Category: 8. Health

More women at higher risk of breast cancer should be offered a mastectomy, according to a new study led by researchers at the London School of Hygiene & Tropical Medicine (LSHTM) and Queen Mary, University of London.

A new economic modelling analysis found the surgical technique was a cost-effective way of reducing the likelihood of developing breast cancer when compared to breast screening and medication. It’s hoped the findings could lead to changes in medical guidelines for offering mastectomies.

To identify the risk of women developing breast cancer, clinicians combine genetic and medical data to create personalised risk prediction models. Depending on their risk, clinicians will offer a range of treatment options including: mammograms, MRI screening, surgery, and medication.

Current guidelines recommend risk-reducing mastectomy (RRM) for women at high risk but in practice, this surgery is only offered to those carrying faults in genes that are known to increase the likelihood they will develop the disease (BRCA1/ BRCA2/ PALB2 PV).

Dr Rosa Legood at LSHTM and Professor Ranjit Manchanda at Queen Mary worked with colleagues from Manchester University and Peking University to create a new economic evaluation model to determine the level of risk at which RRM is the most cost-effective treatment.

Results from their model, published in JAMA Oncology, indicated that mastectomy was a cost-effective treatment for women aged 30 or above who have a one in three chance (35% risk) or greater of getting breast cancer in their lifetime This suggests there is scope to offer RRMs beyond those carrying the specific BRCA1/ BRCA2/ PALB2 genetic mutations.

Using data from women aged between 30 and 60 years, results from their simulations showed that offering RRM to women in this cohort could potentially prevent 6,500 of the 58,500 cases of breast cancer that are diagnosed every year in the UK.

Undergoing risk reducing mastectomy (RRM) is cost-effective for women 30-55 years old with a lifetime breast cancer risk of 35% or more.

These results can support additional management options for personalised breast cancer risk prediction, enabling more women at increased risk to access prevention. Offering RRM could both save lives by preventing cancers and provide good value for money for the NHS.”

Dr. Rosa Legood, Associate Professor at LSHTM

Professor Ranjit Manchanda, Professor of Gynaecological Oncology at Queen Mary, said: “For the first time, we define the risk at which we should offer RRM. Our results could have significant clinical implications to expand access to mastectomy beyond those patients with known genetic susceptibility in high penetrance genes- BRCA1/ BRCA2/ PALB2 – who are traditionally offered this.

“This could potentially prevent ~6,500 breast cancer cases annually in UK women. We recommend that more research is carried out to evaluate the acceptability, uptake, and long-term outcomes of RRM among this group”.

For their model, the researchers used guidelines from the National Institute for Health and Care Excellence (NICE) to determine whether a treatment is considered cost-effective. NICE deems a treatment cost effective if it typically brings one additional year of health for no more than £20,000-£30,000 per patient (known as the ‘willingness to pay’ threshold). The researchers’ model used a threshold of £30,000/Quality Adjusted Life Year.

The study used data from women aged 30-60 years old with varying lifetime breast cancer risks between 17% and 50%, and who were either undergoing RRM or receiving screening with medical prevention according to currently used predictive models.

The authors acknowledged limitations in their research including the lack of data on the level of risk reduction from RRM for non BRCA women at increased risk, and the lack of long-term data on the quality-of-life implications of RRM.

The diagnosis of a suspected lung, head, and neck cancer called NUT carcinoma should include additional testing capable of detecting gene fusions that are definitive markers of the disease, according to a study by Dana-Farber Cancer Institute investigators. The study showed that more than 75 percent of patients with NUT carcinoma may not be immediately diagnosed because standard-of-care DNA testing does not detect NUT carcinoma fusion genes.

Tests that can identify gene fusions that are specific to NUT carcinoma include NUT immunohistochemistry (IHC), RNA fusion testing, and NUTM1 FISH (fluorescence in situ hybridization).

The findings were published in Clinical Cancer Research.

If a diagnosis of NUT carcinoma is being considered, standard of care DNA-based testing is insufficient and clinicians should consult with pathology colleagues about ordering a better gold standard test such as NUT immunohistochemistry or RNA-based mutation sequencing. Early accurate diagnosis is key to getting patients on the correct treatment and clinical trials.”

Dr. Jia Luo, co-senior author, thoracic oncologist at the Lowe Center for Thoracic Oncology, Dana-Farber

NUT carcinoma is an aggressive squamous cell cancer. A patient might be suspected of having NUT carcinoma if they are young, have little to no history of smoking, and have a poorly differentiated cancer in the lungs, head, or neck. Median survival for patients with NUT carcinoma is 6.7 months.

NUT carcinoma is defined by fusions of the NUTM1 gene with other genes. Gene fusions occur when errors in the genome glue two genes together, resulting in the production of a malfunctioning protein. 

Luo and co-senior author Christopher French, MD, of Brigham and Women’s Hospital, initiated the study to determine the best means of detecting these gene fusions and definitively diagnosing NUT carcinoma. They examined the diagnostic results of 116 NUT carcinoma tumors that had undergone molecular testing using a range of panel tests including next-generation DNA sequencing, circulating tumor DNA (ctDNA) testing, and tests that identify gene fusions.

They found that DNA sequencing and ctDNA testing detected NUT fusions less than 25 percent of the time. In contrast, NUT IHC, RNA fusion testing, and NUTM1 FISH testing detected NUT carcinoma fusions much more reliably, respectively 100 percent, 84 percent, and 92 percent of the time.

“These findings warrant immediate change to the diagnostic workflow for patients with suspected NUT carcinoma,” says Luo.

This approach of performing DNA testing and RNA fusion testing simultaneously is used in other cancers in which the identification of gene fusion is needed to make a diagnosis. 

The study also took an inventory of other mutations detected by the tests in the NUT carcinoma cases. More than half of the cases did not contain a second cancer-associated gene mutation, but some did. 

Those that did contain additional gene mutations turned out to be genes associated with epigenetic, cell cycle and DNA repair pathways. Luo and colleagues are initiating laboratory studies to determine if targeting these mutations could benefit patients. 

“This study characterized the common mutations seen in NUT carcinoma, which will help researchers develop future effective combination treatments,” says Luo.

Women living in racially and economically segregated neighborhoods in New York City are more likely to be diagnosed with advanced-stage breast and cervical cancer, American Cancer Society (ACS) researchers have reported.

The group also studied colorectal cancer but did not find any similar disparities, said lead author Qinran Liu, PhD, of the ACS, in a statement. The results were published July 24 in the Journal of the National Cancer Institute.

“Our research shows that structural barriers in segregated neighborhoods continue to delay diagnosis for breast and cervical cancers — even among individuals eligible for screening,” Liu noted. “But there is positive news. We found no disparities in stage at diagnosis for colorectal cancer. This may in part reflect the impact of local equity-focused initiatives for early detection of colorectal cancer in New York City. However, the results for colorectal cancer may not be applicable to other areas, especially those without such early detection initiatives.”

Stage at diagnosis is a critical determinant of cancer survival and long-term outcomes, Liu and colleagues explained, noting that “despite advances in early detection, minoritized racial and ethnic populations are more likely to be diagnosed with advanced-stage cancers than the non-Hispanic white population.”

To assess links between race and socioeconomic status and cancer stage, the team conducted a study that included census-tract data of almost 100,000 cancer cases from New York State Cancer Registry data (2008 to 2019). The data consisted of 58,970 diagnosed cases of breast cancer, 4,790 of cervical cancer, and 34,689 of colorectal cancer. Each cancer case was assigned a “neighborhood segregation score” that captured both racial and economic factors.

The main finding was that “advanced-to-localized stage incidence-rate ratios were significantly higher in areas that were both economically deprived and racially concentrated (either non-Hispanic Black or Hispanic) compared to the most affluent and non-Hispanic, white-concentrated areas for breast and cervical cancer,” the team reported.

Advanced-to-localized breast cancer stage incidence-rate ratios by race
Type of cancer	Non-Hispanic white	Hispanic	Non-Hispanic Black
Breast cancer	33.3%	37.3%	43.1%
Cervical cancer	47.5%	50.1%	60.3%
Colorectal cancer	57.4%	57.5%	57%

The results have “direct implications for cancer prevention and early detection efforts by identifying neighborhoods with the greatest disparities in stage at diagnosis,” according to Liu.

“This information can inform targeted resource allocation and guide interventions such as patient navigation services and investments in healthcare infrastructure — strategies that can facilitate earlier diagnosis with the goal of improving outcomes,” she said.

The complete study can be found here.

MOGADISHU, (July 24, 2025) –  The combined number of cases of five infectious diseases have doubled in Somalia since mid-April as aid cuts force hundreds of health clinics to close, with children under five the worst impacted, Save the Children said.

Since April, cases of measles, diphtheria, whooping cough, cholera and severe respiratory infections have doubled from about 22,600 to over 46,000^[1], with children under five representing around 60% of cases.^[2]

At least 357 new suspected cases of measles, diphtheria or cholera – all of which can be prevented by vaccines – were reported among under-fives in the past week alone, according to the Ministry of Health.

So far this year, Somalia has reported 6,267 suspected cases of cholera, with 60% (3,739) among under-fives. At least eight people are known to have died from the illness, including five children under five.

The measles outbreak has also hit children under five hardest, with the youngest children accounting for an estimated 75% of 5,436 reported cases.

In Somalia, the sharp rise in vaccine-preventable diseases is linked to the recent aid cuts, which have impacted the health system’s capacity to deliver essential services, including routine immunization, and to treat and run catch-up campaigns to increase the immunity necessary to halt the outbreak.

Save the Children said these outbreaks are compounding existing humanitarian challenges, such as malnutrition, overcrowding in camps for displaced people, and limited access to healthcare. Overstretched health facilities, misinformation, and stigma regarding some healthcare are further exacerbating the crisis. 
In May, Save the Children reported that at least 55,000 children supported by the aid agency in Somalia^[3] will lose access to lifesaving nutrition services, as aid cuts have forced about 47, or one-third, of Save the Children-supported nutrition services to close.  

Besides nutrition, these clinics provided other health services, and their closure means families and children are going without critical health services, including immunization. The aid agency is warning that the reduced capacity of the health system to respond to outbreaks is likely to lead to frequent and deadly outbreaks on a scale not previously seen in Somalia.

Save the Children’s Country Director for Somalia, Mohamud Mohamed Hassan, said: 
“The neglect of the health system in Somalia due to aid cuts is directly impacting children. Already, children have died of diseases we have treated and kept at bay in the past. Unless the aid cuts are reversed and more resources are put in place to support the health system, we are worried the situation will rapidly deteriorate, placing immense strain on vulnerable communities, particularly children under five.

“Somalia remains one of the countries with the highest number of zero-dose children in sub-Saharan Africa. The funding cuts have not only disrupted immunization programs but have also weakened the ability of health partners to respond effectively to ongoing and emerging outbreaks.

“Equally alarming is the spread of a SARI (severe acute respiratory infections) and influenza-like illness. Due to limited laboratory capacity, the country is currently unable to identify the specific viral agent responsible for this respiratory outbreak, which further complicates the response.

“We are urgently calling for sustained investment in Somalia’s health system, particularly in surveillance, immunization, outbreak response and increasing access to primary health care services to put an end to the disease outbreaks and keep children alive.”

With the impact of aid cuts already being felt by families and children across Somalia, the situation is projected to get worse with countries in Africa forecast to be impacted the most by global aid cuts as the OECD projects a drop of between 9-17% in official development assistance (ODA) in 2025 – the third consecutive year of decline.

This will impact approximately 300 million people who rely on ODA as a source of emergency relief and as a promise of a better future through education, healthcare, and economic opportunities.

Save the Children is actively engaged in national disease surveillance, prevention, and response efforts. We are supporting health facilities in hotspot regions, such as Banadir, Bay, and Mudug, through case identification, referral, and treatment.

A disease outbreak is the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season, according to the WHO.

Save the Children has been working in Somalia and Somaliland since 1951, with programs throughout the country that support children’s healthcare, education, and food needs. Last year, we reached 3.2 million people, including 1.9 million children.  

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Notes to Editors:  
[1] Case numbers of measles, diphtheria, whooping cough, cholera and severe respiratory infections. Taken from the Federal Government of Somalia, Ministry of Health, ISDR Epidemiology bulletins. The latest data covers reporting week 28 (July 7 to 13) and is compared with data from around 3 months ago (week 14), which covers March 31 to April 6.

[2] While weekly cases of illnesses among children under 5 are available in these bulletins, the cumulative number of cases for 2025 among children under 5 is only available for cholera. To estimate cases among children under 5 for other illnesses addressed in this PR, Save the Children used the available data on share of cases of measles, diphtheria and severe acute respiratory illness among under 5s for weeks 14 and 28 and took an average across these two weeks to estimate the cumulative number of cases among those under 5 in 2025. No age breakdown data was available for whooping cough, which is therefore excluded from the 60% estimation.

[3] According to a Save the Children internal analysis of impacted projects. The total children that could be affected as a result of funding cuts to Save the Children and other partners is at least 290,000. 
 

A seven-year international, multi-centre clinical trial led by London Health Sciences Centre Research Institute (LHSCRI) and St. Michael’s Hospital, a site of Unity Health Toronto, has found that a new ventilation mode called proportional assist ventilation (PAV+™) could improve outcomes for patients in the intensive care unit (ICU) who require help breathing. The study is published in the New England Journal of Medicine.

When patients need ventilation to support breathing, critical care physicians have the choice of using different modes on ventilator machines. This includes a standard mode called pressure support ventilation (PSV) that is available on most ventilators and provides the same level of breathing assistance at all times, as well as a newer mode called proportional assist ventilation (PAV+^TM) that adjusts the level of breathing support based on the patient’s needs.

PAV+^TM is a newer mode of ventilation that personalizes ventilation support to each patient. The goal of this study was to compare PAV+^TM to the more common mode, PSV, and determine if PAV+^TM leads to a decrease in the length of time a patient requires ventilation.”

Dr. Karen Bosma, Scientist at LHSCRI, Physician at London Health Science Centre (LHSC), and Associate Professor of Medicine at Western University

While the study did not find a significant difference in the length of time patients remained on ventilation between the two modes, it did reveal meaningful benefits associated with PAV+. Patients in the PAV+ group came off sedation at a faster rate while on mechanical ventilation, and had fewer days of delirium during the trial. This is an important finding, as patients who experience prolonged sedation and delirium while in the ICU are at greater risk of experiencing psychological and cognitive problems long-term.

The study enrolled 722 patients, including patients from LHSC and St. Michael’s Hospital. Of those, 573 were randomly assigned to either PAV+^TM or PSV mode of ventilation and were included in the analysis. The median time spent on mechanical ventilation was 7.3 days in the PAV+^TM group and 6.8 days in the PSV group. In addition, patients were checked daily for signs of delirium. In the group using PAV+^TM, delirium was seen in about 23 per cent of the days patients were assessed, compared to 26 per cent in the PSV group. The study also found that, over the course of the patient’s treatment on the ventilator, the use of sedative drugs was reduced at a faster rate in patients in the PAV+ group.

“Even small advances that improve patient wellbeing during and after an ICU stay are highly valuable,” says Dr. Laurent Brochard, clinician-scientist at St. Michael’s Hospital. “This is what we found here and we want to continue exploring this approach, which only requires adjusting ventilator settings.”

Looking ahead, the researchers note they plan to use the data from this trial to conduct additional studies.

“This is one of the largest ventilation studies to date examining these two modes of ventilation, and over the last seven years we have gathered a lot of crucial data on critically ill patients on a ventilator,” says Dr. Bosma. “Future research will use artificial intelligence to analyze this data helping us better understand PAV+^TM and how it may minimize specific health consequences associated with prolonged ventilation.”

This modified Delphi study convened a panel of experts in biomedical ethics and reached consensus that the principles of beneficence, non-maleficence, and autonomy are related to our previously proposed definitions of over- and undertreatment in older adults with cancer. The panel also reached consensus that, in most cases, it is unethical to make a treatment recommendation without (1) formal assessment of patient frailty (e.g., via a geriatric assessment) and (2) the opportunity for a patient to share their values, goals, and/or preferences. The panel did not reach consensus regarding the relationship between justice and over-/undertreatment; however, the panel concluded that justice applies to undertreatment when an oncologist withholds potentially beneficial cancer treatment in an older patient based on their age alone.

Tensions among bioethical principles can lead to over- and undertreatment in older adults with cancer (Table 5). With near unanimous agreement on the first round, the panel reached consensus that valuing the principle of beneficence over nonmaleficence can lead to overtreatment. This overemphasis on beneficence stems from biomedical reductionism, focusing more on the cancer-centric benefits of treatment rather than the impact of a treatment on the whole patient [14]. The panel agreed that the criteria of our definition of overtreatment appropriately elevated the overlooked principle of nonmaleficence. The concept of “minimizing harm” in older patients—especially those who are frail—must be weighed equally alongside “maximizing benefit” in terms of cancer control [2].

The panel reached consensus that overtreatment can also occur when oncologists prescribe cancer treatment out of a belief they are adhering to their specialty’s professional ethics, even when there is no evidence regarding treatment effects in older patients, or when existing evidence suggests that harms outweigh benefits. Providing a less intensive treatment option—including different drugs, reduced dosing, reduced frequency, or no treatment altogether—may be seen as failing to uphold a professional duty to provide patients treatment options that maximize cancer control [15, 16]. Oncologists may therefore view that cancer recurrence or progression in an older patient prescribed a less intensive treatment option poses a greater risk than the increased toxicity resulting from a more intensive treatment option. This calculus in decision-making has even been called the “Oncologist’s Wager”, an allusion to the historical “Pascal’s Wager” that concluded that the severity of the potential negative consequences of not pursuing an action (in the case of oncology, cancer spreading or recurring after a recommendation for less intensive or no treatment) were always greater than the potential negative consequences of pursuing an action (in oncology, toxicity after a recommendation to treat cancer) [17]. One implication of our findings is that by reasserting the principle of nonmaleficence alongside the principle of beneficence, oncologists will better adhere to their specialty’s professional ethics when they acknowledge that a given treatment’s harms may outweigh its benefits in frail older patients. In these scenarios, prescribing a less intensive treatment is not a form of undertreatment, but rather an ethically appropriate recommendation that prevents overtreatment.

The panel also reached consensus that tensions between autonomy and other principles can lead to both overtreatment and undertreatment. When nonmaleficence overrides autonomy, undertreatment can occur if an oncologist presumes that an older adult would not accept the risks of cancer treatment without first clarifying patient goals and preferences. When beneficence overrides autonomy, overtreatment can occur if an oncologist presumes the potential benefits of cancer treatment are desirable and prescribes treatment without clarifying goals and preferences. As reinforced by the panel, an older adult has the right to decline a treatment even when the oncologist believes it is of benefit. In this scenario, considering a less intensive option, or no cancer treatment at all, is not a form of undertreatment, but rather an ethically appropriate recommendation that respects patient autonomy.

Conversely, when autonomy overrides nonmaleficence, overtreatment can occur if an oncologist appeases the desire of an older patient (or patient’s family) to receive an intensive cancer treatment, despite the oncologist’s concern that the treatment’s harms likely outweigh its benefits. The overemphasis on preserving patient autonomy in modern medicine has even been referred to as the “tyranny of autonomy”; respecting patient preferences does not imply elevating their superiority in all cases above oncologists’ expertise [18]. Even if an older patient (or their family) requests an intensive treatment option, an oncologist’s recommendation for a less intensive alternative respects both autonomy and nonmaleficence if the oncologist believes the alternative to be a safer option that provides a benefit better aligned with the patient’s stated goals.

Regarding justice, the panel concluded that withholding a guideline-recommended therapy based on age alone exemplifies a lack of justice. Our definitions of over-/undertreatment advocate for the use of fitness/frailty when evaluating benefits and harms of treatments in older adults, avoiding arbitrary cutoffs based solely on chronologic age [19]. The panel’s inability to reach consensus on relating our definitions to the principle of justice as a whole stems from justice’s inherent call to consider other patients in the healthcare system when making individual-level treatment decisions (Supplemental Figure 3). This aspect of justice stands in contrast to autonomy, beneficence, and nonmaleficence, which are more readily applied to decisions in individual patients. Nonetheless, the virtual discussion session provided insight into how overtreatment of older adults unlikely to benefit from an intensive regimen may lead to undertreatment of other patients in the healthcare system (Supplemental Figure 3B). Moreover, if an older adult who could benefit from cancer treatment cannot access it due to mobility or functional limitations, geographic distance, or unreliable transportation, this lack of access reflects system-level inequalities that contribute to undertreatment (Supplemental Figure 3A) [20]. The same applies to an older adult unable to access a geriatric assessment and interventions that in turn leads to suboptimal cancer treatment [21].

Leading cancer organizations such as the American Society of Clinical Oncology (ASCO) now recommend formal assessment of frailty, by way of a geriatric assessment in older adults undergoing systemic cancer treatment [22, 23]. Our panel concluded that, in most cases, prescribing cancer treatment without frailty assessment raises ethical concerns. Frailty assessment shifts a cancer-centric view of treatment effects to a more holistic, patient-centered view, one that considers whether treatment benefits and harms differ in frail older adults compared to the fitter and/or younger patients who are overrepresented in clinical trials [24]. Evaluation of benefits and harms in light of an older adult’s physiology mitigates the risk of making treatment decisions based on age alone, which violates justice. This shift to a more patient-centered evaluation of benefits and harms also resolves the tension between beneficence and nonmaleficence, since it encourages weighing the tumor-specific benefits of treatment against the risk of treatment toxicity [25, 26]. At the same time, simply labeling a patient as “frail” (e.g., from gestalt and not after formal geriatric assessment) and withholding guideline-based treatments solely on that basis can reflect undertreatment—just as it can when decisions are based only on chronological age. This is especially problematic when a treatable cancer is the main cause of a patient’s frailty, or when addressing other frailty factors could improve tolerance to beneficial cancer therapies [27].

In this vein, a more patient-centered evaluation via formal frailty assessment reveals other health deficits (e.g., comorbidities, cognitive impairment, or functional limitations) that often present concurrently with cancer in older patients. Our definition of undertreatment includes the failure to recognize and optimize these nononcologic health deficits, since their optimization can mitigate toxicity risk and promote adherence to cancer treatment [28]. Recent randomized controlled trials conclude that oncology care that is guided by frailty assessment (compared to standard oncology care) informs anti-cancer treatment modifications and/or supportive care interventions that mitigate overtreatment of an older adult’s cancer and undertreatment of their nononcologic conditions [29,30,31]. Evidence from trials is more limited regarding the effectiveness of frailty assessment in improving long-term survival, as the survival outcomes are assessed at 6-month and 12-month endpoints in the large RCTs. Also, caution should be exercised against reflexive treatment de-escalation simply because a patient has one or more health deficits found on geriatric assessment. Geriatric assessment is meant to augment and improve clinical judgment, not supersede it. Just as withholding guideline-recommended treatments based only on labeling a patient as “frail” can reflect undertreatment, withholding guideline treatments based only on the presence of functional or cognitive deficits may also reflect undertreatment, especially if the patient prioritizes life prolongation above other outcomes.

Moreover, identifying and addressing deficits such as hearing and/or cognitive impairment early in the treatment decision process can also better ensure that oncology teams deliver fair and informed communication. Evaluating deficits includes considering the ability of the older patient to receive information on treatment decisions, to weigh risks and benefits of different options, and to ascertain his/her overall capacity to accept or reject a treatment recommendation. Indeed, formal frailty assessment has been shown to (1) raise awareness of aging-related concerns among oncologists and (2) improve their communication with older patients and caregivers [32, 33]. Since the way in which an oncologist presents different treatment options plays a determining role in the final treatment decision, a formal frailty assessment of health domains essential to older adult well-being expands a cancer-centric discussion to a more patient-centered discussion.

The panel also reached unanimous consensus that, in most cases, it is unethical to prescribe cancer treatment without first offering older patients the opportunity to share their goals and preferences. Whereas some older patients prioritize cancer control just as much as younger patients, other older adults prioritize maintaining independence and avoiding time spent in the hospital [34]. In the latter case, aggressive treatments may present more harm than benefit if their side effects jeopardize function and quality of life—even if the treatments lengthen life [35]. Evidence suggests that there is often inadequate communication regarding goals of care between patients, families, and oncologists, undermining autonomy and potentially contributing to over-/undertreatment [36,37,38]. Multiple interventions have been tested to improve goals of care communication in oncology, such as decision aids and communication training for oncologists [39, 40]. Our findings underscore the importance of these efforts, particularly in older patients for whom benefits of intensive therapy have not been established. Our proposed criteria of over-/undertreatment require defining the “benefits” older adults wish to pursue and the “harms” they wish to avoid. Obtaining these goals and preferences reasserts respect for patient autonomy, resolving tensions between this principle and others.

There are limitations to this study. First, we did not explore other ethical frameworks that may apply to our definitions of over-/undertreatment. We focused on the Beauchamp and Childress principles that are the most widely taught and recognized frameworks among the medical community. Although the tensions that can arise among these ethical principles are often cited as a limitation for their use in guiding treatment decisions, our work reveals that identifying these tensions can better explain how over- and undertreatment occurs. Second, our Delphi panel consisted of experts in biomedical ethics from North American institutions. Lack of representation outside of North America may influence the generalizability of our findings, and different countries and cultures may vary the application of ethical principles to decision-making in older patients. Finally, the very attempt to apply ethical standards to better define over- or undertreatment in older adults may appear problematic, since the benefits and harms of novel treatments in older adults are often uncertain. However, treatment decisions must still be made despite this uncertainty, and the lack of evidence to guide such decisions necessitates adherence to bioethics.

In conclusion, this work establishes the ethical principles underlying over-/undertreatment in older adults with cancer. The identification of relevant tensions among these principles is a vital step towards reducing over-/undertreatment, ensuring older patients receive appropriate care when facing limited evidence. Our findings suggest an ethical imperative to scale formal assessment of frailty via the geriatric assessment for more widespread use in oncology practice, as well as evaluation of patient goals and preferences.