Disparities in care of older adults of color with cancer: A narrative review

Abstract This review describes the barriers and challenges faced by older adults of color with cancer and highlights methods to improve their overall care. In the next decade, cancer incidence rates are expected to increase in the United States for people aged ≥65 years. A large proportion will be older adults of color who often have worse outcomes than older White patients. Many issues contribute to racial disparities in older adults, including biological factors and social determinants of health (SDOH) related to healthcare access, socioeconomic concerns, systemic racism, mistrust, and the neighborhood where a person lives. These disparities are exacerbated by age‐related challenges often experienced by older adults, such as decreased functional status, impaired cognition, high rates of comorbidities and polypharmacy, poor nutrition, and limited social support. Additionally, underrepresentation of both patients of color and older adults in cancer clinical research results in a lack of adequate data to guide the management of these patients. Use of geriatric assessments (GA) can aid providers in uncovering age‐related concerns and personalizing interventions for older patients. Research demonstrates the ability of GA‐directed care to result in fewer treatment‐related toxicities and improved quality of life, thus supporting the routine incorporation of validated GA into these patients' care. GA can be enhanced by including evaluation of SDOH, which can help healthcare providers understand and address the needs of older adults of color with cancer who face disparities related to their age and race.


| INTRODUCTION
It has been estimated that cancer incidence will increase by 67% from 2010 to 2030 for people aged 65 years or older in the United States (US).In the same time period, cancer incidence is also estimated to increase by 99% for racial and ethnic minorities of any age. 1 With the aging population and the change in demographics of the total US population towards increased representation of ethnic minority groups, a greater number of older (≥65 years) adults of color are expected to face a cancer diagnosis. 1Given that adults of color have higher incidence rates and worse outcomes for many cancer types compared with White adults, 2 new strategies are needed to ensure equitable care as this underserved patient population ages.
In this review, we discuss cancer disparities and factors contributing to inequities in the care of older adults of color with cancer.Identifying the needs and challenges of these patients is the first step to providing appropriate and personalized care and optimizing patient outcomes.Based on supporting evidence, we advocate for widespread implementation of an enhanced geriatric assessment (GA) to personalize and improve care and measures that support older adults and older adults of color with cancer.

| CANCER DISPARITIES IN OLDER ADULTS OF COLOR: BACKGROUND
Cancer disparities, described as differences in incidence, mortality/survival, screening rates, stage at time of diagnosis, and evidence-based treatment, 3,4 between racial and ethnic groups in the US are well-documented. 5,6verall cancer incidence and death rates are highest for Black men of all ages in the US (Figure 1).Analysis by cancer type demonstrates that incidence rates of liver and stomach cancers are between 1.6 and 2.2 times higher for Alaskan Native/American Indian, Asian or Pacific Islander, Hispanic, and Black patients compared with White patients.Additionally, Black patients experience more than double the incidence of myeloma compared with White patients (Table 1). 2 While mortality rates from cancer have decreased across all racial and ethnic groups over the past decade, Black patients continue to experience the highest mortality rates both overall and for most cancer types 2,7 ; especially stomach, cervical, and multiple myeloma.][10] Black patients are generally diagnosed later in the disease course and have a higher likelihood of having advanced disease at diagnosis for cancers where screening is recommended (e.g., lung, colorectal, female breast, and cervical cancers), compared with other racial and ethnic groups. 11This may be due in part to the fact that screening guidelines do not take into account the increased prevalence of genetic mutations such as PALB2 and BRCA 1/2, and age-specific incidence for certain cancers in Black patients. 6,12tudies in the US suggest that Black patients are less likely to receive evidence-based care (e.g., guidelineconcordant care) than White patients for several types of cancers, including lung, colorectal, and breast cancers. 4,6dditionally, a California-based study found that Black, Hispanic, and certain Asian minority subgroups had an increased likelihood of delays in surgical treatment after a breast cancer diagnosis, compared with White patients. 13ancer disparities between younger and older patients also exist.Older age is the greatest risk factor for cancer overall, as well as in many cancer types. 146][17][18] Additionally, although survival has improved in several cancers in recent years, these improvements have been less pronounced for older individuals. 195][26][27] Black patients (65-84 years) experience higher overall incidence of multiple simultaneous cancers, diagnoses at a later stage in the disease course, and lower survival rates compared with White patients of the same age range. 27Depending on the cancer type, disparities between racial groups can increase or decrease with age; for example, there is some evidence that differences in mortality between Black and White patients decrease with age in men with prostate cancer (i.e., improvements in survival were greater for older Black patients vs. older White patients) and increase for women with ovarian cancer (i.e., improvements in survival were smaller for older Black patients vs. older White patients). 19

IN OLDER ADULTS OF COLOR
The determinants of disparities in older adults of color are multifactorial and interconnected (Figure 2).Clinical and age-related physiologic disparities can lead to treatment disparities.Social determinants of health (SDOH) and clinician bias can also impact these age and race/ethnic disparities associated with cancer diagnosis, treatment, and outcomes.Efforts by the National Comprehensive Cancer Network (NCCN), National Minority Quality Forum, and the American Cancer Society Cancer Action Network, as well as the American Society of Clinical Oncology (ASCO) have been ongoing to not only better understand and disentangle the main causes of these disparities, but identify strategies and recommendations for improving equity in cancer diagnoses, treatment, and outcomes. 28,29

| Clinical factors
Older patients, patients of color, and patients who are part of both groups may have worse cancer outcomes due to clinical and biological factors, such as existing comorbidities, advanced stage of diagnosis, and different tumor biology.These clinical factors could lead to differences in available/recommended treatment options, response to therapy, and outcomes.

| Comorbidities
Comorbidities are highly prevalent among older adults with cancer; in an analysis of Medicare beneficiaries (aged >65 years), 67% with a cancer diagnosis had more than three other chronic conditions. 30][33] These differences could be attributed to lifestyle and environmental factors, lack of access to quality care, and appropriate long-term management of these conditions.
Patients with cancer and comorbidities have worse 5-year survival outcomes compared with those without comorbidities across tumor types. 34][36][37][38][39] Furthermore, individuals with multiple comorbidities have a lower likelihood of receiving surgical intervention, radiation, and chemotherapy compared with patients without comorbidities, despite evidence showing a survival advantage associated with treatment, suggesting that undertreatment may also be an issue for these patients. 31,35A B L E 1 Cancer burden disparities for racial and ethnic minority groups compared with the White population in the United States a .In addition to comorbidities, physiologic changes with age in older adults (i.e., decreased kidney or liver function, and cognitive decline) can affect anticancer therapy and outcomes.Declines in kidney and liver function affecting drug metabolism, declines in kidney-mediated drug elimination, changes in drug distribution due to higher body fat content, and reduction in plasma albumin leading to increased levels of unbound active drugs all potentially increase the chance of a person experiencing adverse reactions to drugs. 35,39The impact of these factors can be mitigated by appropriate treatment adjustment based on thorough evaluation of kidney/ liver function.Older adults are also at an increased risk of malnutrition (ranging from 3% in community settings to 29% in long-term care settings 40 ).Additionally, up to one third of people aged >65 years report hearing loss, 41 and over one fifth of people ≥85 have age-related visual acuity loss or blindness. 42Older age is also associated with cognitive decline; 7% of patients ≥68 years with cancer have diagnosed dementia and 36% of patients ≥70 years with advanced cancer report cognitive impairment. 43,44These issues often are linked with poor treatment tolerance, poor adherence to treatment or supportive care measures, and additional challenges to providing cancer-related care. 35,45,46These age-related determinants of cancer susceptibility, prognosis, or response/tolerance to treatment can be exacerbated by socioeconomic factors (such as access to care or social support) that may vary in different racial/ethnic groups (see section 3.4). 2

| Biologic features of tumors
Although there is limited research characterizing the molecular profile of most tumors for racial and ethnic minority groups, available evidence suggests that the type and frequency of inherited genomic variants vary Multifactorial contributors to cancer disparities in older people of color.
8][49][50] For example, a meta-analysis looking at common mutations in people with lung cancer found that EGFR mutations occurred less frequently in Black patients compared with White, Asian, and Hispanic patients; additionally, BRAF mutations occurred less frequently in Black versus White patients and ALK mutations occurred less frequently in Black versus Hispanic patients. 51By contrast, BRCA2 and PALB2 mutations in breast cancer are thought to be more common in Black patients versus White (non-Hispanic) patients. 12Furthermore, an analysis of the Cancer Genome Atlas found that breast cancers occurring in Black women had higher genomic instability and increased expression of cancer-related signaling pathways compared with those occurring in White women. 52It is widely recognized that increased diversity in the reference human genome sequences used for molecular profiling is needed, so that germline genetic tests can become more applicable to patients of all races and ethnicities. 53,54We should aim to improve our understanding of the genetic diversity among our patients to ensure that all patients are evaluated for possible targeted therapies, which would be highly desirable for older adults, given the better tolerance of these agents.
Although aging is a known cancer risk factor, 55 the landscape of age-associated changes in cancer mutational profiles remains largely uncharted for most tumors. 56A comprehensive genomic analysis of early-and late-onset colon cancer found age-related increases in the mutation rates of several genes (e.g., ASXL1, BRAF, and CEBPA) and specific common oncogenic mutations, such as BRAF V600E. 57A 2022 pancancer, genome-wide study of age-related differences across 35 tumor-types found that older age impacts the number of somatic mutations as well as their evolutionary timing within a tumor, with specific age-associated mutational signatures that reflect differences in underlying oncogenic processes. 55Despite existing evidence suggesting agerelated differences in tumor mutation burden, transcriptional profiles, and types of mutations, 55,57 large-scale studies exploring the biologic basis for age-based differences across tumor types remain limited. 55In particular, data are lacking on the association of cancer and aging as well as the impact of biologic differences for those cancers that occur in younger and older patients. 56Such studies would help us to better utilize existing treatment options as well as understand the options for personalization of therapy using targeted treatments for older adults, which may be better tolerated and provide improved outcomes over standard chemotherapy agents.
Despite evidence of differences in molecular profiles by race/ethnicity and age, the increasing importance of precision medicine, and recommendations by multiple medical society guidelines 58,59 for molecular profiling across multiple malignancies, many adults of color and older adults do not have these analyses performed on their tumors, thereby limiting treatment options and possibly affecting outcomes.Analysis of Medicare results from the Surveillance, Epidemiology, and End Results program found that among 5556 people with a lung cancer diagnosis, 26.2% of White patients and 32.8% of patients of Asian/other descent underwent genetic testing within 2 months of diagnosis compared with 14.1% of Black patients. 60Similarly disparate results are reported for molecular profiling for patients with ovarian cancer. 61A recent analysis of comprehensive genomic profiling in older adults with gastrointestinal cancers found that 55.7% of patients who underwent molecular profiling were aged <65 years, and patients aged ≥75 years were underrepresented, despite the existence of an age-associated increase in high tumor mutational burden. 62Ensuring that older patients of color receive the latest standard of care, including molecular profiling, may help to mitigate disparities in cancer treatment and survival outcomes.

| Lack of clinical trial representation
Clinical trials are crucial for the development of novel treatments but require adequate patient representation to provide physicians with appropriate guidance for treatment planning and recommendations. 2,63nfortunately, people of color and older adults have limited representation in cancer clinical trials. 64,65In a study evaluating 230 trials that led to approval by the US Food and Drug Administration (FDA) of oncology drugs from 2008 to 2018, White patients represented 76.3% of trial participants versus 18.3%, 3.1%, and 6.1% for Asian, Black, and Hispanic patients, respectively. 64Similarly, only 24% of participants were ≥70 years of age in trials registered with the FDA, despite representing 42% of the cancer population. 65Furthermore, only 145 (63%) trials reported race, 18 (7.8%)evaluated the four major race groups in the US, and just 58 (25.2%) documented race subgroup analyses. 64Clinical trial underrepresentation contributes to disparate cancer outcomes, as providers are unable to anticipate how new treatments will affect populations of patients not included in the original trials. 2,63Some providers may hesitate to use new therapies, leading to undertreatment; while others may overtreat patients, extrapolating clinical trial data and making unvalidated treatment adjustments. 66trict eligibility criteria for therapeutic clinical trials are of particular concern.For example, excluding patients with certain comorbidities, such as cardiac, liver, or kidney dysfunction, can disproportionately impact people of color and older adults. 32,67Interventions to minimize restrictive eligibility criteria may lead to more age and racial diversity in clinical trials. 2,68Studies focusing on frail and vulnerable patient populations with comorbidities are also warranted.Furthermore, flexible and age-focused clinical trial designs could increase participation of older adults. 63Incorporating pragmatic design elements should improve access to trials; specific examples include decreasing traveling time or helping patients get to trials, decreasing time spent in cancer centers, as well as bringing more trials to the community, where patients of color and older patients are typically seen. 69Ensuring the inclusion of these populations will provide useful information to providers caring for these patients, as well as helping to address disparities related to age and race/ethnicity.Regulatory agencies, such as the FDA, have guidance to increase representation in clinical trials among older adults and people of color, which may lead the way for improvements in clinical trial diversity. 63,68,69

| Biases, mistrust, and physician- patient communication
3][74] On an individual level, implicit racial bias occurs unconsciously from internalized societal attitudes and stereotypes, and explicit racial bias occurs based on deliberate thought and judgments. 75Studies have shown that implicit bias among non-Black oncologists was associated with shorter and less-supportive interactions with Black patients. 76Personal experiences with racism among people of color may develop into diminished trust in healthcare providers and/or the system in general. 77Poor patientprovider relationships may be shaped by cultural aspects and/or language barriers. 2,3Screening, prevention, and treatment implementation are all strongly influenced by the patient-provider relationship and trust in the medical system. 2,3For instance, high levels of medical mistrust by Black patients have been linked with lower screening rates for colorectal cancer 78 and reduction in quality of life in men with prostate cancer. 79Physician communication style can impact trust as well, with one study showing that poor physician communication led to Black patients with lung cancer having lower trust in their healthcare provider than White patients. 80Mistrust that results from implicit or explicit biases may also contribute to adults of color receiving less aggressive, inappropriate cancer treatments, as well as treatment delays, when compared with White patients. 2,81ge-based discrimination or ageism also exists in the healthcare system at the individual and system level.Health payment structures, lack of geriatric-focused training, and underrepresentation in clinical trials are examples of health-system level challenges for older patients. 82At the individual level, ageism encompasses negative attitudes, communication styles, and decision making from healthcare professionals towards older patients.For example, physicians can act patronizing towards their older patients and involve them less in their healthcare decisions, resulting in inferior outcomes. 83,84Assumptions by providers of decline in cognitive function and frailty in older people with cancer may result in withholding appropriate therapy.Studies have demonstrated undertreatment and lower likelihood of receiving standard treatment in older versus younger patients. 83Lower digital literacy among older adults can also be misinterpreted as cognitive decline and exacerbate these issues. 82Providers should refrain from making assumptions regarding an older adult's goals for cancer therapy, which may differ from those of a younger person. 35For example, some older adults may value quality of life over longevity, especially if their functional status, cognitive abilities, or independence are impacted. 35linicians should discuss and understand their patients' goals and values by encouraging them to ask questions and share their hopes and concerns prior to making treatment decisions. 35,45This is supported by findings of Mohile et al. who showed that inclusion of GA during oncology medical appointments for older patients with advanced cancer improved communication between patients and their healthcare providers about age-related matters. 85learly, strategies establishing trust and minimizing bias among providers and older patients of color are needed to address systemic/institutional biases and to enhance care and cancer outcomes for older adults of color facing a cancer diagnosis.In addition, training programs must increase awareness and counter unconscious bias among providers to improve relationships with older people of color.Partnerships with leaders in the community and patient advocacy groups may raise awareness of preventive measures and available treatment options among older patients and minoritized communities.

| Social determinants of health
Beyond clinical and biological indicators of disease, SDOH can also help explain disparities in both cancer incidence and outcomes by age and race/ethnicity.SDOH are the "conditions in the environments in which people are born, live, work, play, worship, and age that affect a wide range of health, functioning and quality-of-life outcomes and risks". 70There are five key domains for SDOH: economic stability (e.g., opportunities for employment and income level); education access and quality (e.g., graduation rates for high school); social and community context (e.g., social/caregiver support, biases including structural racism, and ageism); healthcare access and quality (e.g., health insurance type and status, health literacy/language barriers, and proximity to facilities); and neighborhood and built environment (e.g., transportation options and socioeconomic status of community). 70SDOH have been found to influence treatment choices, outcomes, and contribute to the lack of participation of older patients and patients of color in clinical trials. 2,71

| Social support
Studies show that social support has a direct effect on the well-being of a person with cancer, and their overall survival. 86Older adults, regardless of race, often depend on family members or other caregivers for home care, transportation, and medication assistance, among other physical and emotional support needs.In recent studies, nearly half of older adults with cancer reported having an unmet social support need, 87,88 with the most common unmet needs being medical and informational. 87Across all domains, patients with less education and household income, who were non-White, had comorbidities, were never married or were divorced had significantly greater unmet needs.Conversely, there is some evidence to suggest that Black and Hispanic people may have improved social support and caregiving preparedness compared with White people, due to structural and environmental forces (e.g., multigenerational housing and low trust in health systems leading to increased reliance on social networks) increasing their use of close family and friend networks. 89Regardless, traditional provider assessments do not detect the support needs of their patients; for example, Seedor et al. showed that 73% of functional status, 44% of nutritional, and 96% of cognitive issues potentially requiring support were undetected by unstructured physician assessments among older metastatic breast cancer patients. 90

| Economic stability and education
Economic stability and education are other important SDOH related to a patient's socioeconomic status.High cancer treatment costs place older adults and patients of color, who have a higher likelihood of living on a fixed/ lower income, at increased risk of financial hardship, potentially leading to nonadherence to recommended treatment regimens and, ultimately, poorer outcomes. 2,46,91ocioeconomic concerns and rising costs may deter some people from fully utilizing healthcare services and receiving the proposed care.For example, Black and Hispanic patients with cancer are twice as likely to use financial coping behaviors, such as skipping medications, than White patients due to financial concerns. 2 3.4.3 |3,92 Insurance status is linked closely to employment and is impacted by age and education, with a strong effect on patients' access to care.A study by Adamson et al. showed that providing health insurance coverage through Medicaid expansion reduced differences between Black and White patients in the time to first treatment for people with advanced cancers.93 While Medicare provides healthcare coverage for most older adults, some patients are not eligible and some services are not covered.Furthermore, even among Medicare beneficiaries, White adults have improved healthcare-related experiences (e.g., getting appointments and care quickly) compared with patients of color.94 The built environment and, specifically, transportation barriers further affect patients' access to care and may impact patients' ability to comply with required follow-up.Lack of driving, limited reliable, consistent, and affordable public transportation, and rural residence are common barriers to continuous treatment and cancer care for patients. In thee cases, the financial burden of transportation and/or supportive care falls on the patient or their family, who may also have limited ability to face these financial hardships.2 These barriers also directly affect patients' access to clinical trials and novel treatment opportunities.Thus, interventions to address logistical barriers and reduce financial burden are warranted, and will result in significant improvement in patients' outcomes.

| ADDRESSING DETERMINANTS OF DISPARITIES IN OLDER ADULTS OF COLOR: AN ENHANCED GERIATRIC ASSESSMENT
To begin to address these underlying determinants of disparity and provide comprehensive care to older adults, a thorough assessment is needed to identify all issues affecting the patient's care, treatment options, and outcomes, regardless of race/ethnicity or circumstance.Anticancer treatments are not contraindicated in older patients.A full GA should be performed to determine the true biological age and fitness of an older adult and to personalize treatments based on functional, cognitive, or psychosocial status, as well as comorbidities and social support (Table 3). 45,83,95Guidelines published by the ASCO, 96 the NCCN, 45 and the International Society of Geriatric Oncology (SIOG) 95 call for GA use for treatment decisions for older adults with cancer.
8][99] The use of GA allows the provider to obtain a more comprehensive understanding of a patient's overall health and social well-being and adjust care accordingly.This approach is highly beneficial for older adults of all races and ethnicities.A meta-analysis of observational and interventional studies assessing GA in patients with cancer found that GA revealed physical function deficits, malnutrition, depression, and comorbidities, and each of these variables were independently associated with chemotoxicity and/or overall survival. 100Similarly, a systematic review showed that GA promoted changes in cancer treatment plans for more than one quarter of patients, usually in favor of therapy deintensification, and recommended supportive care in over 70% of patients. 97A recent study demonstrated that older Black patients with newly diagnosed gastrointestinal cancer have increased frailty rates and limitations in function compared with their White counterparts, despite adjustment for multiple baseline characteristics. 101he gold standard Comprehensive GA is typically conducted by a geriatrics team and has been shown to decrease functional decline in inpatient settings and improve mental health in outpatient settings. 45,95,102The need for dedicated personnel and time limitations during clinic visits pose challenges for the incorporation of such a comprehensive assessment in the oncology outpatient setting. 103,104As such, several tools have been created to help physicians identify patients at risk who would benefit from more thorough evaluation including Geriatric 8 (G8) and Vulnerable Elders Survey (VES-13) (Table 4). 96n oncology-specific GA was developed by the Cancer and Aging Research Group (CARG) and validated for use in clinical trials and routine practice. 105It includes selfadministered questionnaires for many domains, many of which are available in an electronic version facilitating incorporation into routine practice. 96,106Each domain T A B L E 3 GA domains and rationale. 2,35,45,96,115,127ssociation of Community Cancer Centers' "Practical Application of Geriatric Assessment: A How-To Guide for the Multidisciplinary Care Team" 123 provides the available tools for several domains.
within the GA can be evaluated by multiple validated tools allowing the provider to choose the tool that they feel most comfortable with and compose a battery of assessments to fit their practice.The ASCO and the NCCN provide further guidance on the use of the various tools and incorporation of GA into routine practice. 45,96pecific tools for the prediction of the risks for chemotherapy-related toxicity for older adults have also been developed.The CARG chemotherapy toxicity calculator and Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) are toxicity-prediction calculators designed to evaluate the potential risk of grade 3-5 chemotherapy-related toxicities for older patients with cancer. 35,107,108These calculators combine patient, disease, and treatment-related factors to determine toxicity risk.This provides highly valuable information in personalizing the treatment plan and discussing the risk/benefit ratio with patients.However, these tools are not tumor specific; thus, research is ongoing to refine these tools and customize them to specific cancer types.For example, the CARG tool was recently adapted for breast cancer and refined to predict the risk of grade 3-5 chemotherapyrelated toxicity in older adults receiving chemotherapy for early-stage breast cancer. 109 thorough GA, which covers multiple domains associated with the physical and social status of the patients, T A B L E 4 Geriatric and SDOH assessment tools.35,96,105,107,108,112,113,128  must also evaluate SDOH which strongly influence the care of older adults of color.A recent study found that 86% of social support issues identified among older adults with cancer using a GA were undetected by routine clinical assessment.90 As part of the social support evaluation of older patients, specific attention to the patient's housing situation, healthcare access, social support, education, and economic stability is warranted.Cancer treatments are expensive, and older patients, especially those on fixed income, can quickly reach their out-of-pocket maximum for spending resulting in financial toxicity.For patients without other support, this can lead to developing coping strategies such as stopping or skipping medications, and limiting doctor's visits or important diagnostic tests, which can negatively impact outcomes.Additionally, the stress associated with this financial toxicity, in and of itself, can lead to poorer quality of health.110 The answers to these social support questions can provide clinicians with key information to determine the need for additional and targeted supportive care services (i.e., patient navigation services) that can improve treatment adherence and outcomes.111 Validated tools for assessment of SDOH include the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE®) and the Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) screening tool.112,113 PRAPARE was designed to identify those at increased risk of having worse health outcomes utilizing a 17-item questionnaire assessing at least one variable across four general domains (personal characteristics, family and home, money and resources, and social and emotional health). Additionally, PRAPARE includeour questions in the category of "Other": specifically concerning incarceration, refugee status, abuse, and domestic violence.112 According to the 2019 Annual Medicaid Managed Care Survey, PRAPARE was deemed the most common social needs screening tool used by Medicaid Managed Care Organizations across the US, with a national engagement rate of 27%.114 However, a combined 50% of health centers continued to utilize internal or alternate systems, indicating a need for improved standardization of screening tools.The AHC HRSN screening tool developed by the Center for Medicare & Medicaid Innovation similarly utilizes a 10-item questionnaire to understand patients' needs across five domains: housing instability, food insecurity, transportation problems, utility help needs, and interpersonal safety.An additional 16 questions across eight supplemental domains may be used to evaluate patients for family and community support, substance use, employment, financial concerns, mental health, education, physical functioning, and disabilities.113 Unlike other social needs screening tools, the AHS HRSN was specifically developed to identify HRSNs whose negative impact on patient health and healthcare utilization can be addressed through community interventions.It is intended for use by healthcare practitioners to support plans for treatment and referrals for community services, thereby potentially reducing overall healthcare utilization and improving patient outcomes.,116 Furthermore, studies have reported that most providers use unvalidated assessment tools for evaluating older adults and rely on the patient interview for determining an individual's fitness for therapy.104,117 Providers cite multiple barriers to wider GA and SDOH assessment implementation (Table 5).Knowledge-related barriers include unfamiliarity/confusion regarding the specific assessments or lack of training in this area.104,116 While routine GA is not mandated for all patients, guidelines recommend a screening GA to identify patients who may need a more comprehensive assessment of their physical, cognitive, and emotional state.45,96 These screening GAs, particularly those related to SDOH, may be administered in the context of telemedicine.
Telemedicine may improve access to GA, particularly for older adults by enabling assessment, diagnosis, and treatment planning, while minimizing access barriers and exposure to pathogens. 118,119In a systematic review of 17 randomized controlled trials, telemedicine procedures evaluated specifically for older adults have demonstrated adherence, patient acceptance, and improvement in patient health outcomes. 120This systematic review also observed substantial evidence supporting telemedicine in older adults as widely accepted, with three studies suggesting telemedicine may lead to improved cognitive function. 120However, the results were mixed for rural and low-resource populations who may face challenges accessing these technologies, and better strategies are needed for implementing these programs in diverse settings.In addition, web-based GA and SDOH methodologies, developed for integration with electronic medical records, 121 have the potential to improve record keeping, portability, and access to clinically relevant GA data for clinicians.
Lack of resources, including time and personnel, is another barrier to GA implementation. 104,116However, many tools can be self-administered by patients or completed with caregiver support. 105,122,123CARG's primarily selfadministered oncology-specific GA tool was successfully implemented in older adults with cancer in a cooperative group setting, with 87% of patients having completed their assessment without aid and with reporting overall satisfaction with the tool. 105Thus, one potential strategy for increasing the conduct of GA in rural and low-resource settings may be to use local community centers or other settings with electronic capabilities as a shared resource to administer telehealth and web-based/remote GA.
When GA abnormalities are identified, social workers, physical therapists, occupational therapists, or nutritionists can provide subsequent patient care and management. 45,96,124Depending on the health system, patient navigation services and social workers may be available to further address barriers to care driven by SDOH measures. 111Specialty services or patient navigation programs may be a significant barrier for small community practices that lack access to these services and see many older adults of color.Use of multidisciplinary teams shared across multiple practices and uniting resources for staff education and management may be helpful for community practices with limited support staff to deliver interventions.
Reimbursement issues, out-of-pocket costs, and patient or family misunderstanding or reluctance can also limit GA implementation. 103,104Older patients who are not well-informed about GA may have concerns regarding such evaluation, and worry about stigma and undertreatment of their condition. 103These obstacles are significantly greater and more difficult to overcome for older patients of color and compound existing multiple disparities and biases.Older people of color who are conscious of the inequities in cancer care may be even more inclined to doubt the value of GA.Language barriers and/or mistrust of healthcare systems may further hinder patient GA uptake.However, patient navigation programs can improve communication between patients and providers to help build interpersonal trust. 111,125Wider education about the goals and benefits of GA is needed for key stakeholders, policymakers, community leaders, and especially patients and their caregivers.Efforts are underway to increase institutional awareness of the specific needs of the elderly and their caregivers, including the Age-Friendly Health Systems program, which seeks to implement evidencebased principles of high-quality care for older adults in healthcare organizations. 126With strong evidence for GAguided care for older adults with cancer, providers must strive to overcome these barriers and incorporate GA into routine clinical practice.

| CONCLUSION
Older adults and older adults of color face exceptional challenges and suffer from inequalities in cancer diagnosis and management, significantly affecting treatment outcomes.Efforts for reducing health disparities due to age and race, and providing equity of care, should be a nationwide top priority.As an initial step, better assessment of older adults of color using guideline-recommended GA, enhanced with SDOH evaluations, will allow for early identification and management of health disparities for each patient and reduce the effect of disparities on patient care and outcomes.Improved knowledge of the barriers to and inconsistencies in the care of this vulnerable patient population, elimination of provider, and T A B L E 5 Barriers to implementation of geriatric and SDOH assessments in oncology and potential solutions. 96,103,104,111,123,129

Barriers to GA and SDOH assessment implementation Potential solutions
Lack of GA-or SDOH-related knowledge or training (e.g., what GA and SDOH tools are available, when each tool should be used, and how to use them) • Training programs for healthcare providers on the use of GA and SDOH integration into clinical care • Refer to guidelines and other websites (ASCO, 96 SIOG, 129 NCCN, 45 ACCC, 123 PRAPARE®, 112 and AHC HRSN 113 ) Lack of resources (e.g., time, support staff, and referral options) • Use GA and SDOH tools that can be self-administered or completed with a multidisciplinary team member and/or caregiver support • Creation of multidisciplinary teams for geriatric care across multiple practices Systemic barriers (e.g., reimbursement) • Increase awareness of GA and SDOH goals and benefits among policy makers

F I G U R E 1
Overall cancer incidence (2015-2019) and mortality (2016-2020) rates (per 100,000) by race and ethnicity in the US for all ages and older adults (≥65 years).Abbreviations: AI/AN, American Indian/Alaskan Native; API, Asian/Pacific Islander; NH, Non-Hispanic.Source: National Cancer Institute Surveillance Epidemiology, and End Results program SEER*Stat Database.Rates are per 100,000 and are age-adjusted to the 2000 US standard population (19 age groups-Census P25-1130).Rates for American Indians/Alaskan Natives only include cases that are in a purchased/referred care delivery area.Incidence data for Hispanics and non-Hispanics are based on the North American Association of Central Cancer Registries Hispanic Latino Identification Algorithm.

4. 1 |
Overcoming barriers to GA in clinical practice

Race/ethnicity, % Breast cancer Cervical cancer Colorectal cancer
Impaired cognition may lead to a reduced comprehension of treatments, slower recognition of side effects, and nonadherence to anticancer therapy • These factors can contribute to poorer survival, functional dependence, depression, delirium, delayed diagnosis of complications, prolonged hospital stays, and increased chemotherapy toxicity Psychological status • Quality of life and function may be negatively impacted by anxiety, depression, and distress • Depression is associated with increased mortality, hospitalization, poor treatment tolerance, low social support, impaired cognition, polypharmacy, treatment noncompliance, and functional decline Association of Community Cancer Centers; AHC HRSN, Accountable Health Communities Health-Related Social Needs; CARG, Cancer and Aging Research Group; CMS, Center for Medicare and Medicaid Services; CGA, comprehensive geriatric assessment; CRASH, Chemotherapy Risk Assessment for High-Age Patients; G, geriatric; GA, geriatric assessment; NACHC, National Association of Community Health Centers; PRAPARE®, Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences; SDOH, social determinants of health; SIOG, International Society of Geriatric Oncology; VES, Vulnerable Elders Survey.
• Seek support from institutional stakeholders Reluctance • Increase awareness of GA and SDOH goals and benefits among patients, caregivers, and the general population • Partner with patient advocacy groups SDOH barriers • Connect patients with resources (such as patient navigation programs) to address SDOH barriers (e.g., access to transportation and financial programs) Abbreviations: ACCC, Association of Community Cancer Centers; AHC HRSN, Accountable Health Communities Health-Related Social Needs; ASCO, American Society of Clinical Oncology; GA, geriatric assessment; NCCN, National Comprehensive Cancer Network; PRAPARE®, Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences; SDOH, social determinants of health; SIOG, International Society of Geriatric Oncology.