Cardio-Oncology in Older Adults: Evidence Gaps, Geriatric Considerations, and Future Directions.

Cardio-oncology has emerged as a critical discipline addressing cardiovascular toxicities from cancer therapies, yet substantial evidence gaps persist for elderly patients, who represent over 60% of new cancer diagnoses. This narrative review synthesizes the current literature on cardio-oncology challenges in older adults (≥65 years), highlighting underrepresentation in clinical trials, compounded risks from frailty, multimorbidity, and polypharmacy, and the paucity of geriatric-specific guidelines. Older adults exhibit heightened susceptibility to cardiotoxicity from antineoplastic therapies due to age-related declines in cardiac reserve and renal function, and baseline atherosclerosis. Comprehensive geriatric assessments (CGA) identify frailty as a key predictor of adverse outcomes, yet their integration into cardio-oncology protocols remains inconsistent, with limited prospective data on risk-stratification tools such as echocardiography and biomarkers. Observational studies underscore disparities in surveillance and management, leading to the undertreatment of cancer and overtreatment of comorbidities. Current cardio-oncology guidelines recognize older age, multimorbidity, frailty, and individualized assessment as important considerations in clinical decision-making. However, validated geriatric-specific thresholds, surveillance strategies, and management algorithms remain limited, particularly for frail older adults and the oldest-old populations. Emerging priorities include multidisciplinary models incorporating geriatricians, randomized trials in frail populations, and real-world evidence on novel agents. This review advocates tailored strategies to optimize shared decision-making, enhance equity, and address current knowledge gaps through CGA-driven research, while proposing a pragmatic age- and frailty-stratified framework to support individualized cardiovascular assessment in elderly cancer patients.