Understanding why older adults choose not to initiate disease-directed oncologic treatment: A qualitative study.

INTRODUCTION: Rising life expectancy has led to an increasing number of older adults diagnosed with cancer, yet this population remains under-represented in clinical research that informs oncologic care. Consequently, treatment decisions for older adults are often made with limited age-specific evidence. This study aimed to understand how older adults navigate decisions not to initiate disease-directed oncologic treatment, in order to inform communication and shared decision making in geriatric oncology. MATERIALS AND METHODS: We conducted a qualitative study using semi structured, in-depth interviews with adults aged 65 years and older who chose not to initiate oncologic treatment following a cancer diagnosis. Fifteen interviews were conducted between September 2023 and May 2025. Interviews were audio recorded, transcribed verbatim, and analyzed using reflexive thematic analysis. RESULTS: Participants aged 65-95 years described a coherent decision-making process centered on avoidance of suffering. Three themes shaped this process: Acceptance of death, expressed in rational, spiritual, or life course terms, framed non-initiation as a meaningful option; personal illness-related experience shaped understanding of treatment implications; and a strong sense of decisional agency guided choices aligned with participants' values and priorities. Together, these elements supported a deliberate choice not to initiate treatment. DISCUSSION: Older adults who decline disease directed oncologic treatment describe a considered, values-based decision-making process rooted in life experience and identity. Conceptualizing non initiation as an active process may support more attuned clinical communication and contribute to discussions of decision quality in aging populations.