Improving diabetes management in older adults with cancer: a quality improvement project to enhance monitoring during steroid-based systemic anti-cancer therapy

Purpose Older adults undergoing systemic anti-cancer therapy (SACT) with steroids are at high risk of developing steroid-induced hyperglycaemia (SIH). However, monitoring and management remain inconsistent. This quality improvement project (QIP) involved developing and evaluating the GOLD diabetes enhanced monitoring pathway, a multidisciplinary, age-adapted initiative for older patients at intermediate SIH risk. Methods The pathway was conducted at Guy’s and St Thomas’ NHS Foundation Trust from February 2022 to June 2025). It included structured risk stratification, home capillary blood glucose monitoring, diabetes education, and telephone follow-up by geriatric clinical nurse specialists. Iterative refinements were made through seven Plan-Do-Study-Act (PDSA) cycles. The primary outcome was the rate of diabetes medication intervention, while secondary outcomes included changes in SACT/steroid regimens, unplanned hospitalisations, and all-cause mortality. Results Of the 172 patients (55% male; mean age 70.9±8.3 years; 74% with pre-existing diabetes), 34% required diabetes medication intervention, primarily the initiation or escalation of gliclazide. Only three asymptomatic hypoglycaemic events occurred. Steroid dose reductions were significantly associated with medication intervention (72% vs 24%, p<0.001). Unplanned hospitalisations occurred in 28% of patients, with only two diabetes-related admissions. All-cause mortality (17%) was associated with male gender, metastatic disease, and malnutrition, but not to diabetes intervention or glycaemic control. Conclusion The GOLD pathway was found to be feasible, safe, and effective for managing SIH in older adults with cancer. Its success highlights the value of multidisciplinary collaboration and iterative refinement in addressing a critical gap in geriatric oncology care and supporting structured diabetes monitoring in clinical practice.