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General principles on the treatment of early-stage and locally advanced breast cancer in older women

Gretchen Kimmick, MD, MS
Pearl H Seo, MD, MPH
Section Editors
Daniel F Hayes, MD
Kenneth E Schmader, MD
Deputy Editor
Sadhna R Vora, MD


For most women, increasing age is the primary risk factor for breast cancer. Of the approximately 230,000 new cases of female breast cancer diagnosed annually in the United States, almost one-half arise in older women (typically defined as age ≥65 years, though this varies in studies).

This topic will review general principles on the treatment of early-stage and locally advanced breast cancer in older women. Where clinical guidance is provided in this topic, the anatomic staging system set forth in the eighth edition of the American Joint Committee on Cancer Staging Manual is used (table 1); however, it is recognized that the studies cited may have used previous editions of the staging system, which is a limitation of existing data. (See "Tumor, Node, Metastasis (TNM) staging classification for breast cancer".)

An overview of the approach to women with newly diagnosed breast cancer and the treatment of breast cancer that applies to all women regardless of age are discussed separately.

(See "Overview of the treatment of newly diagnosed, non-metastatic breast cancer".)

(See "Mastectomy: Indications, types, and concurrent axillary lymph node management" and "Breast conserving therapy" and "Management of the regional lymph nodes in breast cancer".)

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Literature review current through: Nov 2017. | This topic last updated: Aug 14, 2017.
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  1. Wyld L, Garg DK, Kumar ID, et al. Stage and treatment variation with age in postmenopausal women with breast cancer: compliance with guidelines. Br J Cancer 2004; 90:1486.
  2. Enger SM, Thwin SS, Buist DS, et al. Breast cancer treatment of older women in integrated health care settings. J Clin Oncol 2006; 24:4377.
  3. Lavelle K, Todd C, Moran A, et al. Non-standard management of breast cancer increases with age in the UK: a population based cohort of women > or =65 years. Br J Cancer 2007; 96:1197.
  4. Cyr A, Gillanders WE, Aft RL, et al. Breast cancer in elderly women (≥ 80 years): variation in standard of care? J Surg Oncol 2011; 103:201.
  5. Bastiaannet E, Liefers GJ, de Craen AJ, et al. Breast cancer in elderly compared to younger patients in the Netherlands: stage at diagnosis, treatment and survival in 127,805 unselected patients. Breast Cancer Res Treat 2010; 124:801.
  6. Lavelle K, Sowerbutts AM, Bundred N, et al. Is lack of surgery for older breast cancer patients in the UK explained by patient choice or poor health? A prospective cohort study. Br J Cancer 2014; 110:573.
  7. Gennari R, Curigliano G, Rotmensz N, et al. Breast carcinoma in elderly women: features of disease presentation, choice of local and systemic treatments compared with younger postmenopasual patients. Cancer 2004; 101:1302.
  8. Diab SG, Elledge RM, Clark GM. Tumor characteristics and clinical outcome of elderly women with breast cancer. J Natl Cancer Inst 2000; 92:550.
  9. Pierga JY, Girre V, Laurence V, et al. Characteristics and outcome of 1755 operable breast cancers in women over 70 years of age. Breast 2004; 13:369.
  10. Rodrigues NA, Dillon D, Carter D, et al. Differences in the pathologic and molecular features of intraductal breast carcinoma between younger and older women. Cancer 2003; 97:1393.
  11. Malik MK, Tartter PI, Belfer R. Undertreated breast cancer in the elderly. J Cancer Epidemiol 2013; 2013:893104.
  12. Grann VR, Troxel AB, Zojwalla NJ, et al. Hormone receptor status and survival in a population-based cohort of patients with breast carcinoma. Cancer 2005; 103:2241.
  13. Bacchi LM, Corpa M, Santos PP, et al. Estrogen receptor-positive breast carcinomas in younger women are different from those of older women: a pathological and immunohistochemical study. Breast 2010; 19:137.
  14. Poltinnikov IM, Rudoler SB, Tymofyeyev Y, et al. Impact of Her-2 Neu overexpression on outcome of elderly women treated with wide local excision and breast irradiation for early stage breast cancer: an exploratory analysis. Am J Clin Oncol 2006; 29:71.
  15. Honma N, Sakamoto G, Akiyama F, et al. Breast carcinoma in women over the age of 85: distinct histological pattern and androgen, oestrogen, and progesterone receptor status. Histopathology 2003; 42:120.
  16. Anderson WF, Pfeiffer RM, Dores GM, Sherman ME. Comparison of age distribution patterns for different histopathologic types of breast carcinoma. Cancer Epidemiol Biomarkers Prev 2006; 15:1899.
  17. Yancik R, Ries LG, Yates JW. Breast cancer in aging women. A population-based study of contrasts in stage, surgery, and survival. Cancer 1989; 63:976.
  18. Goodwin JS, Hunt WC, Samet JM. Determinants of cancer therapy in elderly patients. Cancer 1993; 72:594.
  19. Schonberg MA, Marcantonio ER, Ngo L, et al. Causes of death and relative survival of older women after a breast cancer diagnosis. J Clin Oncol 2011; 29:1570.
  20. Extermann M, Balducci L, Lyman GH. What threshold for adjuvant therapy in older breast cancer patients? J Clin Oncol 2000; 18:1709.
  21. Extermann M, Aapro M. Assessment of the older cancer patient. Hematol Oncol Clin North Am 2000; 14:63.
  22. Patnaik JL, Byers T, Diguiseppi C, et al. The influence of comorbidities on overall survival among older women diagnosed with breast cancer. J Natl Cancer Inst 2011; 103:1101.
  23. Vaeth PA, Satariano WA, Ragland DR. Limiting comorbid conditions and breast cancer stage at diagnosis. J Gerontol A Biol Sci Med Sci 2000; 55:M593.
  24. Fleming ST, Sabatino SA, Kimmick G, et al. Developing a claim-based version of the ACE-27 comorbidity index: a comparison with medical record review. Med Care 2011; 49:752.
  25. Clough-Gorr KM, Stuck AE, Thwin SS, Silliman RA. Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up. J Clin Oncol 2010; 28:380.
  26. Clough-Gorr KM, Thwin SS, Stuck AE, Silliman RA. Examining five- and ten-year survival in older women with breast cancer using cancer-specific geriatric assessment. Eur J Cancer 2012; 48:805.
  27. McCleary NJ, Wigler D, Berry D, et al. Feasibility of computer-based self-administered cancer-specific geriatric assessment in older patients with gastrointestinal malignancy. Oncologist 2013; 18:64.
  28. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol 2011; 29:3457.
  29. Pallis AG, Fortpied C, Wedding U, et al. EORTC elderly task force position paper: approach to the older cancer patient. Eur J Cancer 2010; 46:1502.
  30. Parks RM, Lakshmanan R, Winterbottom L, et al. Comprehensive geriatric assessment for older women with early breast cancer - a systematic review of literature. World J Surg Oncol 2012; 10:88.
  31. Soubeyran P, Fonck M, Blanc-Bisson C, et al. Predictors of early death risk in older patients treated with first-line chemotherapy for cancer. J Clin Oncol 2012; 30:1829.
  32. Extermann M, Boler I, Reich RR, et al. Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score. Cancer 2012; 118:3377.
  33. Biganzoli L, Boni L, Becheri D, et al. Evaluation of the cardiovascular health study (CHS) instrument and the Vulnerable Elders Survey-13 (VES-13) in elderly cancer patients. Are we still missing the right screening tool? Ann Oncol 2013; 24:494.
  34. Barthélémy P, Heitz D, Mathelin C, et al. Adjuvant chemotherapy in elderly patients with early breast cancer. Impact of age and comprehensive geriatric assessment on tumor board proposals. Crit Rev Oncol Hematol 2011; 79:196.
  35. Caillet P, Canoui-Poitrine F, Vouriot J, et al. Comprehensive geriatric assessment in the decision-making process in elderly patients with cancer: ELCAPA study. J Clin Oncol 2011; 29:3636.
  36. Pallis AG, Wedding U, Lacombe D, et al. Questionnaires and instruments for a multidimensional assessment of the older cancer patient: what clinicians need to know? Eur J Cancer 2010; 46:1019.
  37. Braithwaite D, Satariano WA, Sternfeld B, et al. Long-term prognostic role of functional limitations among women with breast cancer. J Natl Cancer Inst 2010; 102:1468.
  38. Rothman MD, Leo-Summers L, Gill TM. Prognostic significance of potential frailty criteria. J Am Geriatr Soc 2008; 56:2211.
  39. Ferrucci L, Guralnik JM, Studenski S, et al. Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc 2004; 52:625.
  40. Hamaker ME, Jonker JM, de Rooij SE, et al. Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review. Lancet Oncol 2012; 13:e437.
  41. de Glas NA, van de Water W, Engelhardt EG, et al. Validity of Adjuvant! Online program in older patients with breast cancer: a population-based study. Lancet Oncol 2014; 15:722.
  42. Wishart GC, Azzato EM, Greenberg DC, et al. PREDICT: a new UK prognostic model that predicts survival following surgery for invasive breast cancer. Breast Cancer Res 2010; 12:R1.
  43. de Glas NA, Bastiaannet E, Engels CC, et al. Validity of the online PREDICT tool in older patients with breast cancer: a population-based study. Br J Cancer 2016; 114:395.
  44. Puts MT, Hardt J, Monette J, et al. Use of geriatric assessment for older adults in the oncology setting: a systematic review. J Natl Cancer Inst 2012; 104:1133.
  45. Valero S, Migeot V, Bouche G. Who needs a Comprehensive Geriatric Assessment? A French Onco-Geriatric Screening tool. J Geriatric Oncol 2011; 2:130.
  46. Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 2005; 104:1998.
  47. Overcash JA, Beckstead J, Moody L, et al. The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: scoring and interpretation. Crit Rev Oncol Hematol 2006; 59:205.
  48. Molina-Garrido MJ, Guillen-Ponce C. Comparison of two frailty screening tools in older women with early breast cancer. Crit Rev Oncol Hematol 2011; 79:51.
  49. Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†. Ann Oncol 2015; 26:288.
  50. Bellera CA, Rainfray M, Mathoulin-Pélissier S, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol 2012; 23:2166.
  51. Kenis C, Bron D, Libert Y, et al. Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study. Ann Oncol 2013; 24:1306.
  52. Audisio RA, Bozzetti F, Gennari R, et al. The surgical management of elderly cancer patients; recommendations of the SIOG surgical task force. Eur J Cancer 2004; 40:926.
  53. Sandison AJ, Gold DM, Wright P, Jones PA. Breast conservation or mastectomy: treatment choice of women aged 70 years and older. Br J Surg 1996; 83:994.
  54. Sweeney C, Schmitz KH, Lazovich D, et al. Functional limitations in elderly female cancer survivors. J Natl Cancer Inst 2006; 98:521.
  55. Mano M, Fraser G, McIlroy P, et al. Locally advanced breast cancer in octogenarian women. Breast Cancer Res Treat 2005; 89:81.
  56. International Breast Cancer Study Group, Rudenstam CM, Zahrieh D, et al. Randomized trial comparing axillary clearance versus no axillary clearance in older patients with breast cancer: first results of International Breast Cancer Study Group Trial 10-93. J Clin Oncol 2006; 24:337.
  57. Hughes KS, Schnaper LA, Berry D, et al. Lumpectomy plus tamoxifen with or without irradiation in women 70 years of age or older with early breast cancer. N Engl J Med 2004; 351:971.
  58. Martelli G, Miceli R, Costa A, et al. Elderly breast cancer patients treated by conservative surgery alone plus adjuvant tamoxifen: fifteen-year results of a prospective study. Cancer 2008; 112:481.
  59. Chagpar AB, McMasters KM, Edwards MJ, North American Fareston Tamoxifen Adjuvant Trial. Can sentinel node biopsy be avoided in some elderly breast cancer patients? Ann Surg 2009; 249:455.
  60. Deutsch M. Radiotherapy after lumpectomy for breast cancer in very old women. Am J Clin Oncol 2002; 25:48.
  61. Veronesi U, Luini A, Del Vecchio M, et al. Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med 1993; 328:1587.
  62. Smith BD, Gross CP, Smith GL, et al. Effectiveness of radiation therapy for older women with early breast cancer. J Natl Cancer Inst 2006; 98:681.
  63. Pinder MC, Duan Z, Goodwin JS, et al. Congestive heart failure in older women treated with adjuvant anthracycline chemotherapy for breast cancer. J Clin Oncol 2007; 25:3808.
  64. Muss HB, Woolf S, Berry D, et al. Adjuvant chemotherapy in older and younger women with lymph node-positive breast cancer. JAMA 2005; 293:1073.
  65. Du XL, Osborne C, Goodwin JS. Population-based assessment of hospitalizations for toxicity from chemotherapy in older women with breast cancer. J Clin Oncol 2002; 20:4636.
  66. Elkin EB, Hurria A, Mitra N, et al. Adjuvant chemotherapy and survival in older women with hormone receptor-negative breast cancer: assessing outcome in a population-based, observational cohort. J Clin Oncol 2006; 24:2757.
  67. Early Breast Cancer Trialists' Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 365:1687.
  68. Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Peto R, Davies C, et al. Comparisons between different polychemotherapy regimens for early breast cancer: meta-analyses of long-term outcome among 100,000 women in 123 randomised trials. Lancet 2012; 379:432.
  69. Citron ML, Berry DA, Cirrincione C, et al. Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741. J Clin Oncol 2003; 21:1431.
  70. Ryberg M, Nielsen D, Cortese G, et al. New insight into epirubicin cardiac toxicity: competing risks analysis of 1097 breast cancer patients. J Natl Cancer Inst 2008; 100:1058.
  71. Jones S, Holmes FA, O'Shaughnessy J, et al. Docetaxel With Cyclophosphamide Is Associated With an Overall Survival Benefit Compared With Doxorubicin and Cyclophosphamide: 7-Year Follow-Up of US Oncology Research Trial 9735. J Clin Oncol 2009; 27:1177.
  72. Lindeman GJ, Boyages J, Driessen C, Langlands AO. Intravenous or oral adjuvant CMF for node-positive breast cancer. Aust N Z J Surg 1992; 62:556.
  73. Crivellari D, Bonetti M, Castiglione-Gertsch M, et al. Burdens and benefits of adjuvant cyclophosphamide, methotrexate, and fluorouracil and tamoxifen for elderly patients with breast cancer: the International Breast Cancer Study Group Trial VII. J Clin Oncol 2000; 18:1412.
  74. De Maio E, Gravina A, Pacilio C, et al. Compliance and toxicity of adjuvant CMF in elderly breast cancer patients: a single-center experience. BMC Cancer 2005; 5:30.
  75. Fargeot P, Bonneterre J, Roché H, et al. Disease-free survival advantage of weekly epirubicin plus tamoxifen versus tamoxifen alone as adjuvant treatment of operable, node-positive, elderly breast cancer patients: 6-year follow-up results of the French adjuvant study group 08 trial. J Clin Oncol 2004; 22:4622.
  76. Colozza M, Bisagni G, Mosconi AM, et al. Epirubicin versus CMF as adjuvant therapy for stage I and II breast cancer: a prospective randomised study. Eur J Cancer 2002; 38:2279.
  77. Muss HB, Berry DA, Cirrincione CT, et al. Adjuvant chemotherapy in older women with early-stage breast cancer. N Engl J Med 2009; 360:2055.
  78. von Minckwitz G, Reimer T, Potenberg J, et al. The phase III ICE study: Adjuvant Ibandronate with or without capecitabine in elderly patients with moderate or high risk early breast cancer. SABCS 2014; S3-04.
  79. Pallis AG, Ring A, Fortpied C, et al. EORTC workshop on clinical trial methodology in older individuals with a diagnosis of solid tumors. Ann Oncol 2011; 22:1922.
  80. Brollo J, Curigliano G, Disalvatore D, et al. Adjuvant trastuzumab in elderly with HER-2 positive breast cancer: a systematic review of randomized controlled trials. Cancer Treat Rev 2013; 39:44.
  81. Slamon D, Eiermann W, Robert N, et al. Adjuvant trastuzumab in HER2-positive breast cancer. N Engl J Med 2011; 365:1273.
  82. Tolaney SM, Barry WT, Dang CT, et al. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer. N Engl J Med 2015; 372:134.
  83. Jones SE, Collea R, Paul D, et al. Adjuvant docetaxel and cyclophosphamide plus trastuzumab in patients with HER2-amplified early stage breast cancer: a single-group, open-label, phase 2 study. Lancet Oncol 2013; 14:1121.
  84. Owusu C, Klepin HD, Kimmick GG, Sutton L. Safety and efficacy of single-agent adjuvant trastzumab in older women with breast cancer. Journal of Clinical Oncology 2010; 29 (15S):TPS109.
  85. Hamberg P, Bos MM, Braun HJ, et al. Randomized phase II study comparing efficacy and safety of combination-therapy trastuzumab and docetaxel vs. sequential therapy of trastuzumab followed by docetaxel alone at progression as first-line chemotherapy in patients with HER2+ metastatic breast cancer: HERTAX trial. Clin Breast Cancer 2011; 11:103.
  86. Vaz-Luis I, Keating NL, Lin NU, et al. Duration and toxicity of adjuvant trastuzumab in older patients with early-stage breast cancer: a population-based study. J Clin Oncol 2014; 32:927.
  87. Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Davies C, Godwin J, et al. Relevance of breast cancer hormone receptors and other factors to the efficacy of adjuvant tamoxifen: patient-level meta-analysis of randomised trials. Lancet 2011; 378:771.
  88. Dowsett M, Cuzick J, Ingle J, et al. Meta-analysis of breast cancer outcomes in adjuvant trials of aromatase inhibitors versus tamoxifen. J Clin Oncol 2010; 28:509.
  89. PACE participants, Audisio RA, Pope D, et al. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Crit Rev Oncol Hematol 2008; 65:156.
  90. Hind D, Wyld L, Beverley CB, Reed MW. Surgery versus primary endocrine therapy for operable primary breast cancer in elderly women (70 years plus). Cochrane Database Syst Rev 2006; :CD004272.
  91. Hind D, Wyld L, Reed MW. Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer: cochrane review. Br J Cancer 2007; 96:1025.
  92. Chakrabarti J, Kenny FS, Syed BM, et al. A randomised trial of mastectomy only versus tamoxifen for treating elderly patients with operable primary breast cancer-final results at 20-year follow-up. Crit Rev Oncol Hematol 2011; 78:260.
  93. Johnston SJ, Kenny FS, Syed BM, et al. A randomised trial of primary tamoxifen versus mastectomy plus adjuvant tamoxifen in fit elderly women with invasive breast carcinoma of high oestrogen receptor content: long-term results at 20 years of follow-up. Ann Oncol 2012; 23:2296.
  94. de Glas NA, Jonker JM, Bastiaannet E, et al. Impact of omission of surgery on survival of older patients with breast cancer. Br J Surg 2014; 101:1397.
  95. 2014 San Antonio Breast Cancer Symposium publication number [S3-04]: The phase III ICE study: Adjuvant Ibandronate with or without capecitabine in elderly patients with moderate or high risk early breast cancer and Medpagetoday meeting coverage. http://www.medpagetoday.com/MeetingCoverage/SABCS/49106 (Accessed on November 19, 2015).
  96. Balakrishnan A, Ravichandran D. Early operable breast cancer in elderly women treated with an aromatase inhibitor letrozole as sole therapy. Br J Cancer 2011; 105:1825.
  97. Wink CJ, Woensdregt K, Nieuwenhuijzen GA, et al. Hormone treatment without surgery for patients aged 75 years or older with operable breast cancer. Ann Surg Oncol 2012; 19:1185.
  98. Burstein HJ, Harris LN, Marcom PK, et al. Trastuzumab and vinorelbine as first-line therapy for HER2-overexpressing metastatic breast cancer: multicenter phase II trial with clinical outcomes, analysis of serum tumor markers as predictive factors, and cardiac surveillance algorithm. J Clin Oncol 2003; 21:2889.
  99. Jones A. Combining trastuzumab (Herceptin) with hormonal therapy in breast cancer: what can be expected and why? Ann Oncol 2003; 14:1697.
  100. Charif M, Lower EE, Kennedy D, Kumar H. The effect of HER-2/neu inhibition on prolonging clinical benefit with fulvestrant treatment for metastatic estrogen receptor. SABCS 2014; P3-05-16.
  101. Calle R, Pilleron JP, Schlienger P, Vilcoq JR. Conservative management of operable breast cancer: ten years experience at the Foundation Curie. Cancer 1978; 42:2045.
  102. Weissberg JB, Prosnitz LR. Treatment of early breast cancer with primary radiation therapy: rationale, results, and techniques. Bull N Y Acad Med 1982; 58:203.