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

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PURPOSE: Older adults undergoing systemic anti-cancer therapy (SACT) with steroids are at high risk of developing steroid-induced hyperglycaemia (SIH). However, monitoring and management remain inconsistent. This quality improvement project (QIP) involved developing and evaluating the GOLD diabetes enhanced monitoring pathway, a multidisciplinary, age-adapted initiative for older patients at intermediate SIH risk. METHODS: The pathway was implemented at Guy's and St Thomas' NHS Foundation Trust between February 2022 and June 2025. This included collaborative planning, structured risk stratification, diabetes education, home capillary blood glucose monitoring, telephone follow-up by geriatric clinical nurse specialists, medication and safety protocols. Iterative refinements were made through seven Plan-Do-Study-Act (PDSA) cycles. The primary outcome was the rate of SIH requiring diabetes medication intervention, whilst secondary outcomes included changes in SACT/steroid regimens, unplanned hospitalisations, and all-cause mortality. RESULTS: Of the 126 patients (58% male; median age 74 years [IQR: 70-79]; 77% with pre-existing diabetes), diabetes medication intervention was provided in 32%, primarily with the initiation or escalation of gliclazide. Only three asymptomatic hypoglycaemic events occurred. Unplanned hospitalisations occurred in 28% of patients (n = 35), with only two admissions related to diabetes. All-cause mortality (33%, n = 41) was associated with metastatic disease, malnutrition, and social isolation, but not with glycaemic control or diabetes intervention. CONCLUSION: The GOLD pathway appears feasible, safe, and effective in managing SIH in older adults with cancer. Its success highlights the value of multidisciplinary collaboration and iterative refinement in addressing a critical gap in geriatric oncology care, as well as supporting structured diabetes monitoring in clinical practice. Larger multi-centre implementation effectiveness evaluation will enable sustainable, cost-effective practice across diverse settings.

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