Healthcare Professionals' Perceptions of Decision-Making for Older Patients with Cancer Receiving Systemic Therapy: A Systematic Review and Qualitative Evidence Synthesis

Abstract

Decision-making about systemic therapy in older adults with cancer is complex due to frailty, clinical uncertainty, and competing treatment goals. Limited evidence exists synthesizing how healthcare professionals support decision-making in geriatric oncology. This qualitative systematic review searched four databases through November 2025 and conducted citation tracking. Thematic synthesis was performed, and confidence in findings was assessed using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). Twelve studies involving 212 healthcare professionals were included. Two analytical and six descriptive themes were identified. Healthcare professionals sought to minimize treatment-related harm while respecting patients’ values and life perspectives. Decision-making was shaped by clinical judgment integrating geriatric assessment findings, healthcare professionals’ perspectives, ethical considerations regarding beneficence and autonomy, and structural factors such as resource limitations and interprofessional collaboration. These findings highlight the need for clinical expertise, collaboration across oncology, primary care, and geriatric care providers, and system-level support for geriatric-informed care.

INTRODUCTION

Cancer is one of the leading causes of morbidity and mortality worldwide. In 2022, an estimated 20 million new cancer cases were diagnosed and 9.7 million deaths occurred globally.¹) The global population is aging,^2,3) and aging is the strongest risk factor for cancer development.⁴) As a result, the burden of cancer is increasingly concentrated among older adults. Historically, older adults have been less likely to receive guideline-recommended treatments⁵) and are often excluded from multimodality cancer therapies due to frailty and reduced physiological reserve.⁶) However, advances in cancer treatment have expanded therapeutic opportunities for older adults.⁷) In particular, the shift toward outpatient-based systemic therapy has increased the feasibility of treatment in this population. Indeed, the number of older adults receiving systemic therapy has been increasing.⁸) These changes have made treatment decision-making for systemic therapy in older adults a critical issue in geriatric oncology.

In recent years, the use of comprehensive geriatric assessment (CGA) has been internationally recommended to support treatment decision-making in older adults with cancer.⁹) CGA provides a comprehensive evaluation of multiple domains, including physical function, cognition, psychological status, and social conditions.¹⁰) It has also been shown to reduce treatment toxicity and improve quality of life.¹¹) However, its implementation in clinical practice remains limited due to time constraints and insufficient human and material resources.¹²) Although CGA can identify vulnerabilities that are not captured by conventional measures such as the Eastern Cooperative Oncology Group (ECOG) performance status, it remains unclear which of its domains are most strongly associated with clinical outcomes.^13,14) Therefore, treatment decision-making in practice often relies on healthcare professionals’ clinical experience and judgment.¹⁵)

In this context, healthcare professionals play a key role in supporting decision-making for older adults with cancer. Decision-making about systemic therapy involves balancing expectations of treatment effectiveness and survival,¹⁶) along with the goal of maintaining functional independence,¹⁷) against concerns about treatment burden, functional decline,^13,18) and fear of disease progression.¹⁹) Shared decision-making (SDM), which is based on dialogue among patients, families, and healthcare professionals, has been emphasized as an important approach in such situations.²⁰) Family members are also actively involved in decision-making while respecting patients’ values and preferences.^21,22) However, in geriatric oncology, healthcare professionals often experience difficulty navigating patients’ vulnerability and clinical uncertainty,²³) making the implementation of SDM challenging in practice. Decision-making in this context involves clinical judgment that integrates patients’ conditions, treatment goals, and ethical considerations under conditions of uncertainty. Such judgment may be understood as practical wisdom, enabling appropriate action based on ethical reflection and clinical experience.

Thus, decision-making about systemic therapy in older adults with cancer occurs within a complex context influenced by treatment benefits and burdens, patients’ and families’ values, and healthcare system and resource constraints. Although the importance of CGA and SDM is widely recognized, their implementation in clinical practice remains limited, and healthcare professionals’ experiences and perceptions play a crucial role. While qualitative studies have explored treatment decision-making in this population, there has been limited qualitative evidence synthesis integrating these findings to examine how healthcare professionals support decision-making under conditions of clinical uncertainty and ethical tension. In particular, it remains insufficiently theorized how healthcare professionals integrate multiple considerations, including balancing treatment benefits and harms, respecting patient autonomy, and fulfilling their professional responsibilities. Therefore, this systematic review and qualitative evidence synthesis was conducted to explore healthcare professionals’ experiences and perceptions regarding decision-making for systemic therapy in older adults with cancer. By elucidating how healthcare professionals integrate clinical judgment and ethical reasoning under uncertainty, this study advances theoretical understanding of decision-making in geriatric oncology and informs clinical practice.

MATERIALS AND METHODS

Study Design and Protocol Registration

This study was conducted as a qualitative systematic review with thematic synthesis to explore healthcare professionals’ perceptions and experiences of decision-making for older adults with cancer receiving systemic therapy. Decision-making in older adults with cancer is particularly complex due to multimorbidity, frailty, functional decline, and competing health priorities. Understanding healthcare professionals’ perspectives is therefore essential to optimize geriatric oncology practice.

The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.²⁴) The completed PRISMA 2020 checklist is provided in Supplementary Table S1. The review protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD420250655491).

Search Strategy

A comprehensive literature search was performed in the following electronic databases: MEDLINE (via PubMed), CINAHL, Web of Science Core Collection, and APA PsycINFO. The search strategy was developed using the Joanna Briggs Institute PICo framework (Population/Participants, Phenomenon of Interest, and Context), which is recommended for qualitative evidence synthesis.²⁵) Controlled vocabulary and free-text terms were combined using Boolean operators. The full search strategies for all databases are provided in Supplementary Table S2. To identify additional relevant studies and ensure comprehensive coverage, we conducted supplementary citation-based searching. Specifically, we performed forward citation tracking of included studies using Google Scholar and backward reference list screening to identify articles citing or that are foundational to these studies. This approach is consistent with established snowballing methods for systematic reviews.²⁶) Records identified through citation tracking were assessed separately from database search results in accordance with PRISMA 2020 reporting standards. The search period was extended from that specified in the registered protocol to include studies published through November 2025.

Eligibility Criteria

This systematic review was conducted in accordance with a pre-specified protocol that defined the inclusion and exclusion criteria. Studies were included if they met the following criteria: (1) involved healthcare professionals caring for older adults aged 65 years or older who had received systemic therapy for cancer; (2) reported qualitative data on healthcare professionals’ experiences or perceptions of treatment decision-making for patients receiving systemic therapy; (3) used qualitative or mixed-methods designs; and (4) were peer-reviewed articles published in English.

Qualitative study designs included qualitative descriptive studies, phenomenological studies, grounded theory approaches, and interview-based studies. Mixed-methods studies were included only if qualitative data could be extracted separately. Studies were excluded if they were quantitative studies, case reports, review articles, or publications in languages other than English.

Study Selection

The literature search and removal of duplicate records were conducted by a research librarian (M.N.). Two reviewers (K.H. and H.T.) independently screened titles and abstracts for potential eligibility, and subsequently screened full texts of potentially relevant articles against the inclusion criteria.

Disagreements at any stage were resolved through discussion. When consensus could not be reached, a third reviewer (S.K.) was consulted. The study selection process is presented in the PRISMA flow diagram (Fig. 1).

Fig. 1.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 flow diagram of the study selection process.

Quality Assessment

The methodological quality of the included studies was assessed using the Critical Appraisal Skills Programme (CASP) qualitative research checklist.²⁷) This tool evaluates clarity of aims, methodological rigor, recruitment strategy, data collection, reflexivity, ethical considerations, data analysis, findings, and overall value of the research.

Two reviewers (K.H. and H.T.) independently conducted the quality appraisal. Discrepancies were resolved through discussion with a third reviewer (S.K.) until consensus was reached. Quality appraisal results are presented in Table 1.

Table 1.

Methodological quality assessment of the included studies using the CASP checklist

Study	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10
Sutton et al.36)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Rodenbach et al.37)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Kumar et al.38)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Loh et al.39)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Tsuboi et al.40)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Foley et al.41)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Bluhm et al.42)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Brom et al.43)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Puts et al.44)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Bluhm et al.45)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Dhotre et al.46)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y
Schildmann et al.47)	Y	Y	Y	Y	Y	CT	Y	Y	Y	Y

CASP, Critical Appraisal Skills Programme; Y, yes; N, no; CT, cannot tell.

Data Extraction and Thematic Synthesis

Data were extracted by the first author (K.H.) using a standardized extraction form. Extracted information included authors, year, country, study design, setting/context, data collection methods, data analysis methods, study aims, participant characteristics, and main findings. The accuracy of the extracted data was independently verified by two co-authors (H.T. and S.K.).

Qualitative findings were synthesized using the thematic synthesis approach described by Thomas and Harden.²⁸) This approach involves three stages: (1) line-by-line coding, (2) development of descriptive themes, and (3) generation of analytical themes.

First, participant quotations and authors’ interpretations from the results sections of included studies were coded line-by-line. Codes were compared and grouped to form descriptive themes. These descriptive themes were then interpreted in relation to the review objective to generate higher-level analytical themes. Analytical rigor was ensured through iterative discussions among the review authors until consensus was reached. If relevant information was unclear, the reviewers reached consensus based on the information reported in the original studies.

Assessment of Level of Confidence in the Findings

Confidence in the synthesized findings was assessed using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.^29-35) CERQual evaluates confidence in qualitative evidence based on four components: methodological limitations, coherence, adequacy of data, and relevance.

For each review finding, these four components were assessed and rated as having no or very minor concerns, minor concerns, moderate concerns, or serious concerns. Based on these assessments, an overall level of confidence was assigned to each finding and classified as high, moderate, low, or very low confidence. The final CERQual assessment levels were determined through discussion and consensus among the authors.

RESULTS

Study Selection and Characteristics

The study selection process is presented in Fig. 1. A total of 4,031 records were identified through database searching (MEDLINE via PubMed, CINAHL, Web of Science Core Collection, and APA PsycINFO). After removing 1,010 duplicate records, 3,021 records remained for title and abstract screening, of which, 2,976 records were excluded. From the 45 reports retrieved and assessed for full-text eligibility, 33 were excluded. In addition, all the 15 records identified through forward and backward citation tracking using Google Scholar were excluded. Finally, the 12 studies that met the inclusion criteria were included in the final synthesis.^36-47)

Of the included studies, six were conducted in the United States, two in the United Kingdom, and one each in Canada, Japan, the Netherlands, and Switzerland. A total of 212 healthcare professionals participated across all studies. Most studies were conducted in hospital-based oncology settings and focused on decision-making about systemic therapy for older adults with advanced or incurable cancer (Table 2).

Table 2.

Characteristics of the included studies

Study (year), Country	Design	Setting/Context	Data collection	Data analysis	Aim	Participants (HCPs)	Main findings
Sutton et al.36) (2025), UK	Mixed methods approach (qualitative sub-study)	Outpatient oncology day unit; decision-making about systemic anti-cancer therapy in older adults.	Semi-structured interviews	Thematic analysis	To explore patients’, carers’, and clinicians’ perceptions of treatment decision-making in older adults with cancer, and the acceptability of the electronic frailty index in informing systemic anti-cancer treatment decisions.	Clinicians (n=12):	Clinicians perceived chemotherapy in frail older adults as a treatment with uncertain benefit and substantial risk, using the electronic frailty index as a supportive tool rather than a replacement for clinical judgment in shared decision-making.
						-Clinical nurse specialist (41.7%)
						-General practitioner (25.0%)
						-Clinical oncologist (8.3%)
						-Geriatrician (8.3%)
						-Medical oncologists (8.3%)
						-Palliative care consultant (8.3%)
Rodenbach et al.37) (2024), USA	Qualitative study	Academic transplant centers; simulated decision-making conversations regarding allogeneic hematopoietic cell transplantation in older patients with myelodysplastic syndromes.	In-depth semi-structured interviews	Qualitative analysis	To explore communication strategies used by transplant hematologists to facilitate decision-making among older adults who are high-risk patients.	Hematologists (n=37):	Key strategies included managing uncertainty, providing information tailored to patient needs, and aligning with patient values.
						-Large urban area (65%)
						-Moderate size city that draws from a rural state (35%)
Kumar et al.38) (2023), USA	Qualitative study	Oncology practice settings; treatment decision-making for newly diagnosed Hodgkin lymphoma among practicing oncologists.	Semi-structured interviews	Thematic analysis	To gather perspectives from and to examine the decision processes among oncologists caring for patients with newly diagnosed Hodgkin lymphoma.	Oncologists (n=22)	Oncologists perceived that decision-making required balancing curative potential with treatment burden, managing prognostic uncertainty, and adapting communication to patients' needs.
Loh et al.39) (2021), USA	Qualitative study	Academic tertiary cancer center and community oncology settings; treatment decision-making in older adults with acute myeloid leukemia (AML).	Individual semi-structured in-depth interviews	Content analysis	To elicit factors influencing treatment decision-making among older patients with AML and community oncologists.	Community oncologists (n=15):	Community oncologists cited frailty, high toxicity risk, limited treatment options, and uncertain prognosis as challenges in treating older patients with AML. They struggle to balance aggressive treatment with quality of life.
						-Oncologists (86.7%)
						-Hematologists (80.0%)
Tsuboi et al.40) (2020), Japan	Qualitative study	Oncology settings; palliative chemotherapy decision-making in older adults with advanced cancer.	Individual semi-structured in-depth interviews	Content analysis	To evaluate the experiences and needs of older patients with advanced cancer, their families, and their physicians in palliative chemotherapy decision-making.	Physicians (n=15):	Physicians viewed older adults as vulnerable due to frailty, comorbidities, and reduced treatment tolerance. They described difficulty discussing treatment limitations and navigating family expectations.
						-Organ specialists (100%)
Foley et al.41) (2019), Switzerland	Interpretative approach	Oncogeriatric setting; experiences of older adults receiving palliative chemotherapy, including home-based medication management.	Open-ended interviews	Thematic analysis	To explore how elderly cancer patients and health professionals perceive, experience, and adapt to the demands of palliative chemotherapy within an oncogeriatrics context.	Health professionals (n=12):	Elderly cancer patients experienced significant treatment burden and adapted by reorganizing their daily lives and relying on support. Health professionals viewed elderly patients as physiologically vulnerable with limited tolerance, emphasizing individualized plans and clear communication.
						-Oncologists (42%)
						-Nurses (58%)
Bluhm et al.42) (2017), USA	Qualitative descriptive study	Oncology practice; end-of-life chemotherapy decision-making in incurable cancer.	Individual semi-structured in-depth interviews	Content analysis	To investigate the influence of patient age on oncologists' chemotherapy decisions at the end of life.	Oncologist (n=17)	Oncologists identified patient age as a key factor in their chemotherapy decisions. They believed older adults with cancer were less likely to want or tolerate treatment.
Brom et al.43) (2017), The Netherlands	Longitudinal qualitative study	Hospital oncology settings; shared decision-making processes in advanced cancer care.	Face-to-face in-depth interviews	Open coding based on grounded theory and longitudinal thematic analysis	To gain greater insight into treatment decision-making in patients with advanced cancer by examining how the four steps of shared decision making are adhered to in clinical decision-making regarding chemotherapy.	Physicians (n=18)	Many physicians perceived themselves as having a decisive role in decision-making, believing that not all patients could make their own decisions and that physicians therefore needed to take the lead in their patients' best interests.
Puts et al.44) (2017), Canada	Mixed method multi-perspective longitudinal study	Academic cancer centers; chemotherapy treatment decision-making among older adults with advanced solid tumors.	Semi-structured interviews and surveys	Thematic analysis	To explore how older adults with cancer, their families, oncologists, and family physicians experience and navigate chemotherapy treatment decision-making.	Healthcare professionals (n=28):	Healthcare professionals perceived older adults as vulnerable due to frailty and comorbidities, influencing cautious treatment recommendations. Communication gaps arose between patient/family expectations and clinician risk assessments.
						-Oncologists (46.5%)
						-Family physicians (53.5%)
Bluhm et al.45) (2016), USA	Qualitative study	Oncology practice; prescribing late-stage chemotherapy near end of life.	In-depth individual interviews	Content analysis	To examine factors that influence oncologists' decisions about late chemotherapy.	Oncologists (n=17):	Oncologists reported that they would unlikely offer treatment to very sick older patients with nonresponsive advanced cancer because they are unlikely to benefit from treatment.
						-Academic tertiary care (70.5%)
						-Private practice (29.5%)
Dhotre et al.46) (2016), USA	Hermeneutic phenomenology research	Large oncology clinic; nurses’ experiences with patients discontinuing chemotherapy.	In-depth interviews	Thematic analysis	To describe the lived experience of oncology nurses who care for patients with cancer who choose to discontinue palliative chemotherapy.	Oncology nurses (n=7)	Oncology nurses perceived that, among older adult patients, the small amount of added lifespan potentially gained through chemotherapy was often outweighed by the overwhelming side effects.
Schildmann et al.47) (2013), UK	Qualitative study	Tertiary and district hospitals; oncologists’ perspectives on treatment decision-making in advanced cancer.	Individual semi-structured in-depth interviews	Thematic analysis	To explore medical oncologists' experiences with advanced cancer and their views on the relevance of medical and non-medical criteria for decisions about limiting treatment.	Physicians (n=12):	Physicians reported that variation in nonmedical factors influences professional decisions about offering or limiting cancer treatment in advanced cancer, alongside medical criteria.
						-Cancer center/tertiary care hospital (66.7%)
						-District general hospital (33.3%)

AML, acute myeloid leukemia; HCPs, healthcare professionals.

Methodological Quality of Included Studies

Overall, the methodological quality of the included studies was rated as moderate to high. Most studies clearly stated their research aims, employed appropriate qualitative methodologies, and provided detailed descriptions of their data collection and analysis processes. However, more than half of the studies provided limited information regarding researcher reflexivity and the relationship between researchers and participants. No studies were excluded based on the CASP quality appraisal.

Overview of Synthesized Findings

The qualitative evidence synthesis identified two analytical themes: “Minimizing harm in treatment decision-making” and “Negotiating roles and limits in decision-making support.” These themes reflected healthcare professionals’ efforts to minimize potential harm associated with systemic therapy while navigating tensions related to their roles and responsibilities in supporting decision-making of patients and their families. Each analytical theme comprised three descriptive themes. Although the included studies covered both hematological malignancies and solid tumors, some differences in clinical emphasis were noted. Studies focusing on hematological malignancies more often highlighted treatment tolerance, toxicity, and response to therapy within intensive or potentially curative treatment settings, whereas studies on solid tumors, especially in advanced disease, more frequently emphasized treatment burden, potential harm, and palliative treatment goals in older adults. However, these differences did not alter the overarching thematic structure, and findings were therefore synthesized across cancer types while acknowledging heterogeneity in treatment contexts. Confidence in each descriptive theme was assessed using the GRADE-CERQual approach, based on its four components, and an overall level of confidence was assigned to each finding. Detailed CERQual assessment levels are presented in Table 3.

Table 3.

Summary of themes and level of confidence in the review findings (GRADE-CERQual)

Main theme	Descriptive theme	Summary	CERQual
			Level of confidence	Explanation
Minimizing harm in treatment decision-making	Assessing treatment risks in light of physical vulnerability and aging	Treatment risks were perceived as heightened in older patients due to age-related physical vulnerability and reduced treatment tolerance. Participants viewed potential treatment harms as potentially outweighing expected benefits. In studies involving hematological malignancies, particular attention was placed on treatment-related toxicity and the tolerability of intensive therapies.	Moderate confidence	Methodological limitations: No or very minor concerns.
				Coherence: Minor concerns.
				Adequacy of data: No or very minor concerns.
				Relevance: Minor concerns.
	Clinical principles for maintaining treatment safety and continuity	Treatment safety and continuity were perceived as needing to be carefully balanced through adherence to clinical principles. Understanding patients’ health status and treatment history was viewed as essential for making appropriate treatment-related judgements. Studies involving hematological malignancies additionally emphasized treatment response and tolerability as important considerations in ongoing treatment decisions.	Moderate confidence	Methodological limitations: No or very minor concerns.
				Coherence: Minor concerns.
				Adequacy of data: No or very minor concerns.
				Relevance: Minor concerns.
	Justifying treatment decisions by respecting patients’ values and life perspectives	Treatment decisions were perceived to be ethically justified when aligned with patients’ values, preferences, and life perspectives. Such considerations were viewed as particularly important when the benefits of treatment were uncertain.	High confidence	Methodological limitations: No or very minor concerns.
				Coherence: No or very minor concerns.
				Adequacy of data: No or very minor concerns.
				Relevance: No or very minor concerns.
Negotiating roles and limits in decision-making support	Interprofessional and system-level support for decision-making	Decision-making support was perceived as relying on interprofessional collaboration and healthcare system structures. However, resource limitations and unclear professional roles often constrained effective decision-making support. In some studies, particularly those involving hematological malignancies, geriatric assessment was considered useful for patient evaluation but not always directly applicable to treatment decision-making.	Moderate confidence	Methodological limitations: No or very minor concerns.
				Coherence: Minor concerns.
				Adequacy of data: No or very minor concerns.
				Relevance: Minor concerns.
	Tensions and hesitation in delegating treatment decisions to patients	Delegating treatment decisions to patients was perceived as desirable yet challenging. Healthcare professionals experienced tension in determining how much guidance to provide while respecting patient autonomy.	Moderate confidence	Methodological limitations: No or very minor concerns.
				Coherence: Minor concerns.
				Adequacy of data: No or very minor concerns.
				Relevance: Minor concerns.
	Reflective self-positioning in treatment decision-making	Treatment decision-making was perceived to be influenced by healthcare professionals’ personal emotions and professional roles. Emotional identification with patients and the responsibility to provide treatment sometimes created internal conflict and hesitation.	Low confidence	Methodological limitations: No or very minor concerns.
				Coherence: Minor concerns.
				Adequacy of data: Moderate concerns.
				Relevance: Minor concerns.

Theme 1. Minimizing Harm in Treatment Decision-Making

Assessing treatment risks in light of physical vulnerability and aging

Healthcare professionals regarded physical vulnerability as a central factor in decision-making about systemic therapy for older adults with cancer. Across many studies, aging was recognized not merely as a background characteristic, but as an important factor influencing treatment eligibility. Older patients were perceived to have reduced treatment tolerance compared with younger patients, and healthcare professionals expressed concerns that comorbidities and functional decline could increase the severity of treatment-related toxicity and adverse events. Although systemic therapy may provide potential benefits, healthcare professionals were concerned that its physical and psychological burden might outweigh these benefits. One physician noted, “I think that palliative chemotherapy is not as effective as expected despite its hardship,”⁴⁰) highlighting the imbalance between treatment burden and expected benefit. Similarly, an oncology nurse stated, “[Chemotherapy is] just more overwhelming to them than the younger population,”⁴⁶) indicating that treatment may be more burdensome for older patients. Another healthcare professional reflected, “Once in a while maybe one out of five people I've found it helps them. Most of them I’ve found it’s just burdensome,”³⁹) suggesting that clear treatment benefits were perceived as limited, while the burden of treatment was more prominent in many older adults. Healthcare professionals carefully weighed the potential benefits of systemic therapy against its associated risks and recognized that treatment might increase suffering rather than prolong meaningful survival. Underlying these considerations was an acknowledgement that treatment could result in more harm than benefit for some older patients. (CERQual: Moderate confidence)

Clinical principles for maintaining treatment safety and continuity

Healthcare professionals expressed a commitment to continuing treatment whenever possible while ensuring patient safety. Rather than simply determining whether treatment should be initiated or withheld, they emphasized the importance of carefully assessing patients’ overall health status and prior treatment experiences as the basis for decision-making. One physician stated, “It was an easy decision for him in the sense that he already had chemo experience,”⁴⁴) indicating that prior experience with systemic therapy could support decisions to continue treatment. Healthcare professionals also emphasized that safe treatment delivery depended not only on patients’ physical condition but also on the availability of social support and an appropriate care environment. One participant explained, “It’s really the 70–80-year-olds at home by themselves on chemo because when it falls apart, there’s nobody there for them... I think that that’s definitely [missing] in the assessment of these patients [….] that home support,”³⁶) highlighting the importance of family support and home care conditions for treatment continuity. Another physician reflected, “In her case I wasn't expecting it to be overwhelmingly effective, but it had some potential benefit and relatively low toxicity,”⁴²) illustrating a clinical judgment in which treatment continuation was considered appropriate given the potential benefit and expected low toxicity. These findings suggest that maintaining treatment safety and continuity was not solely aimed at prolonging survival, but reflected a clinical principle of supporting treatment within an acceptable level of burden to the patient. (CERQual: Moderate confidence)

Justifying treatment decisions by respecting patients’ values and life perspectives

Healthcare professionals considered respect for patients’ values and life perspectives to be a fundamental component of treatment decision-making. There was a shared recognition that older adults, regardless of age, remain autonomous individuals who have the right to decide whether to receive treatment. One study noted, “[Older adult patients with cancer] in a palliative stage could choose to receive their chemotherapy,”⁴¹) emphasizing that patients retain the ability to make treatment decisions even in the palliative stage. At the same time, healthcare professionals recognized that older patients were more likely to carefully weigh the potential benefits and burdens of treatment and, in some cases, decide against systemic therapy. One participant explained, “So the older the patients are, the higher the chances that they are going to say no to chemotherapy that might not be that effective,”⁴²) suggesting that patients may decline treatment when the expected survival benefit is limited. Another participant observed, “[The older patients] can't figure out transportation…and they think it’s just gonna put a burden on their family,”⁴⁶) indicating that patients’ decisions were influenced by concerns about family burden and social circumstances. In addition, one healthcare professional explained, “Since older people have their own values and philosophies on life and death, I try to respect them as much as possible when considering the treatment options,”⁴⁰) highlighting the importance of older adults’ perspectives on life and death in treatment decision-making. These findings suggest that healthcare professionals supported decision-making not solely based on clinical effectiveness, but by considering patients’ broader values, including their perspectives on life, death, and relationships with family. Decision-making among older adults was understood not only in terms of physical vulnerability, but also as a process that respects individual values and dignity. (CERQual: High confidence)

Theme 2. Negotiating Roles and Limits in Decision-Making Support

Interprofessional and system-level support for decision-making

Healthcare professionals recognized that interprofessional collaboration and institutional support were essential for supporting effective decision-making. However, they also identified a gap between an ideal support system and the realities of available healthcare resources. One example was the lack of standardized assessment tools to guide clinical decision-making. As one participant noted, “We can send patients for geriatric assessments. They’re very accommodating. But again, it helps you [i.e., healthcare professionals] protect the patient... It doesn't help directly our therapy,”³⁸) indicating that despite the availability of CGA frameworks, they did not always directly inform treatment decisions. Resource limitations also influenced decision-making. One participant explained, “They don’t have inpatient chemo at the community hospital, so they need to be seen [attended to] in a tertiary care center,”³⁹) illustrating how constraints in local healthcare infrastructure could limit treatment options. In addition, an oncologist reflected that although family physicians played an important role for many older patients, “We give them information about the plan but we don’t give them supporting education,” and that “we need better infrastructure and communication.”⁴⁴) These comments highlight challenges in communication, role integration, and coordination across healthcare professionals involved in treatment decision-making. These findings suggest that although healthcare professionals viewed decision-making as ideally supported within a comprehensive, collaborative care system, it often occurred within the constraints of institutional and structural limitations. (CERQual: Moderate confidence)

Tensions and hesitation in delegating treatment decisions to patients

Healthcare professionals recognized that the final decision regarding treatment should be made by the patient. However, they also experienced uncertainty about whether it was always appropriate to entrust older patients with such decisions. One physician stated, “I can’t say, I can’t sort of [really] make that decision for you. It’s a very personal decision,”³⁷) clearly expressing the view that treatment decisions ultimately belong to the patient. Similarly, another physician remarked, “Look, I can say you should do this or you should do that, but…he’s the one who has to take the decision in the end because he will be suffering [experiencing] the side-effects,”⁴³) emphasizing that the patient bears the adverse consequences of treatment and must make the final decision. At the same time, healthcare professionals recognized that older patients may be less likely to actively seek information. As one participant noted, “And they [younger patients] ask more often,”⁴⁷) suggesting that older patients may be less inclined to request detailed explanations or engage actively in decision-making. In this context, healthcare professionals found it difficult to determine the extent of guidance they should provide without undermining patient autonomy. These findings suggest that healthcare professionals experienced the tension between respecting patient autonomy and fulfilling their responsibility to protect patients not merely as a communication challenge, but as a deeper ethical dilemma. (CERQual: Moderate confidence)

Reflective self-positioning in treatment decision-making

Healthcare professionals reflected on their own roles and emotional responses when supporting the decision-making of older patients. One participant stated, “I overlap my parents when I face an elderly [older adult] patient,”⁴⁴) acknowledging a tendency to view older patients through the lens of their own parents. This emotional identification may create internal conflict in their professional judgment. Healthcare professionals also described how their professional role as treatment providers influenced their decision-making. When patients expressed a strong desire to be given the treatment, by saying as follows, “Just please give me a chance,” the healthcare professionals reported that “It’s very hard to say no.”⁴⁵) This reflects the emotional difficulty of balancing medical appropriateness with patients’ wishes. Healthcare professionals found themselves navigating the tension between their professional responsibility of offering treatment and their ethical obligation to avoid overtreatment. These findings suggest that decision-making support involved not only the provision of information and recommendations but also the influence of healthcare professionals’ personal perspectives, emotional responses, and sense of professional responsibility. (CERQual: Low confidence)

DISCUSSION

This study synthesized qualitative evidence on healthcare professionals’ experiences and perceptions of decision-making about systemic therapy in older adults with cancer. The findings suggest that decision-making support extends beyond treatment selection and involves balancing the minimization of harm related to physical vulnerability with respect for patients’ values, within institutional and ethical constraints. Rather than representing a purely technical determination of medical appropriateness, decision-making in geriatric oncology emerges as a practice that integrates clinical judgment and ethical consideration under conditions of uncertainty. Importantly, this process is shaped not only by individual clinical judgments but also by broader structural factors, including healthcare resources and interprofessional collaboration.

Collectively, these findings have important implications for geriatric oncology practice. Decision-making support should not rely solely on chronological age or standardized tools, but integrate CGA with individualized clinical judgment. While CGA provides critical information about functional status and frailty, its interpretation requires contextual and ethical deliberations. Strengthening multidisciplinary collaboration and fostering clinical space for ethical reflection may help ensure that frailty, patient values, and social context are systematically incorporated into treatment planning.

Healthcare professionals clearly recognized that age-related declines in physiological reserve reduce treatment tolerance in older adults with cancer, and they expressed strong concern that the harms of treatment might outweigh its potential benefits. These findings are consistent with previous research indicating that frailty, rather than chronological age alone, is a critical factor in treatment decision-making for older adults receiving systemic therapy.⁴⁸) In geriatric oncology, the usefulness of CGA for comprehensively evaluating functional status and vulnerability is well established. However, its implementation in clinical practice remains limited due to its complexity and resource requirements.⁴⁹) Furthermore, it has been emphasized that treatment decisions should be guided by biological rather than chronological age, given the considerable heterogeneity among older adults.⁵⁰)

In this context, healthcare professionals are required to make clinical judgments under conditions of uncertainty, where clear and standardized decision criteria may be unavailable.⁵¹) Such judgment may be understood as practical wisdom, a form of clinical competence that is particularly essential in geriatric medicine, where heterogeneity, multimorbidity, and frailty complicate standardized decision algorithms. In geriatric oncology, practical wisdom enables healthcare professionals to translate assessment findings into ethically sound and context-sensitive treatment recommendations. Practical wisdom develops through experience and ethical reflection, particularly in situations where formalized guidelines cannot fully capture the complexity of clinical reality.⁵²)

Importantly, patients’ values play a central role as a reference point for decision-making under uncertainty. Healthcare professionals support decision-making not only by considering medical appropriateness, but also by considering patients’ life perspectives, social circumstances, and relationships with family. This finding suggests that decision-making for older adults with cancer is not solely a clinical determination, but a patient-centered practice that respects autonomy and dignity. Overall, the findings of this study indicate that decision-making about systemic therapy in older adults with cancer represents a practice that integrates clinical judgment under uncertainty with respect for patients’ individual values.

Next, we discuss the ethical tensions arising from healthcare professionals’ sense of responsibility and the structural limitations of systems and resources for supporting decision-making of older adults with cancer. Healthcare professionals recognized that the final decision regarding treatment should ultimately be made by the patient, even in older age. At the same time, they are aware that their professional role as treatment providers influences their recommendations and judgments. Previous research has shown that physicians who prioritize beneficence tend to continue treatment even in older and frail patients.⁵³) In addition, treatment continuation may be preferred to avoid the moral distress associated with the decision to discontinue treatment.⁵⁴) These findings suggest that healthcare professionals’ sense of responsibility and self-reflection may influence decisions in ways that favor continued treatment.

The present findings also suggest that healthcare professionals’ personal perspectives and emotional responses may shape how treatment decisions are supported in clinical practice. Participants described viewing older patients through personal reference points, such as reflecting on their own parents, and experiencing difficulty declining treatment when patients strongly wished to continue therapy. These findings do not suggest that treatment decisions are driven solely by healthcare professionals’ personal values. Rather, they suggest that clinical judgments arise from the interaction of professional responsibility, emotional engagement, and ethical commitment. Previous work has shown that clinicians’ judgments are influenced not only by clinical knowledge but also by awareness of their own emotional responses, assumptions, and personal perspectives during patient encounters.⁵⁵) Studies have also highlighted the ethical challenges of balancing overtreatment and undertreatment in older adults with cancer⁵³) and the moral distress experienced by oncology professionals when navigating difficult treatment decisions.⁵⁴) Reflective awareness of these influences may therefore support ethically sound and patient-centered decision-making in geriatric oncology and underscores the importance of making such influences explicit within multidisciplinary discussions, where diverse professional perspectives can help balance individual judgments.

However, healthcare professionals experienced ethical conflict regarding whether it is appropriate to entrust treatment decisions entirely to patients, given that the patients bear the burden of treatment-related adverse effects. Specifically, tension arises between the ethical principle of respecting patient autonomy and the obligation to protect vulnerable patients and prevent harm, consistent with the principle of beneficence. This tension aligns with previous research indicating that older patients’ autonomy may be constrained by physical vulnerability and the organizational structure of healthcare systems.⁵⁶) These findings highlight the ethical complexity of supporting decision-making in older adults with cancer.

SDM has been widely recognized as an important theoretical framework for achieving patient-centered care, particularly in contexts such as cancer treatment, where multiple treatment options exist and patients’ values play a central role.²⁰) However, the implementation of SDM depends not only on interactions between healthcare professionals and patients, but also on structural conditions such as adequate time, sufficient resources, and effective interprofessional collaboration. In this study, differences in roles between tertiary care centers and community healthcare settings, as well as limited coordination among healthcare professionals, were identified as barriers to effective decision-making support. A previous study has also reported that organizational structures and team dynamics influence treatment decision-making,⁵⁷) and that insufficient coordination across institutions and professional roles may limit the consistency with which treatment options are presented to patients.⁵⁸) Therefore, promoting SDM in geriatric oncology requires system-level strategies, including institutional support for CGA, protected time for multidisciplinary discussion, and integration of geriatric expertise into oncology services. The findings also suggest that different healthcare professionals may be contributing distinct perspectives to treatment decision-making. Oncologists were primarily concerned with balancing treatment benefits and harms and determining treatment feasibility, whereas family physicians were perceived as important sources of continuity, trust, and support for patients navigating complex decisions. In addition, geriatric assessment provided valuable information on frailty and functional vulnerability, although participants reported challenges in translating assessment findings into treatment recommendations. Together, these findings indicate that multidisciplinary support in geriatric oncology requires not only the involvement of multiple professionals but also effective communication, role integration, and shared interpretation of patient information across disciplines. Without such structural support, decision-making may rely disproportionately on individual clinicians’ experience rather than consistent geriatric-informed practice.

These findings underscore that decision-making in geriatric oncology is embedded within healthcare systems and organizational structures, and cannot be reduced to individual clinician–patient interactions alone.

Strengths and Limitations

A key strength of this study is that it synthesized qualitative evidence on healthcare professionals’ experiences and perceptions of decision-making support about systemic therapy in older adults with cancer. This synthesis provides a comprehensive understanding of the multiple dimensions shaping decision-making, including clinical uncertainty, ethical tensions, and structural constraints within healthcare systems. In addition, the use of the GRADE-CERQual approach to assess confidence in the synthesized findings enhanced the transparency and rigor of the review.

The study has a few limitations that should be acknowledged. Most of the included studies were conducted in high-income countries, which may limit the transferability of the findings to different healthcare systems and cultural contexts. Furthermore, the included studies involved healthcare professionals supporting patients with both hematological malignancies and solid tumors, across diverse treatment stages and clinical settings. Although some differences in clinical emphasis were observed between cancer types, these did not result in distinct higher-order themes. Therefore, findings were synthesized across cancer types while acknowledging heterogeneity in treatment contexts. Nevertheless, the heterogeneity in clinical context may have influenced healthcare professionals’ experiences and perceptions and should be considered when interpreting the findings. Future qualitative evidence syntheses focusing on specific cancer types or treatment settings may provide more context-specific insights into decision-making support for older adults with cancer. Finally, this review included only studies published in English, and therefore, the possibility of language bias cannot be excluded.

Conclusion

This study found that healthcare professionals involved in decision-making about systemic therapy for older adults with cancer strive to minimize treatment-related harm while navigating tensions in their roles and responsibilities toward patients and families. Healthcare professionals regarded age-related vulnerability as a key consideration and developed clinical approaches aimed at balancing treatment safety and continuity. At the same time, respect for patients’ values and life perspectives serves as a central foundation for final decision-making.

Healthcare professionals also experience ethical tension between respecting patient autonomy and fulfilling their professional responsibility to protect vulnerable patients. In addition, structural constraints, including limited healthcare resources and insufficient interprofessional collaboration, pose challenges to effective decision-making support.

These findings suggest that promoting decision-making support for older adults with cancer requires not only individual efforts by healthcare professionals, but also system-level support, including stronger collaboration between oncology and primary care professionals, effective use of geriatric assessment, and improved healthcare resources.

SUPPLEMENTARY MATERIALS

Supplementary materials can be found via https://doi.org/10.4235/agmr.26.0051.

Table S1.

PRISMA 2020 checklist

Table S2.

Search strategy for electronic databases