1]. According to the 2021 cancer registration statistics [2,3], the number of newly diagnosed cancer patients was more than 277,000, an increase of 10.8% (270,002) compared to last year, and as of January 2022, the number of cancer patients in Korea was 2.43 million, accounting for 4.7% of the total population, of which 1.19 million were aged 65 and above, making 1 in 7 people aged 65 and above a cancer patient. According to the statistics on causes of death [4], 22.4% of all deaths are due to cancer, which continues to be the leading cause of death every year, with people aged 80 and over accounting for 53.8% of all deaths, an increase of 17.0% from 10 years ago.

Although the disease burden of older cancer patients is increasing, their treatment decisions must take into account a complex set of diagnostic, therapeutic, and prognostic uncertainties that can lead to considerable disagreement about the best course of action. In particular, older patients may want limited involvement in treatment decisions, preferring to leave treatment decisions to their physicians [5-9]. Several studies report that most cancer specialists are reluctant to treat patients based on their advanced age alone and often choose less intensive treatments that are not optimal options [7,9]. In addition, most countries still do not have standardized approaches or guidelines in the decision-making process of treating elderly cancer patients, or are not well prepared to treat for elderly cancer patients with varying degrees of severity [10,11]. Korea is not much different, and there is a lack of research investigating patients’ understanding of treatment decision making in elderly cancer patients, or even basic research on the extent of professionals’ awareness.

Understanding the attitudes of cancer specialists toward the treatment of elderly patients is key to developing strategies to improve cancer treatment for elderly patients. To investigate and evaluate this, surveys have been conducted in other countries with different samples of elderly cancer patients and response rates [12-15], but none have been conducted in Korea. Therefore, we aimed to provide objective evidence that would be helpful in making treatment decisions for elderly cancer patients by investigating the perceptions related to treatment decision-making among Korean oncologists. This study was conducted to determine the level of awareness and the main factors influencing the decision-making process of specialists treating elderly cancer patients in Korea, and to investigate what needs to be improved to improve decision-making.

1. Study population

We surveyed physicians working in general hospitals or tertiary general hospitals in Korea regarding treatment decision- making for elderly cancer patients from July 8 to August 26, 2022. We sent the URL of the online survey to medical societies through a survey cooperation letter, and 19 out of 28 medical societies cooperated with the survey. The survey was conducted with subjects who understood the purpose and content of the study and voluntarily agreed to participate. The study was approved by the Institutional Review Boards of the National Evidence-based Healthcare Collaborating Agency (IRB number: NECA-IRB21-016, Date of registration: 17-June-2021).

2. Questionnaire and measurement

The survey questionnaire consisted of a 57-item single- or multiple-choice questionnaire in four parts as follows: (1) basic characteristics of respondents; (2) factors influencing geriatric cancer treatment decisions; (3) perceptions of geriatric cancer treatment-related items; (4) perceptions of improvements to enhance geriatric cancer treatment decisions.

Basic characteristics included baseline characteristics, clinical characteristics, institutional characteristics, satisfaction with institutional support systems, intention to use a geriatrician, presence of clinical practice guidelines, and need for clinical practice guideline development. Among the factors that influence geriatric cancer treatment decisions, ‘functional status’ refers to an individual’s ability to perform activities of daily living. The online survey took approximately 10-15 minutes to complete. This survey was conducted by Global Research Institute using their proprietary platform.

3. Statistical analysis

The sample size was estimated based on previous studies and calculated using a survey sample size calculator. The survey had a response rate of 23.0% (382/1,661). 382 cases were required to detect a margin of error of 5% at the 95% confidence level. Survey items with refusals or missing responses were excluded from analysis. The collected data were coded using Microsoft Excel^Ⓡ and analyzed using SPSS ver. 25.0^Ⓡ (IBM Corp., Armonk, NY, USA). Demographic, clinical, and socioeconomic characteristics of the respondents were analyzed using descriptive analysis to obtain proportions and means for each question.

1. Characteristics of the respondents

A total of 382 respondents were surveyed, and the results were detailed in Table 1. Their basic characteristics included age: 42.4% in their 40s, 32.5% in their 50s, and 19.4% in their 30s; 73.8% were male; 74.1% had a PhD. In terms of clinical characteristics, the most common specialty was surgical medicine at 50.8%, followed by internal medicine at 27.0%, hematologic oncology at 12.6%. 73.3% worked in private organizations; 82.2% of respondents worked in tertiary general hospital. More than 10 years of clinical experience was most common (67.0%), followed by 5-10 years (17.3%), and less than 5 years (15.7%). The average number of patients seen per week was 36.4% for 50-99, followed by 22.0% for less than 50, 18.3% for 100-149, 13.4% for 200＋, and 9.9% for 150-199. The percentage of cancer patients aged 65 and older seen per week was highest in the 15-30% group at 35.3%, followed by 31.9% in the 31-60% group, 24.1% in the 61-70% group, and 8.6% in the 71-100% group. 82.2% of respondents reported that their organization did not have a geriatrician; 81.4% of respondents reported that their organization had a multidisciplinary consulting system.

Table 1 . Baseline characteristics of the respondents (n=382).

Characteristic		No. of respondents (%)
Age (year)	≤29	1 (0.3)
	30-39	74 (19.4)
	40-49	162 (42.4)
	50-59	124 (32.5)
	≥60	21 (5.5)
Sex	Male	282 (73.8)
	Female	100 (26.2)
Marital status	Unmarried	42 (11.0)
	Married	336 (88.0)
	Other	4 (1.0)
Education	Bachelor	21 (5.5)
	Master	77 (20.2)
	Doctorate	283 (74.1)
	Other	1 (0.3)
Specialties	Hematologic oncology	48 (12.6)
	Internal medicine	103 (27.0)
	Surgical medicine	194 (50.8)
	Diagnostic radiology	6 (1.6)
	Other	31 (8.1)
Organization	Public	102 (26.7)
	Private	280 (73.3)
Type of hospital	General hospital	68 (17.8)
	Tertiary general hospital	314 (82.2)
Board certification (year)	<5	60 (15.7)
	5-9	66 (17.3)
	≥10	256 (67.0)
Average number of patients seen per week (No)	<50	84 (22.0)
	50-99	139 (36.4)
	100-149	70 (18.3)
	150-199	38 (9.9)
	≥200	51 (13.4)
Percentage of cancer patients aged ≥65 seen per week (%)	15-30	135 (35.3)
	31-60	122 (31.9)
	61-70	92 (24.1)
	71-100	33 (8.6)
Does your organization have a geriatrician?	Yes	68 (17.8)
	No	314 (82.2)
Do you have a multi-disciplinary consulting system?	Yes	311 (81.4)
	No	71 (18.6)
Are you satisfied with the support system at your organization?	Satisfied	72 (18.8)
	Neutral	198 (51.8)
	Unsatisfied	112 (29.3)
Are you willing to use a geriatrician if one is available?	Yes	282 (73.8)
	Neutral	73 (19.1)
	No	27 (7.1)
Do you believe there are available clinical guidelines for geriatric cancer patients?	Yes	49 (12.8)
	Neutral	141 (36.9)
	No	192 (50.3)
Do we need clinical guidelines for geriatric cancer patients?	Yes	325 (85.1)
	Neutral	49 (12.8)
	No	8 (2.1)

The percentage of respondents who were satisfied with their organization’s support system (18.8%) was lower than the percentage who were dissatisfied (29.3%). When asked if they would use a geriatrician if one were available, 73.8% of respondents said yes. When asked, “Do you believe there are clinical guidelines available for geriatric cancer patients?”, 12.8% answered yes and 50.3% answered no. When asked about the need for the development of clinical guidelines for geriatric cancer patients, 85.1% of respondents answered “yes”.

The majority (82.2%) of participants agreed that they would be less inclined to treat the patients if they were older. Among those who answered “yes” to the question, the age threshold for treatment was “85-89 years” (40.4%), followed by “75-84 years” (32.2%), “90 years or older” (19.1%), “65-74 years”, and “other” (4.1% each).

2. Factors influencing geriatric cancer treatment decision-making

Elderly cancer patients were asked to prioritize 1-3 out of 8 factors that were important in their treatment decisions; the first priority factor was “patient decision” (24.9%), followed by “cancer type” (22.0%) and “functional status” (17.0%). The second priority factor was “cancer stage” (26.4%), followed by “functional status” (19.4%), “cancer type”, and “patient frailty” (12.8% each). The third most important factor was “functional status” (21.2%), followed by “patient frailty” (16.2%) and “patient age” (15.4%). Prioritized responses to 8 factors related to cancer treatment decision-making in the elderly are shown in Figure 1.

Figure 1. Ranking of important factors in treatment decision making for older cancer patients

Of the eight considerations, 94.8% of respondents considered “functional status” to be the most important, followed by “patient decision” (90.8%), “patient frailty” (89.3%), and “cancer stage” (88.5%). The importance responses for 8 factors regarding cancer treatment decision making in older adults are summarized in Table 2.

Table 2 . Level of importance agreement for factors influencing geriatric cancer treatment decision-making (n=382).

	Agree*	Disagree†	Neutral‡
Functional status	94.8%	0.3%	5.0%
Co-morbidity	77.7%	1.3%	20.9%
Cancer type	75.9%	3.1%	20.9%
Cancer stage	88.5%	0.8%	10.7%
Patient decision	90.8%	0.5%	8.6%
Patient age	69.4%	6.0%	24.6%
Patient family intention	58.6%	6.0%	35.3%
Patient frailty	89.3%	1.6%	9.2%

Based on a Likert scale, where 1=strongly disagree, 2=somewhat disagree, 3=neutral, 4=somewhat agree, and 5=strongly agree..

Some percentages may not total 100% due to rounding..

*Percent “agree” was calculated using the sum of physicians who chose a 4 or 5 on the Likert scale. ^†Percent “disagree” was calculated using the sum of physicians who chose a 1 or 2 on the Likert scale. ^‡Percent “neutral” was calculated using physicians who chose a 3 on the Likert scale..

For the overall importance of 26 items (cancer/patient/ practice/organization related domain) considered in cancer treatment decision making for the elderly, the highest number of respondents (99.5%) considered “patient’s quality of life”, followed by “cancer stage” (99.2%), “patient’s functional age”, “nutritional status”, and “ability to live independently” (98.4% each). Table 3 summarizes the results of the top 10 rankings.

Table 3 . Top 10 rankings regarding geriatrics cancer treatment decision-making in 4 domains (n=382).

	Not very important (①)		Somewhat important (②)		Very important (③)		Important (②＋③)
	%		%		%		%
Patient’s quality of life	0.5		33.0		66.5		99.5
Cancer stage	0.8		42.9		56.3		99.2
Patient’s functional age	1.6		30.1		68.3		98.4
Nutritional status	1.6		47.4		51.0		98.4
Ability to live independently	1.6		50.5		47.9		98.4
Severity of cancer symptoms	1.8		41.1		57.1		98.2
Co-morbidity/medication overdose	2.4		71.2		26.4		97.6
Patient understanding	2.4		55.2		42.4		97.6
Side effects of cancer	3.1		59.9		36.9		96.9
Type of primary cancer	3.4		50.3		46.3		96.6
Difficulty in applying treatment	3.4		54.2		42.4		96.6

Among the four cancer-related items, “cancer stage” was the most important (99.2%), followed by “severity of cancer symptoms” (98.2%), “type of primary cancer” and “difficulty in applying treatment” (96.6% each). The importance of the fifteen patient-related items was highest for “patient’s quality of life” at 99.5%, followed by “patient’s functional age”, “nutritional status” (98.4% each), and “ability to live independently” (97.9%), while “patient’s visible age” was lowest at 77.5%. For the three practice-related items, “use of best practice guidelines” was most important (95.0%), followed by “access to additional consultation with specialists” (92.9%) and “access to palliative treatment” (91.1%). For the four organization-related items, the highest importance was for “collaboration with other stakeholders in the health care organization” (94.7%), followed by “distance between home and hospital” (87.1%), “access to local healthcare network” (83.3%), and “delays before treatment” (82.0%). The response results of 26 items in four domains are summarized in Supplementary Table 1.

3. Perceptions of geriatric cancer and treatment related clinical actions

For ten clinical actions related to geriatric cancer treatment, 91.6% of respondents agreed that “I modify treatment plans for older cancer patients to take into account their level of frailty and overall functional status,” followed by “I believe that the medical treatment of older adults with cancer needs to be improved” (89.0%) and “I would appreciate additional education on topics related to the treatment of older adults with cancer” (87.4%). Supplementary Table 2 summarizes the results of respondents’ perceptions of geriatric cancer treatment related clinical actions.

4. Perceptions of improvements to enhance geriatric cancer treatment decision making

We explored perceptions of what needs to be done to improve decision-making for older cancer patients at the organizational, national, or public level. When it comes to support needs at the organizational level, 79.3% of the respondents thought that “a support system for multidisciplinary discussions” was the most important, followed by “educational programs on caring and treatment for elderly cancer patients” (77.5%) and “standardized geriatric assessment tools” (75.1%). When it comes to agreeing on support needs at the national or public level, 78.5% of respondents said that “providing regular education and training programs on caring and treatment for elderly cancer patients” and “providing support to train geriatric specialists” are the most needed, followed by “developing a nationally standardized geriatric assessment tool” (77.5%) and “providing the up-to-date information to support decision making in caring for elderly cancer patients” (76.2%) (Table 4).

Table 4 . Awareness of areas for improvement in geriatric cancer treatment decision making (n=382).

Section	Items	Agree*	Disagree†	Neutral‡
Organizational level	A support system for multidisciplinary discussions	79.3%	3.4%	17.3%
	Educational programs on caring and treatment for elderly cancer patients	77.5%	3.1%	19.4%
	Standardized geriatric assessment tools	75.1%	2.9%	22.0%
	Support staff trained to specialize in geriatrics	70.9%	5.2%	23.8%
	Awareness activities to improve treatment for elderly cancer patients	65.7%	5.2%	29.1%
	Support clinical research involving elderly cancer patients	53.9%	9.7%	36.4%
National or public level	Providing regular education and training programs on caring and treatment for elderly cancer patients	78.5%	2.9%	18.6%
	Providing support to train geriatric specialists	78.5%	2.9%	18.6%
	Developing a nationally standardized geriatric assessment tool	77.5%	2.4%	20.2%
	Providing the up-to-date information to support decision-making in caring for elderly cancer patients	76.2%	3.7%	20.2%
	Encouraging multidisciplinary decision-making support activities	68.3%	3.7%	28.0%
	Supporting clinical research involving elderly cancer patients	62.6%	9.4%	28.0%

Based on a Likert scale, where 1=strongly disagree, 2=somewhat disagree, 3=neutral, 4=somewhat agree, and 5=strongly agree..

Some percentages may not total 100% due to rounding. *Percent “agree” was calculated using the sum of physicians who chose a 4 or 5 on the Likert scale. ^†Percent “disagree” was calculated using the sum of physicians who chose a 1 or 2 on the Likert scale. ^‡Percent “neutral” was calculated using physicians who chose a 3 on the Likert scale..

The most common area of improvement to improve decision making for elderly cancer patients was “development of clinical guidelines for the treatment of elderly cancer patients” (38.7%), followed by “provision or dissemination of accurate information about the treatment of elderly cancer patients” (25.4%), and “involvement of geriatric specialists in multidisciplinary consultations” (14.9%). The results for areas to improve treatment decision making for older cancer patients are shown in Figure 2.

Figure 2. Area to improve treatment decision making for older cancer patients

Treatment of older patients (65 years and older) with cancer can be challenging due to a number of medical, physiological, social, and economic factors, and there are many different stakeholders involved in the decision-making process. In this study, we investigated the attitudes and perceptions of physicians treating elderly cancer patients regarding treatment decision-making. Korean physicians treating elderly cancer patients were most likely to agree that “functional status” is the most important factor influencing treatment decisions for cancer patients, and ranked “patient decision” as the highest. However, the patient’s decision was the factor that was most often agreed to be very important on a 5-point scale, so this is likely a result of methodological differences in the analysis of importance agreement levels. Overall, functional status, patient decision, patient frailty, and cancer stage were considered important factors by Korean physicians, with more than 80% agreement. This is similar to the findings of Pang et al. [11], who reported that the most important factors influencing treatment decisions in elderly cancer patients were patient health status, comorbidities, patient decision, cancer type and stage, and Mohile et al. [16], who reported that patient age, functional impairment, and cognitive impairment were important considerations.

In this study, the majority of physicians (82.2%) agreed that they would be less inclined to treat the patients if they were older, and those who agreed were most likely to practice for less intensive treatment for cancer patients aged 85-89 years. In contrast to Pang’s study [11], where 80% of the responding physicians admitted that they were less inclined to treat patients over 75 years of age, our study found a higher level of agreement for less intensive treatment, with 91.8% agreeing for patients over 75 years of age. These findings are consistent with the fact that most physicians are still reluctant to provide standard treatment to elderly patients simply because of their advanced age. Due to the multifactorial nature of geriatric cancer, older cancer patients tend to be diagnosed later, have less complete evaluations, receive less advice from oncologists, and have unequal access to treatment decisions, resulting in suboptimal treatment [17].

Regarding the level of systems in place for the treatment of elderly cancer patients in Korea, the percentage of geriatricians was low (17.8%), but the level of multidisciplinary collaboration was higher than 80%. Satisfaction with institutional support systems was low, with more than 70% of respondents agreeing with the demand to utilize geriatricians and more than 85% agreeing with the need to develop clinical guidelines for geriatric cancer patients. A study by Pang et al. [11] also reported that although geriatrics has been a specialty in Singapore for 25 years, there is still no formal geriatric oncology service in Singapore and no standardized approach or guidelines in the decision-making process of treating elderly cancer patients.

In elderly cancer patients, anticancer treatments must be tailored to the life expectancy and functional status of each patient to ensure that the patient lives long enough to tolerate the side effects of the prescribed treatment and to achieve real benefit. The importance on decision making items of each decision dimensions for older cancer patients in this study was ranked in the following order “patient’s quality of life,” “cancer stage,” “patient’s functional age,” “nutritional status,” “patient’s ability to live independently,” “severity of cancer symptoms,” “comorbidities/medications,” “side effects of cancer,” “type of primary cancer,” and “difficulty using treatment,” which is similar to recent perceptions of importance for older cancer patients [17,18]. Therefore, a more structured approach is needed to optimize treatment options for older cancer patients. To standardize and facilitate the decision-making process in a multidisciplinary team, geriatric assessment scales have been developed [19,20], and several studies have been conducted to evaluate their validity and practical applicability in healthcare settings [21-23]. However, optimized healthcare services for geriatric cancer patients such as a standardized comprehensive geriatric assessment have not yet been activated in Korea, so more policy support and clinical efforts are needed.

This lack of geriatric specialists and high need for standardized GA tools for older cancer patients is consistent with the findings of previous studies. Mohile et al. [16]. found that only 23% of community oncologists use a standardized GA tool in their clinical practice, highlighting that GA helps to identify age-related factors (e.g., cognitive impairment and functional status) that are known to influence morbidity and mortality in older cancer patients but are often unrecognized in clinical practice. Several guidelines, including NCCN, recommend the use of GA to identify patients at risk for adverse events in older cancer patients [24]. Although GA has been validated in clinical oncology settings [25,26], oncologists are limited in its adoption due to lack of knowledge, training, and institutional barriers. However, the clinical practice item with the highest level of agreement in this study, “I modify treatment plans for older cancer patients to take into account their level of frailty and overall functional status” is a clinically meaningful and acceptable outcome given the proven ability of GA information to influence treatment decisions [23,27,28].

The need for support at both the hospital and national level to provide educational programs related to the caring and treatment of older cancer patients to improve treatment decision-making was also identified as a need in our study. This is consistent with previous studies that have shown that geriatric education is essential and that there is a high need for education or a lack of formal education for geriatric oncology patients [16,29]. Mohile et al. [16]. emphasized the need for further research to evaluate and improve geriatric education for oncologists. The study also examined the level of agreement on areas for improvement to improve decision-making in the treatment of older cancer patients, and the development of clinical guidelines for the treatment of older cancer patients was cited. This reflects the growing importance for oncologists to recognize geriatric issues as the population ages to ensure that appropriate, evidence-based healthcare is provided that helps and does not harm patients.

Despite these findings, there are several limitations to this study. First, there may have been selection bias due to the voluntary nature of the study and limited access to participants, which may have resulted in a lack of representativeness. Second, response bias may have been greater in an online environment due to the nature of the survey, and the anonymity of an environment free of social norms, unlike interviews or paper surveys, may have led to more candid responses. Third, while we did our best to keep the survey neutral and organized, the order of the questionnaire may have introduced a question order bias that could have affected responses. Fourth, although the number of physicians who participated in the survey cannot be said to be fully representative of the target population, a strength of the study is that many of the participants were physicians with more than 10 years of clinical experience and sufficient exposure to older cancer patients. Finally, the target population of cancer specialists included both diagnostic and nondiagnostic specialists, which may have resulted in incomplete responses due to different perspectives on relevant items such as clinical behaviors. Despite these limitations, the inclusion of physicians with relatively extensive clinical experience from a variety of specialties, which increases the generalizability of the findings, is a major strength of the study.

In this online web survey, physicians involved in the treatment of elderly cancer patients in Korea showed a high level of agreement for less intensive treatment in elderly cancer patients, most commonly seen in elderly cancer patients aged 75 years and older. While they valued the patient’s decision in treatment decisions, they also considered functional status, patient frailty, and cancer staging as important factors. To improve treatment decisions for older cancer patients, the first essential strategy may be to provide support systems for multidisciplinary discussion, geriatric cancer patient-related education and training programs, and support for the development of geriatric experts. In addition, support from professional societies and national body should be strengthened to facilitate the development and dissemination of clinical guidelines for the management of older cancer patients and the provision of objective information.

This study was supported by the National Evidence-based Healthcare Collaborating Agency (NECA; project number NA22-006).

All authors have no conflict of interest relevant to this study.