Purpose of Review <p>Polypharmacy is highly prevalent among elderly with cancer due to multimorbidity, supportive medications, and complex treatment regimens. It poses challenges of adverse drug reactions, drug–drug interactions, and adherence difficulties. This review explores the epidemiology, clinical consequences, and strategies for medication optimisation and adherence support in geriatric oncology.</p> Recent Findings <p>Emerging evidence demonstrates that pharmacist-led medication reviews, comprehensive geriatric assessment, and tools such as STOPP/START, Beers Criteria, and the FORTA list improve prescribing quality and facilitate deprescribing. Digital health interventions, including telemonitoring and connected pill systems, enhance adherence. Artificial intelligence and machine learning–based predictive models are beginning to identify patients at risk of adverse drug events or non-adherence, although integration into oncology work flows remains limited.</p> Summary <p>Polypharmacy and non-adherence remain major barriers to optimal cancer care in older adults. Multidisciplinary optimisation, combined with digital and AI innovations, offers a pathway to safer and more effective treatment.</p>