A team at Guy’s and St Thomas’ NHS Foundation Trust in London set out to close this gap with a structured, age-adapted initiative known as the GOLD diabetes enhanced monitoring pathway, developed within the Geriatric Oncology Liaison Development clinic. Reporting their work in the European Geriatric Medicine journal, the researchers describe a quality improvement project conducted between February 2022 and June 2025, in which a multidisciplinary group of geriatricians, oncologists, diabetologists and clinical nurse specialists translated national guidance from the UK Chemotherapy Board and the Joint British Diabetes Societies for Inpatient Care into a practical, locally tailored system for older patients at intermediate risk of steroid-induced hyperglycaemia.

The pathway began with careful risk stratification. Patients were classified as low risk if they had an HbA1c below 48 mmol/mol and no history of diabetes, and were followed by their oncology team and general practitioner. High-risk patients, including those on insulin, those with HbA1c of 64 mmol/mol or above, glucose readings of 15 mmol/L or higher, pancreatic cancer, or a previous episode of steroid-induced hyperglycaemia, were referred directly to specialist diabetes services. The intermediate group, typically those with HbA1c between 48 and 63 mmol/mol or capillary glucose between 11 and 14.9 mmol/L, or patients with diabetes managed on oral agents who did not meet high-risk criteria, became the focus of the GOLD pathway.

Once enrolled, each patient received a capillary blood glucose meter and personalised education from a geriatric clinical nurse specialist, delivered face to face or by telephone within days of referral, because the interval between referral and the start of systemic anti-cancer therapy is often extremely short. Education covered the symptoms of high and low blood sugar, how to recognise diabetes emergencies, glucose targets, and practical demonstrations of the meter, all calibrated to each patient’s health literacy, cognition and physical abilities, with caregivers involved where necessary. During every treatment cycle, patients checked their glucose on the day of steroid administration and the following two days, before breakfast and before the evening meal, a schedule designed to capture the late-afternoon and evening peaks characteristic of steroid-induced hyperglycaemia.

Telephone follow-up by nurse specialists after each cycle formed the backbone of the monitoring system. The team reviewed all glucose readings, assessed food intake and treatment side effects, and applied decision-making algorithms for intervention. Hyperglycaemia was defined as at least two readings above 15 mmol/L, and hypoglycaemia as any reading below 4 mmol/L. When medication was required, the protocol favoured gliclazide, a sulphonylurea that directly stimulates insulin secretion and thereby counteracts the steroid-driven suppression of pancreatic beta-cell function. The team deliberately adopted a higher intervention threshold of 15 mmol/L, compared with the 12 mmol/L in national guidance, reflecting broader glycaemic targets for older people and a conscious effort to avoid hypoglycaemia and its consequences, particularly in patients with poor oral intake or renal impairment.

The implementation itself was iterative. The pathway was refined through seven Plan-Do-Study-Act cycles between 2022 and 2023, each incorporating feedback from healthcare professionals and addressing specific local barriers such as the feasibility of glucose measurement, intervention thresholds and the medication titration process. Risk criteria were sharpened over successive cycles, with the glucose range adjusted from 12–20 to 11–15 mmol/L and the HbA1c range expanded from 48–59 to 48–64 mmol/mol. Fortnightly multidisciplinary meetings were introduced from January 2023 to review complex cases, and the geriatric nursing team grew increasingly autonomous in managing intermediate-risk patients, reducing the burden on specialist diabetes services while retaining rapid access to expert advice.

In total, 126 patients were enrolled, with a median age of 74 years, 58% male, and 77% living with pre-existing diabetes. The most common tumour sites were the oesophagus, colon and breast, and 94% received chemotherapy as their primary systemic anti-cancer therapy, most commonly supported by dexamethasone at a median daily dose of 8 mg for the first four days of each cycle, chiefly for its anti-emetic and anti-allergic properties. Comprehensive geriatric assessment data, available for 81% of participants, revealed a largely pre-frail population with a median Clinical Frailty Scale score of 3, and identified malnutrition in 46% of the cohort, alongside social isolation, functional impairment and recent falls in smaller proportions. Personalised geriatric interventions, spanning physiotherapy, occupational therapy, dietary support and medication management, were implemented for the vast majority of those with identified impairments.

The results paint a picture of a pathway that is both feasible and safe. Clinical advice on diabetes management was provided to 89% of patients, and diabetes medication intervention was required in 32%, with gliclazide initiated or escalated in 92% of those cases. Women and patients with pre-existing diabetes were significantly more likely to need medication. Critically, only three hypoglycaemic events occurred, all asymptomatic and all managed without clinical consequences. Among 35 unplanned hospital admissions within a year, only two were related to hyperglycaemia, and there were no episodes of diabetic ketoacidosis or hyperosmolar hyperglycaemic syndrome, and no admissions for hypoglycaemia. During a median follow-up of 300 days, 41 patients died, but mortality was associated with metastatic disease, malnutrition and social isolation rather than with glycaemic control or diabetes intervention, suggesting that proactive metabolic monitoring did not add risk in this fragile population.

The pathway also influenced cancer treatment itself in measurable ways. Steroid regimens were modified for 24% of patients, almost always involving dose reductions driven by hyperglycaemia, and in 80% of those cases the adjustment was linked to the need for diabetes medication. While steroid reduction triggered treatment toxicity symptoms in four patients, leading to early discontinuation or dose reduction of the anti-cancer protocol in two, the overall signal was one of balance: oncologists could taper steroids with confidence knowing that a safety net existed for the metabolic consequences. Notably, secondary referrals to the diabetes team fell dramatically over the project period, from 36% of patients enrolled in 2022 to just 5% in 2025, evidence that the geriatric team’s growing expertise was absorbing demand that would otherwise have overwhelmed specialist services.

The authors are candid about limitations. The single-centre design, the predominance of pre-frail patients, the absence of a comparator group and the use of clinical rather than validated tools for some geriatric domains all constrain generalisability, and under-ascertainment of nocturnal or asymptomatic glycaemic excursions cannot be excluded with intermittent fingerstick testing. Even so, the team argues that the GOLD pathway offers a robust, patient-centred model for integrating geriatric, oncology and diabetes care, aligned with national and international recommendations for multidisciplinary management of older adults with complex needs. Future priorities include multi-centre validation, comparative and randomised designs to confirm effectiveness, integration of continuous glucose monitoring and digital health tools to reduce nursing workload, evaluation of patient-reported outcomes and cost-effectiveness, and incorporation of patient feedback to improve usability for those who struggle with glucometer technology. If those steps succeed, structured diabetes monitoring could become a standard component of geriatric oncology, ensuring that the steroids that help fight cancer no longer silently undermine the patients receiving them.

Subject of Research: A quality improvement project evaluating an age-adapted, multidisciplinary diabetes monitoring pathway for older adults with cancer undergoing steroid-based systemic anti-cancer therapy.

Article Title: Improving diabetes management in older adults with cancer: a quality improvement project to enhance monitoring during steroid-based systemic anti-cancer therapy

Article References: Liuu, E., Evans, R., Bassas-Letissier, N., Amaratunga, G., Compton, S., Georgiou, A., Kalsi, T., Liu, Y.-F., Maguire, J., Nottage, C., Rush, H. L., & Welch, C. (2026). Improving diabetes management in older adults with cancer: a quality improvement project to enhance monitoring during steroid-based systemic anti-cancer therapy. European Geriatric Medicine. https://doi.org/10.1007/s41999-026-01585-w

Image Credits: AI Generated

DOI: 10.1007/s41999-026-01585-w

Keywords: geriatric oncology, diabetes, steroid-induced hyperglycaemia, systemic anti-cancer therapy, quality improvement, multidisciplinary care, gliclazide, blood glucose monitoring, older adults, comprehensive geriatric assessment, hypoglycaemia, cancer treatment