Barriers and Opportunities for Implementing Precision Oncology in Geriatric Cancer Care

Precision oncology can guide treatment selection and treatment omission in older adults, but molecular actionability alone does not establish an acceptable individual benefit-burden balance. This focused narrative review examines tumor biology, host vulnerability, and implementation barriers, prioritizing randomized trials, prospective cohorts, and guidance published during 2019-2025. Clonal hematopoiesis complicates plasma variant interpretation, and genomic risk must be distinguished from prediction of treatment benefit. The GAP70+ and GAIN trials demonstrate that geriatric assessment linked to management reduces serious treatment toxicity in general oncology; their results do not directly validate geriatric integration into molecular tumor boards. Older-adult studies including RESPECT, EORTC 75111-10114, Alliance A171601, and ASTER 70s inform specific biomarker-selected treatment decisions while exposing limitations in evidence for frail patients. Targeted treatment may complement chemotherapy as maintenance, and de-escalation requires indication-specific evidence. Genomic assays in early breast cancer should be requested when the result can change a realistic treatment choice, rather than offered or withheld solely according to age. Existing American Society of Clinical Oncology (ASCO), Food and Drug Administration (FDA), and European Organisation for Research and Treatment of Cancer (EORTC) responses to underrepresentation provide a foundation for more inclusive research. A proposed clinical framework combines validated molecular evidence, geriatric assessment, medication review, and shared decisions, with reassessment of function and goals. Prospective evaluation should establish whether this integration improves treatment delivery, function, quality of life, and goal concordance.