Apocalyptic horsemen of geriatric oncologyConsidering the processes we encounter and must overcome to reduce the burden of Geriatric Oncology, I am reminded of the scriptural description of the Four Horsemen of the Apocalypse, War, Pestilence, Famine, and Death. All are synergistic and portend devastating outcomes. The Apocalyptic Horsemen that we must engage and thwart in Geriatric Oncology, include Genomic Infidelity, Cellular Senescence, Inflammaging and Diabesity.Genomic Infidelity, including DNA mutagenesis, rearrangement and epigenetic changes, continuously increases over the lifespan. It provides the enabling, disruptive background for almost all malignant transformation (1,2). These processes essentially throw the switches that result in oncogene activation and inactivation of tumor suppressor genes. While extensive DNA Damage Response Pathways and Epigenetic Regulatory Systems exist to counteract these changes, their inexorable progression leads to cancer as a common disease of older adults (3).Cellular senescence, which may be associated with mutagenesis, as well as with cumulative environmental influences, leads to a number of age-associated phenotypes that significantly impact geriatric oncology. These include immuno-senescence, myo-senescence, sarcopenia, and the senescence associated secretory phenotype (SASP). Immuno-senescence results in loss and/or alterations in the immune system that may contribute to age-associated declines in immuno surveillance leading to a permissive milieu for tumor growth and increased susceptibility to infectious organisms. Senescence of muscle satellite cells accompanied by inadequate nutrition and physical activity, may contribute to decreases in skeletal muscle mass resulting in age-associated sarcopenia (4). The latter can lead to frailty, falls, functional decline, and death (5). At the same time, sarcopenia can interfere with patient tolerability of cancer therapies ( 6). Yet another consequence of senescence is the SASP, in which cells lose their proliferative capacity, and increase their secretion of inflammatory cytokines, many of which may amplify tumor growth supportive factors in the tumor microenvironment (7-9).Inflammaging has been identified as age-associated chronic, sterile, low-grade inflammation that occurs in response to endogenous cell debris and metabolic errors. It may particularly occur in pathways that mediate gut-liver, gut-brain, and/or gutadipose tissue communication and interactions (10). Unlike classic acute inflammation, which is usually targeted at destroying foreign pathogenic organisms, and then terminates once the pathogens are eliminated, inflammaging is low-grade and ongoing (11). Consequences, of inflammaging include synthesis and release of cytokines including TNF, IL-1, IL-6, and IL-8, as well as epigenetic changes leading to accelerated biological aging as demonstrated by altered patterns of DNA methylation (10).Diabesity denotes the expanding worldwide prevalence of obesity, its association with increased incidence of diabetes an...