Geriatric Assessment in Oncology: Moving From Impairment‐Directed Management to Patient‐Values‐Aligned Care

We read with great interest the review by Yamamoto et al. [1] on the evolution of geriatric assessment (GA) in oncology. The authors convincingly show that GA-guided management (GAM) has moved beyond risk stratification toward multidisciplinary intervention, reducing toxicity and improving treatment completion. However, we believe that two interconnected issues—insufficiently explored lessons from negative trials and the persistent omission of patient-defined values—deserve deeper discussion, especially when “quality of life” is understood not as a scale score but as dignified, meaningful survival. Yamamoto et al. attribute the null results of the 5C trial [2] and PROGNOSIS-RCT to delayed GA timing or case mix. While these are plausible, a more fundamental lesson is emerging: even when GA is timely and multidisciplinary, it may fail to improve what patients truly care about. In the GERICO trial [3], geriatric intervention significantly increased chemotherapy completion (45% vs. 28%), yet quality of life (QoL) did not improve. This dissociation—completing treatment without gaining QoL—suggests that conventional endpoints (toxicity grades, completion rates, generic QoL instruments) may not capture the outcomes that matter most to older adults, such as preserving the ability to walk to the toilet, staying cognitively intact, or not becoming a burden on family. Recent evidence strongly supports this concern. Among older patients with bladder cancer, 40% prioritized maintaining independence over prolonging life, and GA domains did not predict those priorities [4]. In a secondary analysis of the GAP70+ trial [5], 71.7% of 706 older adults with advanced cancer preferred QoL over survival, yet their actual clinical outcomes (toxicity, hospitalizations, survival) were indistinguishable from those who prioritized survival—a striking responsiveness gap [6]. Moreover, older patients starting chemotherapy rated “maintaining cognitive function” as more important than living longer (82.2%) [7]. Even among patients with non-curable cancer, treatment goals change over time, with preserving independence remaining a top priority for nearly one-third [8]. These findings indicate that GA-based research has been measuring the right domains (function, cognition, nutrition) but possibly the wrong endpoints. We therefore propose that the next logical step after GAM is Patient-Values-Aligned Management (PVAM)—a framework that explicitly integrates each patient's personal health priorities into GA-driven care plans. Two practical tools can operationalize this. First, Goal Attainment Scaling (GAS), endorsed by the FDA for patient-focused drug development, allows individualized documentation of whether a patient achieves self-defined goals (e.g., “I want to attend my granddaughter's wedding”) [9]. Second, the Patient Priorities Care (PPC) model, proven to reduce treatment burden and improve alignment with what matters most in older adults with multiple conditions [10], could be adapted to oncology and embedded within Japan's long-term care insurance framework. Table 1 contrasts conventional endpoints used in major GA trials with patient-driven alternatives that better capture what older adults with cancer value most—dignified, meaningful survival defined by the patient, not by the toxicity table. In conclusion, Yamamoto et al. have masterfully summarized the shift from assessment to intervention. We suggest a further evolution: from intervention to values-aligned care that places dignified, meaningful survival at the center of geriatric oncology. T.C. and C.Q. conceived the letter concept, performed the literature analysis, and drafted the manuscript. H.D. and X.L. critically revised the manuscript for important intellectual content and provided supervision. All authors approved the final version and agree to be accountable for all aspects of the work. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.