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. 2025 Jul 24;26(1):105.
doi: 10.1186/s12910-025-01255-9.

Ethics of overtreatment and undertreatment in older adults with cancer

Clark DuMontier  1   2   3 , William Dale  4 , Anna C Revette  5 , Jane Roberts  5 , Ameya Sanyal  5 , Neha Perumal  5 , Eric C Blackstone  5 , Hajime Uno  5 , Mary I Whitehead  6 , Lewis Mustian  6 , Tammy T Hshieh  7   5 , Jane A Driver  8   7 , Gregory A Abel  7   5   9
Affiliations

Ethics of overtreatment and undertreatment in older adults with cancer

Clark DuMontier et al. BMC Med Ethics. .

Abstract

Background: Over-/undertreatment are pervasive in older adults with cancer, and challenges arise in applying the principles of bioethics: beneficence, nonmaleficence, justice, and patient autonomy. The objective of this study was to determine whether these ethical principles relate to over-/undertreatment for older adults, and how tensions among the principles may contribute.

Methods: We conducted a modified Delphi study with 13 experts in biomedical ethics for iterative rounds of data collection. In the first round, we presented via electronic questionnaire our previously published definitions of over-/undertreatment in older adults with cancer. We then asked which ethical principles related to each definition, followed by how over-/undertreatment might arise from conflicts among different ethical principles. Consensus for each question was defined as ≥ 75% of experts answering "agree" or "strongly agree". The second round consisted of a virtual discussion with nine of the panel experts led by a qualitative researcher to summarize round one results and review questions that did not reach consensus, followed by a second questionnaire including those questions.

Findings: Experts reached consensus that beneficence, non-maleficence, and autonomy were related to over-/undertreatment in older adults with cancer. Consensus was reached (92%) that overtreatment can occur when oncologists overemphasize beneficence valuing the potential benefit of cancer treatments, while underemphasizing non-maleficence with respect to treatment toxicities. Consensus was also reached (85%) that undertreatment reflects a lack of justice in equitable consideration of cancer treatments that could provide similar net benefits in older adults compared to younger adults. Lastly, consensus was reach 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) or (2) the opportunity for the patient to share their values, goals, and preferences.

Interpretation: Our findings elucidate the ethical principles underpinning over- and undertreatment in older adults with cancer.

Keywords: Ethics; Geriatric oncology; Oncology; Overtreatment; Undertreatment.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: This project was approved as exempt by the Office for Human Research Studies, Dana-Farber/Harvard Cancer Center Institutional Review Board: Protocol #23-181. All participants provided verbal informed consent; the requirement to obtain written consent was waived by the IRB. All aspects of the research study were conducted in compliance with the Helsinki Declaration. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Flow diagram of selection of experts of biomedical ethics into modified Delphi study
See this image and copyright information in PMC

References

    1. DuMontier C, Loh KP, Bain PA, et al. Defining undertreatment and overtreatment in older adults with cancer: a scoping literature review. J Clin Oncol. 2020;38:2558–69. - PMC - PubMed
    1. DuMontier C, Loh KP, Soto-Perez-de-Celis E, et al. Decision making in older adults with cancer. J Clin Oncol. 2021;39:2164–74. - PMC - PubMed
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