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Abstract

This qualitative study explored the decision-making process regarding continuation of systemic therapy among older adults with advanced cancer, focusing on how treatment choices are interpreted within the context of aging and remaining life. Seventeen participants aged ≥70 years with recurrent or metastatic cancer receiving systemic therapy were recruited from two cancer centers in Japan. Semi-structured interviews were conducted and analyzed using a modified grounded theory approach. The analysis identified six interrelated categories describing a dynamic decision-making process. Central to this process was discovering a moderately acceptable state, which functioned as a turning point through which participants recalibrated expectations of treatment and health in relation to aging. This turning point enabled participants to integrate cancer treatment into the aging process rather than perceiving treatment and aging as competing forces. Throughout the process, adopting more flexible views of health shaped how participants evaluated treatment burden, partial effectiveness, and acceptability over time. These findings highlight treatment continuation as an evolving interpretive process grounded in aging and uncertainty, underscoring the importance of nursing practices that support older adults in reflecting on lived experiences and making treatment decisions aligned with their values in later life.

Keywords

older adults advanced cancer systemic therapy decision-making modified grounded theory approach Japan

Introduction

In this study, the term “older adults” is operationally defined as individuals aged 70 years or older, consistent with recent recommendations from the European Society for Medical Oncology (ESMO) and the International Society of Geriatric Oncology (SIOG), which indicate that geriatric assessment and geriatric-focused management should be implemented for patients aged ≥70 years (ESMO/SIOG Cancer in the Elderly Working Group, 2024). The global cancer burden is increasingly concentrated among older adults. In Japan, adults aged ≥65 years accounted for 88.3% of cancer-related deaths in 2022 and 75.5% of new cancer diagnoses in 2019 (Foundation for Promotion of Cancer Research, 2024). Similar trends have been observed internationally in the context of population aging. Importantly, advances in cancer care—including targeted therapies, immunotherapy, and the shift to outpatient treatment—have expanded the feasibility of systemic therapy among older adults who were previously considered unsuitable candidates. Recent reviews have demonstrated that these therapeutic developments have substantially altered the treatment landscape, resulting in a growing number of older adults receiving ongoing systemic therapy in clinical practice (Battisti et al., 2020). Consequently, cancer care for older adults has become an increasingly important focus in contemporary oncology.

Older adults are frequently underrepresented in clinical trials, resulting in limited evidence to guide systemic therapy in this population (Ludmir et al., 2019). Consequently, standardized treatment strategies for older adults with cancer remain insufficiently established (Sedrak et al., 2021). Older adults are particularly vulnerable to frailty, which is associated with reduced physiological reserve, functional decline, impaired activities of daily living, and diminished quality of life (Handforth et al., 2015). These vulnerabilities are further compounded by comorbidities and polypharmacy during cancer treatment (Goede, 2023). Therefore, opportunities to receive systemic cancer treatment often decline with advancing age (Bastiaannet & Pilleron, 2025).

From the perspective of older adults undergoing systemic therapy, experiences during treatment often evolve over time, as individuals live with cancer and age-related changes. At the initiation of therapy, many patients expect therapeutic benefit and life prolongation but remain uncertain about side effects and prognosis (Lindhardt et al., 2024). However, as treatment continues, older adults frequently experience cumulative physical burden, declining functional status, and challenges in maintaining activities of daily living (Kenis et al., 2017; Muhandiramge et al., 2022). These changes can influence how patients evaluate the balance between the potential benefits of treatment and its impact on daily life (Shrestha et al., 2019). Such experiences often occur within a context of ongoing uncertainty related not only to disease progression but also to aging and anticipated remaining life. This complexity is particularly pronounced among older adults with advanced or metastatic cancer, for whom treatment is rarely curative and accompanied by uncertainty regarding disease trajectory and remaining life (Kolsteren et al., 2022).

Decision-making regarding cancer treatment has been widely examined in oncology and geriatric oncology research. Previous studies have explored how older adults evaluate treatment options in relation to expected benefits, treatment burden, and quality of life (DuMontier et al., 2021). Moreover, qualitative research has started to highlight how treatment decision-making unfolds within ongoing interactions with healthcare systems and professionals. For example, a grounded theory study suggested that treatment decision-making among older adults with cancer may be shaped through relational interactions with healthcare professionals and broader healthcare contexts, indicating that decisions may develop through ongoing relational processes (Strohschein, 2019). Similarly, a recent qualitative systematic review highlighted the complex factors influencing treatment decision-making among older adults with cancer, including uncertainty about prognosis, treatment toxicity, and the desire to maintain independence and daily functioning (Lewis et al., 2025). In addition, decision-making in cancer care has been conceptualized through frameworks such as shared decision-making, which emphasize collaborative deliberation between patients and healthcare professionals based on patients’ values and preferences (Charles et al., 1997; Elwyn et al., 2012). These models have contributed substantially to improving patient involvement at key decision points, particularly at treatment initiation, and shared decision-making continues to play a central role in supporting treatment decision-making among older adults with cancer (Gans et al., 2024). However, existing decision-making frameworks have often conceptualized decisions as discrete events occurring at identifiable time points within clinical encounters (Elwyn et al., 2017). In contrast, treatment continuation among older adults with advanced cancer often involves repeated reassessment over extended periods, during which patients’ physical condition, values, and perceptions of acceptable outcomes may change (Lewis et al., 2025). Preferences expressed at treatment initiation may not remain stable as patients experience cumulative treatment burden, functional decline, or shifts in life priorities. Therefore, the ongoing process through which older adults decide to continue systemic therapy in the context of aging and advanced disease remains insufficiently understood.

In this context, nurses play an important role in supporting decision-making regarding cancer treatment. As healthcare professionals who maintain continuous contact with patients across treatment trajectories, nurses are well positioned to provide emotional, informational, and practical support that facilitates deliberation about ongoing care and values clarification (Stacey et al., 2017; Tariman et al., 2012). However, despite recognition of this role, organizational constraints and workload often limit the ability of nurses to fully engage in decision-making support in clinical practice (Komatsu & Komatsu, 2023; Tariman & Szubski, 2015).

Therefore, this study aimed to clarify the decision-making process through which older adults with advanced cancer consider and choose to continue systemic therapy. Specifically, the study explored how patients interpret treatment experiences over time, how perceptions of aging and everyday life affect their evaluations of treatment acceptability, and how these interpretations influence decisions about treatment continuation. By elucidating this dynamic and process-oriented decision-making trajectory, the study seeks to contribute to a deeper understanding of treatment continuation in later-life cancer care and inform nursing support that aligns with patients’ evolving values and lived experiences.

Methods

Study Design and Justification

This study employed a qualitative research design using the modified grounded theory approach (Kinoshita, 2020). To clarify the decision-making process regarding continuation of systemic therapy among older adults with advanced cancer, a process-oriented analytic approach was required. Previous studies have identified multiple factors shaping treatment experiences among older adults undergoing cancer therapy, such as anticipated benefits, treatment-related side effects, functional decline, and family involvement (Kenis et al., 2017; Lindhardt et al., 2024). However, these factors have largely been examined as relatively static determinants, providing limited insight into how decisions are repeatedly re-evaluated over time as individuals live with aging, ongoing treatment, and uncertainty.

Therefore, the modified grounded theory approach, originally developed in Japan (Kinoshita, 2020), was selected to capture the dynamic and temporal nature of decision-making in this context. The modified grounded theory approach, adapted from the grounded theory approach developed by Glaser and Strauss (1967), generates substantive theories within a limited scope through systematic and explicit procedures of qualitative data analysis (Kinoshita, 2020). This methodology is particularly appropriate for examining process-related characteristics of phenomena and enables the identification of turning points and interrelationships among concepts over time. In the context of advanced cancer in later life—where treatment continuation is repeatedly reconsidered rather than resolved at a single point—this analytic framework allowed us to elucidate how older adults continuously evaluate treatment experiences and integrate ongoing therapy into the trajectory of aging.

Definition of Terms

Decision-Making

In this study, decision-making was defined as a dynamic, interpretive, and context-dependent process through which individuals consider and re-evaluate possible courses of action over time. In the context of cancer treatment continuation, decision-making was conceptualized as an ongoing process that evolves through patients’ experiences of treatment, health status, and everyday life rather than as a single discrete event (Lewis et al., 2025). Additionally, treatment decision-making in oncology is a collaborative process between patients and healthcare professionals within shared decision-making frameworks (Charles et al., 1997; Elwyn et al., 2012).

Older Adults

Older adults are defined as individuals aged ≥70 years. This operational definition aligns with recent ESMO/SIOG recommendations identifying patients aged ≥70 years as a key population for geriatric-focused assessment and management in oncology practice (ESMO/SIOG Cancer in the Elderly Working Group, 2024).

Advanced Cancer

Advanced cancer refers to recurrent, metastatic, or unresectable cancer for which systemic therapy is administered with palliative rather than curative intent and treatment decisions are made in the context of prognostic uncertainty.

Continuation of Systemic Therapy

Continuation of systemic therapy is defined as the ongoing receipt of anticancer treatment following initiation. In this study, continuation refers to patients’ repeated decisions to proceed with treatment while reassessing tolerability and daily functioning, rather than uninterrupted or indefinite therapy.

Participants

The study population comprised adults aged ≥70 years with a confirmed diagnosis of advanced cancer who were undergoing systemic cancer therapy at the time of recruitment. The inclusion criteria were as follows: (1) documented recurrent or metastatic cancer; (2) ongoing receipt of systemic cancer therapy, defined as at least two courses of cytotoxic chemotherapy or at least 2 months of targeted therapy; (3) ability to communicate in Japanese; and (4) absence of moderate to severe dementia, as determined through a screening process conducted prior to the interview. The exclusion criteria included the following: (1) physical condition judged by the attending physician or nurse to render participation not feasible and (2) inability to complete the screening assessment due to unavailability of the participant or a family member. Participants were recruited through purposive sampling to ensure diversity in age, cancer type, treatment regimen, and cohabitation status, with eligibility initially assessed by attending physicians or nurses. As data analysis progressed, theoretical sampling was employed to further refine emerging categories.

Screening for Dementia

Because this study involved in-depth narrative interviews, participants were required to have sufficient cognitive capacity to engage meaningfully in the interview process. Therefore, the Clinical Dementia Rating (CDR) scale was used solely as a screening tool to determine research eligibility and was not used as a measure of cognitive function or treated as an analytic variable. The CDR assessment was conducted by the researcher prior to the interview, based on interviews with the participant and a family member, using the Japanese version of the CDR (Meguro, 2008, pp. 21–36; Morris, 1993). Individuals with a CDR score ≥2 were defined a priori as ineligible for participation; however, no participants were excluded based on CDR scores in this study. Information obtained through the CDR assessment was used exclusively to determine eligibility and was not shared for clinical decision-making or follow-up.

Data Collection

The study was conducted in collaboration with two designated cancer care hospitals. Potential participants were referred by physicians or nurses from outpatient chemotherapy units and inpatient wards caring for patients with cancer. The researcher first assessed dementia severity using the CDR scale to determine whether individuals met the eligibility criteria.

Afterwards, two types of data were obtained from eligible participants. First, medical records were reviewed to obtain basic demographic information (age, sex, medical history, marital status, cohabiting family members, employment status, and treatment history) and clinical data (diagnosis, disease stage, time of diagnosis, treatment details, adverse events, medication use, and performance status [Eastern Cooperative Oncology Group (ECOG)]). Second, qualitative data were obtained through semi-structured interviews, guided by an interview framework developed by the researcher (Supplemental Material 1). Each participant completed a single interview lasting 30 to 60 min. Interviews were conducted in a private room to ensure confidentiality and audio-recorded on a digital recorder, with participants’ permission. Although each participant was interviewed once, the interview guide was designed to elicit narratives encompassing past experiences, current evaluations, and anticipated future trajectories, allowing exploration of perceived decision-making processes over time rather than longitudinal changes.

Variation in participant age, diagnosis, treatment regimens, and time since diagnosis enhanced data richness. Although a semi-structured interview guide was prepared, it was applied flexibly rather than rigidly. After each interview, the researcher reviewed transcripts and wrote analytic memos to identify emerging areas of interest. These insights informed subsequent interviews, leading to the addition of probing questions when relevant. For example, after early participants emphasized “Evaluating treatment as acceptable while independent” as an important factor in decision-making, later interviews included follow-up questions to further explore how participants evaluated tolerability over time. Thus, although each participant was interviewed once, the guide evolved iteratively in response to the ongoing analysis, consistent with the principles of the modified grounded theory approach. Data collection was performed between January 2019 and August 2020.

Data Analysis

Data were analyzed using the modified grounded theory approach (Kinoshita, 2020). In the modified grounded theory approach, researchers must define the analytical subject (an abstract entity representing the participants) and analytical theme (which narrows the scope of analysis to ensure relevance to the research topic and dataset). In this study, the analytical subject was defined as “older adults with advanced cancer undergoing systemic therapy,” and the analytical theme was defined as “the process of decision-making regarding the continuation of systemic therapy.”

The analysis was performed in the following steps:

Initial data collection and extraction: The interviews with the first five participants were transcribed verbatim. One case rich in content was selected, and data segments relevant to the analytical theme were extracted.

Concept generation: The extracted data were interpreted with reference to the analytical subject and theme, and “concepts” were generated to capture meaning. For each concept, an analysis worksheet was developed, consisting of four elements: concept name, definition, variations, and theoretical memo. An example of this worksheet is provided in Supplementary material 2.

Constant comparative analysis: In practice, analysis proceeded iteratively through constant comparison of transcripts. Concepts were generated and documented in analysis worksheets that included definitions and theoretical memos and gradually organized into emerging subcategories and categories. Data from subsequent participants were analyzed through constant comparison with previously generated concepts to refine similarities and differences. Analytic memos were written after each interview to capture emerging similarities, contrasts, and challenges to existing concepts. Through this iterative process, concepts were further refined and organized into provisional subcategories and categories. Theoretical sampling was conducted to further refine emerging categories, including sampling participants with continued employment to examine its potential influence on treatment continuation; however, employment affected contextual circumstances rather than function as a core analytic dimension. This analytical process informed ongoing refinement of interview questions and concept definitions.

Formation of categories: The interrelationships among concepts were examined, leading to the development of subcategories and categories. Theoretical saturation was considered reached when, after analyzing data from 14 participants, no new variations or categories emerged across diverse characteristics such as cancer type, treatment regimen, and living situation. This judgment was made through iterative peer discussions within the research team to ensure analytic consensus. Therefore, data from three additional participants were analyzed to confirm cases, verifying that the structure of the concepts, subcategories, and categories remained stable.

Integration and storyline development: The relationships among the categories and their overall coherence were examined. A result diagram was created to illustrate the process related to the analytical theme, accompanied by a written storyline.

All interviews were conducted and transcribed verbatim in Japanese, and the analysis was performed using the original Japanese transcripts. Categories, concepts, and illustrative quotations were translated to English after completion of the analysis. Translation focused on conveying the intended meaning of participants’ narratives rather than on literal word-for-word correspondence.

Ensuring Rigor and Trustworthiness

To enhance the rigor, credibility, and trustworthiness of the analysis, the research team repeatedly reviewed analysis worksheets, concept generation, and category development until interpretive consensus was reached. To further enhance analytic rigor, the researcher participated in a modified grounded theory approach study group, where discussions with other researchers addressed the selection of the analytical subject and theme, as well as the initial process of concept generation (Kinoshita, 2003, pp. 159–172). In addition, ongoing comparisons of generated concepts and their definitions, including examination of similar and contrasting cases, were conducted to refine the analysis.

Reflexivity and Positionality

The primary researcher is a nurse researcher with extensive prior clinical experience in oncology care. This background informed sensitivity to participants’ narratives, while requiring ongoing reflexive attention to assumptions regarding treatment continuation and aging. Reflexive memo writing and peer discussions within the research team were used throughout the analytical process to critically examine how professional perspectives may affect data interpretation.

Ethical Considerations

This study was approved by the Ethics Committee of the School and Graduate School of Nursing and Social Services, Health Sciences University of Hokkaido (Approval No. 18N025025) and the ethics committees of the participating institutions and conducted in accordance with established ethical guidelines for research involving human participants. Potential participants were identified by attending physicians or nurses; however, all study explanations and consent procedures were conducted directly by the researcher, who was not involved in participants’ clinical care. Participation was voluntary, and participants were informed that declining or withdrawing would not affect ongoing treatment or care.

Written informed consent was obtained from the participants prior to enrollment after providing them written and verbal explanations of the study and ensuring opportunities for questions. Interviews were conducted, at times convenient for the participants, in private rooms to protect privacy; participants’ physical condition were monitored throughout and procedures were established to involve clinical staff if distress occurred, although no such instances arose.

All data were handled confidentially. Identifiable information was removed at collection and replaced with coded identifiers, with linkage files stored securely and accessible only to the researcher for withdrawal-related requests. In disseminating the findings, care was taken to prevent identification of individual participants, institutions, or regions.

Results

Participants

Table 1 provides an overview of participant characteristics.

Table 1.

Overview of Participant Characteristics.

ID	Sex	Age	CDR¹	Co-resident(s)	Employment	Diagnosis	Stage	PS²	Time since diagnosis	Interview duration (min)	Current treatment
A	F	Early 70s	0	Husband	None	Lung	IIIC	1	9 months	43	NGT³
B	M	Early 70s	0	Wife, son	None	Gastric	IV	0	4 months	50	CDDP + S-1⁴
C	M	Late 70s	0	None	None	Bile duct	IIIC	1	4 months	43	GEM + CDDP⁵
D	F	Early 70s	0.5	Husband	None	Gastric	IV	1	14 months	42	S-1⁶
E	F	Late 80s	0	None	None	Pancreatic	IV	1	92 months	36	S-1
F	F	Early 70s	0	Husband, daughter	None	Malignant peritoneal mesothelioma	IV	1	78 months	32	PEM⁷
G	M	Early 70s	0	Wife	Employed	Gastric	IIIC	1	30 months	40	S-1
H	M	Early 80s	0	Wife	None	Gastric	IV	1	48 months	43	Capecitabine⁸
I	M	Late 70s	0	Wife	None	Hypopharyngeal	IV	1	65 months	44	S-1 + Bev⁹
J	M	Early 70s	0	Wife	None	Gastric	IIIC	1	39 months	36	CDDP + CPT-11¹⁰
K	M	Late 70s	0	Wife	None	Gastric	IV	1	42 months	46	S-1
L	M	Early 70s	0	Wife	None	Gastric	IV	1	9 months	38	S-1 + Oxaliplatin¹¹
M	M	Early 80s	0	None	None	Pancreatic	IV	1	4 months	46	S-1 + GEM + PTX¹²
N	M	Early 70s	0	Wife	None	Gastric	IV	1	19 months	52	CPT-11 + CDDP + PTX¹³
O	M	Late 70s	0.5	Wife	None	Colon	IV	1	28 months	38	FOLFIRI + Bev¹⁴
P	M	Early 70s	0	Wife	None	Rectal	IV	0	11 months	40	S-1 + Bev
Q	M	Early 80s	0	Wife	Employed	Pancreatic	IV	1	13 months	37	PTX¹⁵

Note. ¹CDR = Clinical Dementia Rating (used solely for screening to exclude moderate-to-severe dementia; not a measure of cognitive function).

PS = Performance Status (ECOG).

NGT = Nogitecan hydrochloride.

CDDP + S-1 = Cisplatin + Tegafur/Gimeracil/Oteracil potassium.

GEM + CDDP = Gemcitabine hydrochloride + Cisplatin.

S-1 = Tegafur/Gimeracil/Oteracil potassium.

PEM = Pemetrexed sodium hemipentahydrate.

Capecitabine.

S-1 + Bev = Tegafur/Gimeracil/Oteracil potassium + Bevacizumab.

CDDP + CPT-11 = Cisplatin + Irinotecan hydrochloride hydrate.

S-1 + Oxaliplatin = Tegafur/Gimeracil/Oteracil potassium + Oxaliplatin.

S-1 + GEM + PTX = Tegafur/Gimeracil/Oteracil potassium + Gemcitabine hydrochloride + Paclitaxel.

CPT-11 + CDDP + PTX = Irinotecan hydrochloride hydrate + Cisplatin + Paclitaxel.

FOLFIRI + Bev = Calcium Levofolinate hydrate + Fluorouracil + Irinotecan hydrochloride hydrate + Bevacizumab.

PTX = Paclitaxel.

The median participant age was 74.0 years (interquartile range: 71.0–79.5 years). Thirteen participants (76.5%) were male and four (23.5%) were female. Fourteen participants (82.4%) lived with family members, whereas three (17.6%) lived alone. Two participants (11.8%) were employed at the time of the study. Gastric cancer represented the most frequent diagnosis, followed by pancreatic cancer. The median time since cancer diagnosis was 19.0 months (interquartile range: 9.0–45.0 months). All participants had received systemic therapy, either cytotoxic chemotherapy or targeted therapy, as monotherapy or in combination. Based on CDR screening, 15 participants scored 0 and two scored 0.5, indicating no moderate-to-severe dementia. Regarding performance status, two participants had an ECOG score of 0, and 15 had a score of 1.

In this analysis, adaptation related to aging and adaptation related to cancer were analytically distinguished based on the primary focus of participants’ interpretations. Aging-related adaptation encompassed participants’ interpretations of age-related physical decline, anticipated remaining life, and redefinitions of health and daily living, whereas cancer-related adaptation involved responses to disease progression, treatment effects, and cancer-specific uncertainty. Although closely intertwined in participants’ experiences, this distinction was used to clarify how aging and cancer differentially shaped the decision-making process.

The decision-making process of older adults with advanced cancer regarding continuation of systemic therapy comprised 18 concepts, one subcategory, and six categories (Table 2).

Table 2.

Categories, Subcategory, and Concepts.

Categories	Subcategory	Concepts
Facing later-life and treatment burdens	—	Questioning the need to keep striving in old age
		Concerns about the future if treatment is discontinued
		Avoiding accelerated decline due to aging
		Preferring to forgo treatment unless the condition worsens due to age
		Discomfort with facing death without treatment
Pulling toward continuation of treatment	—	Evaluating treatment as acceptable while independent
	Creating benchmarks for continuation	Recovery of strength between treatments
		Recognizing recovery from side effects through continued treatment
		Cancer under control
Fulfillment through supportive relationships	—	Wishing to spend the final years with loved ones
		Reassurance gained from trust in healthcare professionals
		Encouragement from supportive others as motivation
Discovering a moderately acceptable state	—	Assessing a reasonably acceptable condition for one’s age
Integrating cancer treatment into the aging process	—	Accepting the uncertainty of treatment in old age
		Sustaining meaning in daily life through treatment
		Normalizing cancer and treatment as part of the aging process
Adopting more flexible views of health in anticipation of remaining life	—	Receiving treatment in accordance with awareness of old age
	—	Shaping later life based on partial treatment effectiveness

These elements were synthesized into a result diagram (Figure 1) and a corresponding storyline, which together illustrate the relationships among categories and the overall process of decision-making.

Figure 1.

Decision-making process of older adults with advanced cancer regarding continuation of systemic therapy.

Storyline

The findings describe a stage-based decision-making process through which participants repeatedly evaluated whether to continue systemic therapy, moving through interconnected interpretive moments, with discovering a moderately acceptable state functioning as the pivotal turning point organizing the process.

Older adults with advanced cancer initially faced treatment decisions while living with age-related decline and uncertainty about the future. They struggled with physical burdens, memories of previous side effects, and reflections on the finiteness of life, which led them to question whether continuing to strive through treatment was still meaningful in old age.

As participants considered whether to proceed with treatment, they engaged in ongoing evaluation of their current condition. Motivation to continue therapy gradually emerged when treatment was experienced as manageable within daily life, particularly when independence could be maintained and recovery between treatments was possible. These experiences pulled participants toward continuation, even in the absence of expectations for cure.

Through repeated reflection and evaluation, participants reached a turning point at which they came to regard their condition as acceptable for their age. This moderately acceptable state did not imply freedom from burden but reflected a recalibration of expectations that balanced treatment difficulties with functional capacity and everyday activities.

From this point, participants could integrate cancer treatment into their aging process. They accepted the uncertainty of treatment outcomes, sustained meaning in daily life, and accepted cancer and treatment as part of later life.

Throughout this process, participants’ views of health evolved. Rather than defining health in terms of symptom resolution or longevity alone, they adopted more flexible perspectives that emphasized living well in the present while accommodating the realities of aging and ongoing treatment.

Facing Later-Life and Treatment Burdens

This category captured the doubts older adults experienced when confronting the burdens of systemic therapy in later life, as they weighed the meaning of their remaining life against age-related physical decline and treatment burden. As one participant reflected,

If I were young, with a long future ahead, I would definitely have the treatment. But now that I am over 70, I sometimes wonder if it is really worth living longer if the treatment just makes me feel worse. I really feel uncertain. (Participant D)

Participants described uncertainty about what might happen if treatment were discontinued, recognizing that aging bodies no longer functioned as they had when younger. One participant explained, “Since I can still keep going now, I wonder what would happen if I stopped. If I do not have chemotherapy, the cancer will come back, so for now, I want to keep going as long as I can” (Participant K).

This uncertainty was accompanied by a conditional tendency to forgo treatment unless their condition worsened due to age. As one participant stated, “If things did not get worse without chemotherapy, I think it would be okay to stop” (Participant F).

However, this stance was often accompanied by discomfort with the idea of facing death without treatment. As another participant described, “Given my age, I thought about just living naturally without treatment. But then I also felt it might not be right to just wait and die without doing anything” (Participant E).

Pulling Toward Continuation of Treatment

This category described how participants evaluated their treatment experiences to determine whether continuation was manageable within daily life. As long as they remained independent, treatment was not perceived as excessively burdensome, even when adverse side effects were present. One participant explained, “I do have side effects, but they are still tolerable, so I feel like I can keep going. If they became worse, my thinking might change. For now, daily life is only a little inconvenient” (Participant C). Another participant similarly noted,

If bad side effects show up and I need to switch drugs, I think about how limiting the symptoms are. If I can still handle daily life, I keep going. But if I ended up bedridden, I would stop treatment. (Participant Q)

In addition, participants monitored how their bodies responded over time, using recovery from side effects as a benchmark for continuation. This subcategory captured how participants created personal benchmarks—such as recovery from side effects or perceived disease control—to evaluate whether treatment continuation remained manageable. As one participant reflected, “The first couple of weeks after treatment are tough, but by the third week, I feel better. Realizing this through experience gives me the motivation to continue” (Participant M). Perceptions that cancer was under control further supported continuation, as illustrated by another participant, “My liver cancer has become smaller, and the doctor says the treatment is working. That makes me want to keep going” (Participant B).

Fulfillment Through Supportive Relationships

This category highlighted how supportive relationships motivated participants to continue treatment, particularly through the desire to spend their remaining years with loved ones. Family support provided emotional reassurance that enabled participants to endure ongoing treatment. As one participant explained,

What makes it possible for me to keep going is my family. My wife has supported me since I got sick, and my kids care about me. With that support, I can keep going. On my own, I probably could not have. (Participant G)

Trust in healthcare professionals supported treatment continuation, particularly when participants faced uncertainty about treatment and its effects. As another participant reflected, “I do not know enough about the drugs, so I just have to trust the professionals and follow their advice. I learned that trusting healthcare professionals is crucial in treatment” (Participant J).

Discovering a Moderately Acceptable State

This core category captured the point at which participants’ deliberations about treatment converged into a shared evaluative reference. At this point, participants did not simply reach an understanding of their condition but actively re-endorsed the decision to continue systemic therapy under their current circumstances. Participants came to view their current condition as acceptable within the context of aging and ongoing treatment, not in terms of symptom absence or cure but in relation to whether their physical state was reasonably appropriate for their age and allowed them to sustain daily life.

Through repeated treatment experiences, participants reflected on age-related decline and prior suffering from side effects, often evaluating their current condition through comparison with earlier periods of greater difficulty. These comparisons allowed them to recalibrate expectations and accept their present state as “good enough” for their age. As one participant explained,

At first, the side effects were strong, but the treatment worked. Now the side effects are minimal, and I sometimes wonder if it is still working. Sure, I am getting older and closer to my limit, but since I can still do what I enjoy, I would say I am in pretty good shape. (Participant K)

Another participant similarly reflected, “At first, I could hardly eat because of the treatment, but now I can. Compared to those tough times, my condition is much better now. Facing death has made me realize the value of life once again” (Participant L).

Another participant noted,

Compared to the treatment I had before, my physical condition is a bit better now. . . From that state, I would say things have improved. Compared to when I was really unwell, I guess I could say I am doing ‘so-so’. (Participant I)

Integrating Cancer Treatment into the Aging Process

This category described how participants came to integrate cancer treatment into their aging process by accepting cancer as an incurable and unpredictable condition. Rather than viewing treatment as a temporary or exceptional event, participants accepted ongoing therapy as a component of later life.

Participants described accepting uncertainty in treatment outcomes as part of continuing therapy in old age. As one participant explained, “When I restarted treatment, my doctor reassured me it would have minimal impact, and actually, I am doing pretty well now. At my age, I just have to accept it” (Participant P). Another participant similarly noted, “Sometimes the side effects get worse, sometimes they get better. It is about fifty-fifty, and I have come to accept that. Otherwise, I could not have continued with the treatment” (Participant I).

Furthermore, participants emphasized sustaining valued aspects of daily life through treatment. Treatment was reframed as supporting everyday life rather than solely as a means of disease control. As one participant reflected, “As long as the cancer does not grow, even if it does not shrink, I think it is okay to keep going with treatment at my age” (Participant Q).

Another participant described viewing cancer as part of the aging process itself, “I am 78 now, and I see this illness as just one stage in my destined life” (Participant C).

Adopting More Flexible Views of Health in Anticipation of Remaining Life

This category described how participants adopted more flexible views of health in later life, emphasizing balance between treatment burden, daily functioning, and quality of life rather than cure or physical recovery. Treatment decisions were guided by age-related expectations, including avoiding excessive strain and sustaining manageable daily routines. As one participant explained, “I still want to do a lot of things, but my body does not do what I want anymore. So as long as it does, I will keep going with the treatment” (Participant O). Another participant similarly noted, “Since it is pancreatic cancer, I really want to avoid any harsh treatment. I am over 80 now, so I just want to live the rest of my life comfortably” (Participant M).

Additionally, participants considered treatment as meaningful even when its effects were partial, as long as it supported their desired way of living. As one participant reflected, “Instead of strong drugs that weaken me and shorten my life, I would rather have lighter ones that let me keep going at my own pace. I do hope the cancer shrinks, but the treatment effect comes second” (Participant A).

Discussion

Previous research on treatment experiences and decision-making regarding continuation of systemic therapy among older adults has identified key influences such as treatment-related side effects, anticipated benefits, physician recommendations, and family involvement (Lewis et al., 2025; Lindhardt et al., 2024). Clinical status and the ability to maintain independence influence treatment continuation decisions in older adults (Dias et al., 2021; Seghers et al., 2022). However, much of existing literature examined these influences as discrete factors or focused on decision points surrounding treatment initiation, providing limited insight into how older adults integrate these experiences over time while continuing systemic therapy in the context of aging. The present findings highlight the process through which these factors are considered in relation to perceptions of aging and everyday life, shaping decisions about ongoing systemic therapy.

Interpreting Treatment Continuation Within the Aging Process

Older adults with advanced cancer often approached decisions about continuing systemic therapy with hesitation and uncertainty. However, the findings of this study indicate that their decision-making was not a simple act of choosing or rejecting treatment. Rather, it unfolded as an interpretive process through which treatment was situated within the context of aging, extending prior studies that have examined treatment experiences and factors influencing treatment decisions (Lindhardt et al., 2024).

A central feature of this process was the emergence of a turning point at which participants accepted their current condition as acceptable for their age. This shift did not reflect an absence of burden but a recalibration of expectations through which participants reconciled ongoing treatment with age-related change. Previous studies have shown that improvement in side effects can strengthen patients’ willingness to continue therapy (McMullen et al., 2019), a finding that resonates with participants’ experiences. By reframing their condition as moderately acceptable, participants moved beyond dichotomous judgments and engaged with treatment as part of later life. This shift enabled participants to integrate cancer treatment into the aging process rather than perceiving treatment and aging as competing forces. From this perspective, treatment continuation was understood not solely in terms of prolonging survival and maximizing treatment benefit (DuMontier et al., 2021) but as an ongoing effort to sustain everyday life and personal values, supported by relationships with family members and healthcare professionals (Laidsaar-Powell et al., 2016; Yang et al., 2023).

Decision-making in this context was neither linear nor stable. Participants described repeated advances and retreats as they reflected on treatment implications for remaining life, indicating that decisions were affected by ongoing experiences rather than fixed preferences. Such non-linearity distinguishes the process identified in this study from models that conceptualize treatment decisions as discrete events occurring at identifiable points within clinical encounters (Elwyn et al., 2017). Additionally, it aligns with conceptual work emphasizing decision-making as an ongoing meaning-making process in chronic illness (Moth et al., 2016).

Taken together, these findings suggest that treatment continuation in older adults with advanced cancer involves an evolving interpretive process grounded in aging, uncertainty, and meaning-making. By integrating cancer treatment into later life, participants sustained a sense of coherence despite physical decline and prognostic uncertainty, highlighting decision-making as an ongoing process of accepting living with cancer in old age.

Theoretical Contribution of This Study

The theoretical contribution of this study lies in conceptualizing treatment continuation among older adults with advanced cancer as a dynamic, interpretive process rather than a discrete decision-making event. Although prior studies have identified factors such as treatment-related burden, anticipated benefit, functional status, and family support that shape treatment experiences and decisions among older adults with cancer (Battisti et al., 2020; Lindhardt et al., 2024), these elements have typically been examined as relatively stable or discrete determinants. In contrast, the present findings demonstrate that influences on treatment continuation are continuously reinterpreted through lived experience with aging and ongoing treatment, rather than operating as fixed preferences or thresholds.

Central to this process is the emergence of discovering a moderately acceptable state, which functions as a pivotal turning point through which participants recalibrate their expectations of treatment and health. Rather than striving for cure or symptom-free states, participants assessed acceptability by balancing treatment-related difficulties with age-related decline, functional capacity, and the ability to sustain everyday life. This evaluative reference was shaped through repeated experiences and comparison with prior periods of greater difficulty.

While shared decision-making frameworks emphasize collaborative deliberation between patients and healthcare professionals when making treatment decisions (Charles et al., 1997; Elwyn et al., 2012), conceptual work suggested that narrative and meaning-making processes affect how individuals sustain engagement with treatment over time (Moth et al., 2016; Strohschein, 2011). In addition, a grounded theory study showed how interaction contributes to maintaining hope and engagement over time (Strohschein, 2019). The present study illustrates how older adults reconstruct standards of acceptability through ongoing comparison with changing bodily states and life circumstances.

Importantly, this process was identifiable because the study focused on older adults with advanced cancer undergoing continued systemic therapy, a context in which treatment is rarely curative and decisions are revisited over time. Within this context, participants integrated cancer treatment into the trajectory of aging by adopting more flexible views of health that emphasized living well in the present while accommodating physical decline and uncertainty. Consistent with theoretical work suggesting that meaning in later life is grounded in relationships and life context (Golovchanova et al., 2021), the findings demonstrate how treatment continuation functions as an evolving process of meaning-making embedded in aging, complementing existing decision-making frameworks in later-life cancer care.

Dynamic Shifts in Health Perspectives Shaping Decision-Making

Older adults with advanced cancer recognized age-related decline and the burdens associated with treatment and initially tended to believe that systemic therapy was acceptable only as long as it remained within tolerable limits. As treatment continued, however, the experience of maintaining a moderately acceptable state enabled a gradual shift in perspective, whereby participants came to view partial treatment effectiveness that allowed continuation of ordinary life as sufficient. This finding illustrates how adopting more flexible views of health in anticipation of remaining life evolved alongside decision-making over time.

Early in the treatment trajectory, participants often assumed that therapy should not substantially compromise quality of life. When treatment-related burdens increased, they reconsidered continuation; however, awareness of cancer as a life-threatening condition frequently led them to persist. Through ongoing experience, participants developed a readiness to sustain therapy as they recognized that treatment could be accommodated within daily life and aging.

Over time, participants integrated their treatment experiences into a broader understanding of later life, allowing them to reframe therapy from a burden into an acceptable element of aging. Rather than prioritizing maximal therapeutic effectiveness, they came to recognize that partial effectiveness was sufficient if it supported everyday living. Thus, health was no longer defined solely by symptom control or disease eradication but by the capacity to live in accordance with personal values while acknowledging physical decline and uncertainty.

This process was iterative and non-linear. Participants repeatedly reassessed their health perspectives in response to changes in condition and life circumstances, moving between hesitation and acceptance. Flexible updating of health views enabled them to balance treatment and daily living in personally meaningful ways. Previous research has shown that coping strategies and treatment orientations shift in response to changes in health status and that individual values and life experiences shape interpretations of illness trajectories (Bridges et al., 2015; Tariman et al., 2012). However, these studies have not fully clarified how older adults redefine health itself over time when treatment is ongoing and cure is no longer the primary goal.

By illustrating how older adults progressively reconstructed their views of health through continued treatment experiences, the present study advances this understanding. By flexibly redefining what it means to be healthy in later life, participants navigated uncertainty and incorporated cancer treatment into the trajectory of their lives.

Implications for Nursing Practice

The findings of this study offer a practical framework for supporting decision-making among older adults undergoing systemic cancer treatment. Rather than assuming a linear or purely preference-based decision process, the framework highlights how patients’ decisions evolve through ongoing evaluation and reflection in response to aging and treatment-related experiences. Previous research has shown that treatment decision-making among older adults with cancer is shaped not only by clinical considerations but also by relational contexts involving family members and healthcare professionals, which influence how treatment options are interpreted and negotiated (Gong et al., 2021). In addition, studies examining chemotherapy treatment decision-making among older adults demonstrated that patients’ treatment experiences, communication with healthcare professionals, and perceptions of treatment burden influence how treatment decisions are reconsidered over time (Puts et al., 2017). These findings support the importance of providing decision support that considers to patients’ lived experiences and evolving perspectives on treatment within the context of aging.

In the early phases of this process, nurses play a key role in recognizing patients’ doubts and ambivalence regarding continued treatment. Older adults often balance treatment burden against age-related decline and the perceived meaning of further striving. Attentive listening and validation of these concerns can help patients articulate their values and clarify what matters most at this stage.

As patients engage in evaluative reflection about treatment continuation, nurses can support decision-making by focusing on patients’ lived experiences during treatment. Assessing functional capacity, recovery between treatments, and the feasibility of maintaining independence provides concrete reference points for shared discussions. From a practical standpoint, this evaluative process may be supported by existing clinical tools such as geriatric assessment and systematic symptom surveillance when used flexibly to facilitate reflection on whether ongoing treatment remains acceptable within the context of aging and daily life, rather than serving solely as instruments for treatment selection.

Importantly, the findings suggest that a pivotal point may be reached when patients come to regard their condition as acceptable within the context of aging. From a nursing perspective, this process can be interpreted through Frankl’s notion of meaning-making in the face of unavoidable suffering, which emphasizes supporting individuals in finding coherence despite ongoing uncertainty (Frankl, 2006). At this stage, nursing support can facilitate patients’ ability to integrate ongoing treatment into later life by acknowledging uncertainty, sustaining meaning in everyday activities, and reframing treatment as one component of living well in the present. By aligning decision support with patients’ evolving views of health and remaining life, oncology nurses may enhance patients’ sense of coherence and agency throughout the treatment trajectory.

Strengths

This study has several strengths. First, by applying the modified grounded theory approach, it provides a process-oriented theoretical explanation of treatment continuation among older adults with advanced cancer, moving beyond fragmented factor-based descriptions. Second, the exclusive focus on adults aged ≥70 years with recurrent or metastatic disease allowed in-depth exploration of decision-making in a clinically complex population for whom treatment continuation is particularly challenging. Third, by identifying discovering a moderately acceptable state as a pivotal turning point, this study highlights a dynamic evaluative process through which older adults integrate ongoing treatment into later life, extending existing understandings of decision-making beyond balancing side effects and quality of life.

Limitations

This study elucidated the decision-making process regarding continuation of systemic therapy among older adults with advanced cancer; however, several limitations should be considered. First, participants were individuals continuing systemic therapy at the time of the interview. Older adults who had already discontinued therapy or unable to receive or continue treatment because of physical or social constraints were not included. In addition, eligibility criteria required that participants be judged as physically able to participate and complete screening procedures, which likely limited inclusion of individuals experiencing more severe treatment-related side effects or marked functional decline.

Second, data were collected through a single interview with each participant. Accordingly, the findings reflect participants’ retrospective and prospective interpretations of change over time rather than direct observation of temporal transitions in decision-making. Although this narrative approach enabled reflection on past experiences and anticipated futures within a single account, longitudinal designs would be necessary to examine real-time changes across the treatment trajectory.

Third, although the CDR was used solely as a screening tool and no participants were excluded based on CDR scores, the screening process and requirement for family involvement may have favored inclusion of older adults with available caregiving support. Consequently, the findings primarily reflect decision-making processes among individuals with relatively stable physical condition and some degree of social support. These inclusion criteria may have contributed to the prominence of categories related to treatment acceptability and the motivational role of close relationships, limiting transferability to older adults facing severe functional or social constraints.

Finally, the sample included a higher proportion of male participants, which may reflect sex differences in cancer prevalence, treatment patterns, or referral practices and may have influenced the decision-making dynamics identified. Furthermore, because the study was conducted in Japan, the findings should be interpreted within this sociocultural context. Japan is one of the most rapidly aging societies worldwide, and cultural norms related to aging, family relationships, and communication with healthcare professionals may influence how older adults interpret treatment experiences and make decisions regarding treatment continuation. In addition, participants varied in age, time since diagnosis, and treatment history. Data were collected between 2019 and 2020, prior to the wider implementation of geriatric assessment and structured decision-support approaches in oncology. Nevertheless, the core processes identified—such as weighing treatment tolerability, reconciling therapy with aging-related change, and integrating family perspectives—represent enduring aspects of older adults’ experiences with advanced cancer.

Conclusions

This study clarified the decision-making process of older adults with advanced cancer regarding the continuation of systemic therapy. Overall, the findings indicate that the process began with hesitation toward treatment in later life, progressed through ongoing evaluation of treatment continuation, and culminated in discovering a moderately acceptable state that enabled integration of cancer treatment into the aging process. Throughout this process, participants’ evolving views of health in anticipation of remaining life shaped how they interpreted treatment burdens and evaluated continuation within the context of aging.

The findings suggest that nurses may play an important role in supporting patients as they reconstruct the meaning of treatment through personal experiences. Nursing practice is expected to respect diverse values shaped by aging and disease progression while fostering balance between daily life and therapy. Future research should broaden these insights by including patients who discontinue therapy and by examining diverse social contexts.

Supplemental Material

sj-docx-1-gqn-10.1177_23333936261444348 – Supplemental material for Decision-Making Process of Older Adults with Advanced Cancer Regarding Continuation of Systemic Therapy

Supplemental material, sj-docx-1-gqn-10.1177_23333936261444348 for Decision-Making Process of Older Adults with Advanced Cancer Regarding Continuation of Systemic Therapy by Kengo Hirayama in Global Qualitative Nursing Research

Supplemental Material

sj-docx-2-gqn-10.1177_23333936261444348 – Supplemental material for Decision-Making Process of Older Adults with Advanced Cancer Regarding Continuation of Systemic Therapy

Supplemental material, sj-docx-2-gqn-10.1177_23333936261444348 for Decision-Making Process of Older Adults with Advanced Cancer Regarding Continuation of Systemic Therapy by Kengo Hirayama in Global Qualitative Nursing Research

Footnotes

Acknowledgements

The author gratefully acknowledges the patients and their families for their participation, as well as the physicians and nurses who assisted with participant recruitment. The author also expresses sincere gratitude to Professor Emeritus Noriko Hira, Health Sciences University of Hokkaido, for her invaluable guidance throughout the doctoral program. To further strengthen the methodological rigor of this study, the author benefited from discussions within the modified grounded theory approach study group, whose members provided constructive feedback on the analytical subject, theme selection, and the early stages of concept generation. The author also thanks Editage () for English language editing.

ORCID iD

Kengo Hirayama

Ethical Considerations

This study was approved by the Ethics Committee of the School and Graduate School of Nursing and Social Services, Health Sciences University of Hokkaido (Approval Number: 18N025025) and was conducted in accordance with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All participants provided written informed consent.

Consent to Participate

Both written and verbal informed consent were obtained from all participants prior to their inclusion in the study.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the JSPS KAKENHI (Grant Number JP20K19045). The funding source had no role in study design; data collection, analysis, or interpretation; in the writing of the report; or in the decision to submit the article for publication.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study, including the raw de-identified data, are available from the corresponding author on reasonable request.

Statement Regarding Use of AI Tools

No AI tools/services were used during the preparation of this work.

Supplemental Material

Supplemental material for this article is available online.

Author Biography

Kengo Hirayama, PhD, RN, CNS (Certified Nurse Specialist) is an assistant professor at the Sapporo City University, School of Nursing in Sapporo, Hokkaido, Japan.

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