Evolving techniques in breast cancer surgery for older adults: a narrative review

Introduction

Background

Breast cancer represents a significant global health burden, accounting for nearly one-quarter of all cancer diagnoses among women worldwide. With approximately 2.3 million new cases reported in 2022, it ranks as the second most frequently diagnosed malignancy (1). The disease shows a predilection for older populations, with the median age at diagnosis being 61 years. A considerable proportion of patients are elderly, with 45% being over 65 years old and 10% aged 80 years or older at diagnosis (2). However, this demographic is far from homogeneous. It encompasses both healthy, robust individuals with minimal comorbidities and frail patients experiencing significant functional decline. Frailty, multimorbidity, and life expectancy play pivotal roles in determining treatment tolerance and outcomes, underscoring the need for personalized approaches. This demographic reality underscores the critical need for age appropriate treatment strategies that carefully balance oncologic control with quality of life preservation.

For the general population, surgical management of breast cancer has evolved significantly, with breast-conserving surgery (BCS) and mastectomy being the primary options. BCS, often combined with radiotherapy, is preferred for early-stage disease due to its equivalent survival outcomes and preservation of breast tissue. Mastectomy remains a viable choice for patients with larger tumours or those who prefer complete removal of the breast. Advances in oncoplastic techniques and reconstructive surgery have further expanded options, allowing for improved aesthetic outcomes without compromising oncologic safety. These strategies, however, require careful adaptation when applied to older adults, who often present with unique challenges such as comorbidities and age-related physiological changes.

The treatment paradigm for older adults presents unique considerations, particularly in the choice between upfront surgery and primary endocrine therapy (PET), with decisions requiring careful evaluation of tumour biology, patient fitness, and individual preferences. Surgical intervention remains the cornerstone of curative treatment, yet older patients present additional challenges including age-related physiological changes, comorbidities, and variable life expectancies. The evolving landscape of surgical options ranging from conventional excisional procedures to advanced oncoplastic techniques and minimally invasive ablative therapies offers both opportunities and challenges in managing this heterogeneous patient population.

Rationale and knowledge gap

The evidence base for treating older adults with breast cancer remains markedly underdeveloped due to their systematic underrepresentation in clinical trials (3). This knowledge deficit forces clinicians to extrapolate data from younger populations, potentially compromising treatment appropriateness for older patients. The problem is especially pronounced for frail elderly patients, who are frequently excluded from trials despite facing higher risks of treatment complications. Current clinical guidelines often fail to adequately address the wide spectrum of fitness levels among older adults, potentially resulting in overtreatment of frail patients or unnecessary treatment de-escalation in healthier individuals who might benefit from standard therapies. Several critical knowledge gaps persist in this field. First, the comparative effectiveness of upfront surgery versus PET requires further clarification, particularly regarding long term survival outcomes and quality of life measures in different patient subgroups. Additionally, the impact of treatment choices on quality of life, including patient preferences for tumor removal versus avoidance of surgery, remains an understudied yet pivotal factor in shared decision-making. Second, the comparative outcomes of BCS versus mastectomy in older adults need better characterization, particularly regarding long term survival, local control, and quality of life outcomes. Third, the applicability and outcomes of oncoplastic and reconstructive procedures in aging patients with varying breast tissue characteristics and functional status remain poorly characterized. Fourth, emerging local ablation or percutaneous excision techniques show promise but lack robust long term outcome data across all populations, including the older adults. Most importantly, the integration of comprehensive geriatric assessments (CGAs) into surgical decision making processes remains inconsistent despite growing recognition of their potential to predict postoperative outcomes and optimize treatment selection. While CGAs are ideal for evaluating older patients’ fitness for treatment, their implementation can be challenging in resource-limited settings due to the scarcity of geriatric specialists. Alternative approaches include brief geriatric screening tools such as the Geriatric 8 questionnaire or the Vulnerable Elders Survey-13, which can be administered by general healthcare providers to identify high-risk patients requiring more detailed evaluation. Additionally, multidisciplinary teams comprising oncologists, nurses, and social workers can collaborate to assess key areas such as basic and instrumental activities of daily living, coexisting medical conditions using tools like the Charlson Comorbidity Index, and cognitive function through brief tests such as the Mini-Cognitive Assessment. These practical strategies help ensure that geriatric principles are incorporated into decision-making, even in settings without access to specialized geriatric care. Addressing these evidence gaps is essential to develop truly patient centred care paradigms for older breast cancer patients.

Objective

This narrative review aims to provide a synthesis of current evidence regarding surgical management of breast cancer in older adults, with particular emphasis on evolving techniques and individualized treatment approaches. We will critically examine the evidence comparing upfront surgery with PET, evaluating factors such as tumour biology, life expectancy, and treatment tolerance that influence this fundamental treatment decision. Our analysis will then evaluate the existing literature on conventional surgical options including BCS and mastectomy, advanced oncoplastic techniques, reconstructive procedures, and emerging minimally invasive techniques. A special focus will be placed on the role of geriatric assessment tools in surgical decision making and outcome prediction. By systematically examining these aspects, we seek to clarify the risk benefit profiles of various treatment approaches in older patients, develop frameworks for choosing between surgery and PET based on individual patient and tumour characteristics, identify optimal strategies for integrating patient preferences and functional status into treatment planning, and highlight critical knowledge gaps requiring further investigation. Ultimately, this review aims to provide clinicians with an evidence-based framework for optimizing treatment selection while maintaining quality of life in this growing patient population. We present this article in accordance with the Narrative Review reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-25-21/rc).

Methods

To identify relevant literature on the surgical management of breast cancer in older adults, we conducted a thorough search of the PubMed and Google Scholar for studies published from January 1900 to April 2025. Our search strategy employed both Medical Subject Headings (MeSH) terms and free-text keywords, including “breast cancer”, “older adults”, “geriatric”, “elderly”, “breast conservation”, “mastectomy”, “oncoplastic surgery”, “breast reconstruction”, and “local ablative”. We focused on English-language articles that examined surgical approaches for older patients with breast cancer. Included studies comprised clinical trials, observational studies, and systematic reviews that offered significant data on surgical outcomes. We excluded case reports, studies on advanced disease, and publications lacking age-specific results, while omitting duplicated references. Two researchers independently screened titles and abstracts, reviewed full texts of potentially relevant articles, and resolved any disagreements through discussion. Although we did not conduct formal quality assessments, we prioritized high-quality evidence from well-designed studies. Additional relevant publications were identified through manual searches of reference lists. The search strategy is summarized in Table 1.

Surgical approaches for older adults

Upfront surgery versus PET

PET typically includes aromatase inhibitors (AIs) (e.g., anastrozole, letrozole, exemestane) or selective estrogen receptor modulators (e.g., tamoxifen). The comparison of upfront surgery and PET in older women with breast cancer shows varied conclusions based on patient selection, life expectancy, and hormone receptor status. Updated guidelines from the European Society of Breast Cancer Specialists (EUSOMA) and the International Society of Geriatric Oncology (SIOG) in 2021 suggested that surgery provided better local control and survival for patients with a life expectancy over five years (4), as indicated by systematic reviews (5,6). However, a large cohort study countered this by demonstrating that patients with strongly hormone receptor-positive (HR+) tumours had similar breast cancer-specific survival (BCSS) regardless of whether they received PET or surgery, especially with AIs, which yielded a median progression-free interval of around five years (7). This suggests that PET may be a suitable option for patients with a life expectancy under five years or for those with highly endocrine-responsive tumours.

A recent meta-analysis by Chan et al., which included 14 studies with 14,254 patients, demonstrated significantly worse overall survival (OS) with PET compared to primary surgical therapy (PST) [hazard ratio (HR) 1.42, 95% confidence interval (CI): 1.06–1.91, P=0.020]. However, subgroup analysis revealed comparable OS between PET and PST in randomized controlled trials (RCTs) (HR 1.12, 95% CI: 0.97–1.28, P=0.123) and prospective studies (HR 2.15, 95% CI: 0.26–17.83, P=0.479). BCSS was also comparable across all study designs (HR 1.28, 95% CI: 0.87–1.87, P=0.209) (8). Lai et al. strongly supported surgery for its survival and recurrence benefits, while noting that quality of life remained similar across treatment groups (9).

Chan et al. (8) analyzed treatment responses to PET, reporting a median 6-month complete response rate of 14.2% (range, 9.2–28%), partial response of 37.3% (9–47%), and stable disease in 49.0% of patients (19.7–62.6%). Their findings showed that 42.0% of patients (35–62.6%) required a change to second-line therapy, while 15.5% (3.2–40.4%) ultimately underwent salvage surgery.

Surgery is the gold standard for fit older patients with longer life expectancy, offering improved disease control and survival advantages. PET, particularly with AIs, is a reasonable alternative for frail patients or those with strongly hormone-responsive tumours and limited life expectancy. Patient preferences play a significant role in the choice between surgery and PET. While some older adults prioritize tumour removal for psychological relief, others prefer avoiding surgery due to concerns about recovery or complications. Studies indicate that patients who align treatment with their personal values report higher satisfaction and better quality of life, regardless of the chosen modality (9). Frailty assessments should guide this decision, as surgical risks such as delirium, functional decline may outweigh benefits in frail patients. Future guidelines should integrate geriatric assessments and tumour biology to personalize treatment strategies.

BCS versus mastectomy

Equivalent survival between BCS and mastectomy

BCS with radiotherapy has been shown to provide equivalent long-term survival outcomes compared to mastectomy for older women with early-stage breast cancer, based on multiple randomized trials and large observational studies (10-15). More recent population-based studies using propensity score matching have confirmed these findings in older adults (16,17), though some subgroup analyses suggest potential selection biases favouring BCS in patients who receive adjuvant therapies.

Radiotherapy omission in low-risk, HR+ disease

The omission of radiotherapy in older women with low risk, HR+ breast cancer after BCS has been evaluated in several clinical trials. The CALGB 9343 trial and PRIME II study both demonstrated that, while avoiding radiotherapy resulted in higher local recurrence rates with PRIME II reporting 9.5% versus 0.9% at 10 years, this did not translate into differences in distant recurrence or OS (18,19). However, some clinicians consider local recurrence rates above 10% to be unacceptable, particularly for patients who prioritize optimal local disease control (20). Hypofractionated radiotherapy schedules (21,22) or intraoperative radiotherapy (IORT) (23-25) have emerged as potential alternatives, offering reasonable efficacy while reducing treatment duration compared to conventional whole breast irradiation.

Recent trials such as LUMINA, IDEA, and PROSPECT have further refined the criteria for omitting radiotherapy. The LUMINA trial demonstrated a 5-year local recurrence rate of 2.3% in women aged more than 55 with luminal A breast cancer (defined as oestrogen receptor positivity of ≥1%, progesterone receptor positivity of >20%, negative human epidermal growth factor receptor 2 (HER2), and Ki67 index of less than 13.25%) treated with endocrine therapy alone (26). Similarly, the IDEA trial reported a 5-year recurrence-free survival of 99% in postmenopausal women aged 50–69 years with low genomic risk (Oncotype DX score less than 18) (27). The PROSPECT trial highlighted the role of preoperative MRI in selecting patients for radiotherapy omission, achieving a 5-year ipsilateral invasive recurrence rate of 1.0% in women with unifocal, MRI-confirmed T1N0 tumours (28). Ongoing trials like EXPERT (NCT02889874) and DEBRA (NCT04852887) aim to validate these findings using advanced biomarkers (e.g., PAM50) and randomized designs.

Successful implementation of radiotherapy omission strategies depends heavily on consistent endocrine therapy adherence. Research has clearly shown that patients who struggle with medication compliance experience significantly higher recurrence risks when radiotherapy is not administered (29). For elderly patients with questionable ability to maintain endocrine therapy regimens, mastectomy may represent a more suitable option as it avoids both radiotherapy and long term hormonal treatment requirements (9).

Recent findings from the EUROPA trial have contributed valuable new data to this clinical discussion (30). This phase 3 randomized study compared endocrine therapy alone versus radiotherapy in women aged 70 years or older with favourable risk, luminal A type breast cancer. At the 24 month follow up point, patients who received radiotherapy maintained better health related quality of life scores compared to those treated with endocrine therapy alone. While these interim results favour radiotherapy, pending 5-year recurrence data will clarify whether this quality of life advantage justifies any potential trade-offs in cancer control.

In summary, for frail older adults with low-risk HR+ tumors, BCS without radiotherapy may be a pragmatic choice, provided endocrine therapy adherence is feasible. However, for those with cognitive impairment or polypharmacy, mastectomy (avoiding both radiotherapy and long-term hormonal therapy) may reduce treatment burden, albeit with higher short-term surgical risks.

HER2‑positive and triple-negative breast cancer (TNBC)

Emerging evidence suggests that less aggressive surgical approaches may be appropriate for older women with HER2-positive or TNBC. Zhong et al. demonstrated comparable disease-free survival between BCS without axillary lymph node dissection (ALND), sentinel lymph node biopsy (SLNB), or radiotherapy, and mastectomy in patients older than 70 years, despite a higher local ipsilateral recurrence in TNBC (31). In contrast, Mburu et al. found superior survival outcomes with BCS plus radiotherapy compared to BCS alone, mastectomy or mastectomy plus radiotherapy in TNBC patients older than 66 years (32), a finding contextualized by TNBC’s poor prognosis and potential selection biases in observational studies. These studies collectively suggest that certain de-escalated local therapy approaches, such as. BCS with omission of radiotherapy or axillary surgery, may be reasonable options for some older patients, including those with aggressive biologic subtypes. However, the higher local recurrence risk in TNBC highlights the importance of individualized risk stratification and shared decision-making to balance oncologic safety against treatment burden.

Treatment trends and associated outcomes

Despite the evidence supporting BCS, mastectomy rates remained high among older women, potentially due to physician bias, perceived simplicity, or patient preference for avoiding additional treatments (9). However, mastectomy is associated with higher complication rates, including infections and delayed wound healing, particularly in frail patients. Compared to mastectomy, BCS has less impact on cognitive and functional decline (33). Tang et al. specifically examined nursing home residents, a frail subgroup of older adults, revealing unique risks in this population; however, these findings warrant cautious extrapolation, as most older patients are community-dwelling with preserved functional status. Beyond survival outcomes, quality of life considerations are paramount. BCS is often associated with better body image and psychological well-being, while mastectomy may offer peace of mind for those prioritizing maximal local control. Shared decision-making tools that incorporate quality of life metrics can help align treatment choices with individual patient goals (34). Furthermore, breast cancer surgery negatively affects physical activity levels, with the degree of impairment closely linked to surgical extent. Given these risks, preoperative counselling for older women should explicitly address potential functional decline (34).

Future directions

Optimal treatment selection for older breast cancer patients should incorporate geriatric assessments to evaluate life expectancy, functional status, and treatment tolerance, with selected patients (including those who are frail or have low-risk HR+ disease) potentially benefiting from de-escalated approaches like BCS without radiotherapy. Future research should refine radiotherapy techniques to reduce treatment burden, improve endocrine therapy adherence strategies, and further explore surgical de-escalation in aggressive subtypes like HER2-positive and TNBC, while ensuring personalized decision-making that balances oncologic outcomes with quality of life.

Oncoplastic breast surgery (OBS)

OBS has emerged as a valuable approach in breast cancer treatment, combining oncological safety with enhanced cosmetic outcomes (35). However, despite its established benefits, the application of OBS in older women remains underexplored. A review of the literature reveals a significant research gap, particularly regarding how age-related changes in breast composition influence surgical feasibility and outcomes.

Disparities in uptake

The EUSOMA and SIOG guidelines recommend offering older patients the same surgical options as younger patients, including OBS, after accounting for comorbidities and patient preferences (4). Yet, older women are far less likely to receive OBS compared to their younger counterparts (36). In Chia et al.’s review, only 10.8% of OBS patients were aged 65 years or older, highlighting a concerning disparity in access (37).

Impact of breast composition on surgical feasibility

Age-related changes in breast tissue, such as glandular atrophy and increased fatty replacement, pose unique technical challenges for OBS, including higher risks of fat necrosis, seromas, and wound complications (38). Certain OBS techniques, such as dual-plane undermining commonly used in Level I procedures, are less feasible in fatty breasts and may necessitate alternative approaches, such as Level II OBS or mastectomy with reconstruction (38). These anatomical factors, rather than bias alone, may contribute to lower OBS uptake in older patients, particularly those very old or those with significant comorbidities. Moreover, older women frequently have larger, ptotic breasts with low density, further limiting OBS candidacy and steering surgeons toward mastectomy rather than complex oncoplastic resections.

Surgical outcomes and complications

Chia et al. evaluated OBS feasibility in older women using techniques such as central defect reconstruction, perforator flaps, and free dermal fat grafts. While studies reported satisfactory cosmetic results, they also noted higher re-excision rates and wound complications in older patients (39,40). Mattingly et al. also found that age was associated with increased minor complications following oncoplastic breast reduction, underscoring the need for careful patient selection and technique modification (41).

Future directions

OBS offers significant benefits, including reduced mastectomy rates and improved quality of life (42), yet it remains underutilized in older patients due to perceived risks and anatomical challenges. Studies report higher re-excision rates and wound complications in older OBS patients, though no evidence currently links OBS to increased cancer recurrence. The limited data on OBS in this population reflects both its underuse and the lack of high-level evidence supporting its application in older women. To address this, future research should focus on directly comparing outcomes between age groups, defining optimal OBS techniques for low-density breasts, and developing geriatric-specific guidelines to ensure equitable access.

Expanding OBS eligibility for healthy older women could enhance both oncological and aesthetic outcomes, aligning with the principles of personalized, age-inclusive care. As the elderly breast cancer population grows, it is crucial to challenge age-based biases in surgical decision-making and refine OBS approaches for this demographic. With tailored techniques and further research, OBS can remain a viable and effective option for older patients seeking breast conservation with optimal aesthetic results.

Breast reconstruction

Breast reconstruction in older breast cancer patients is a topic of increasing relevance (43), given the rising incidence of breast cancer in aging populations and improved survival rates. The reviewed papers collectively highlight that while reconstruction rates remain lower in older women compared to younger patients, the procedure is both safe and beneficial when tailored to individual patient factors (36,44-49). While breast reconstruction is often discussed in the context of the ‘younger old’, its feasibility and outcomes for the ‘older old’ require careful consideration due to age-related physiological changes and comorbidities.

Reconstruction techniques and outcomes

Implant-based reconstruction is often preferred due to shorter operative times, but it carries higher risks of complications such as infection and capsular contracture in older adults (36,44,45). Autologous reconstruction, particularly the deep inferior epigastric artery perforator (DIEP) flap, is associated with more natural results and lower long-term complication rates, though it involves longer surgery and may pose perioperative risks in patients with vascular disease (46-48). Studies confirm that DIEP flaps in older women yield success and complication rates similar to those in younger patients, with high satisfaction reported. Similarly, research on the transverse myocutaneous gracilis (TMG) flap demonstrated its safety in elderly and overweight populations, reinforcing that age should not exclude patients from consideration for autologous reconstruction (49).

Quality of life and patient satisfaction

Several studies have examined quality of life and patient satisfaction in older breast reconstruction patients, with most reporting favourable outcomes. Sisco et al. (using Duke Health Profile, BREAST-Q, and Holmes-Rovner scales) (43) and Girotto et al. (using SF-36) (50) found that older patients who received post-mastectomy reconstruction had significantly better breast-related body image, psychosocial health, and overall quality of life compared to mastectomy-only patients, though physical function scores were lower. Bowman et al. reported high satisfaction, with 70% rating results as good/excellent and 89% willing to repeat the procedure (51), while De Gournay et al. found no significant differences in physical or sexual health between older latissimus dorsi (LD) flap and mastectomy patients (52). Dejean et al. further supported these findings in DIEP flap patients, demonstrating high psychosocial well-being and satisfaction, concluding that breast reconstruction should be offered to motivated older patients regardless of age (47).

Geriatric assessment and decision-making

CGA evaluates older patients’ fitness for breast reconstruction by analysing physical function, comorbidities, cognition, nutrition, and social support. Integrating CGA into clinical practice enables personalized treatment planning (53). Shared decision-making is crucial as older women often decline reconstruction due to recovery concerns or information gaps (54), compounded by surgeon hesitancy and insurance barriers (53).

Future directions

The evidence supports offering breast reconstruction to healthy older women, with autologous techniques often providing superior long-term outcomes. Preoperative assessment, patient education, and shared decision-making are key to optimizing outcomes in this population.

Emerging minimally invasive techniques

Local ablation techniques

Local ablation techniques, such as cryoablation, radiofrequency ablation (RFA), and high-intensity focused ultrasound (HIFU) (55), are emerging as promising alternatives for older or frail breast cancer patients who may not be ideal candidates for surgery. The ICE3 trial provides robust evidence for cryoablation in women aged greater than 60 with low-risk, early-stage breast cancer (less than 1.5 cm, HR+, HER2-negative) (56). With a 5-year ipsilateral breast tumour recurrence rate of just 4.3% and excellent cosmetic outcomes, cryoablation demonstrates high efficacy and patient satisfaction. The procedure is minimally invasive, performed in outpatient setting, and allows rapid recovery (mean 1.7 days to resume normal activity). However, long-term survival data beyond 5 years remains limited.

Recent retrospective studies suggest that cryoablation is a feasible and well-tolerated option for patients deemed poor surgical candidates due to age or comorbidities. One study of 60 patients (mean age 79.7 years) reported a 10% recurrence rate over a mean follow-up of 21 months (57), while another involving 17 patients (median age 87 years) achieved complete tumour ablation with minimal complications using only local anaesthesia (58). These findings reinforce cryoablation as a viable, minimally invasive alternative for frail elderly patients who cannot undergo conventional surgery.

RFA also shows promise, particularly for small, HR+ tumours. Palussière et al. reported successful ablation in 21 elderly patients (median age 79 years), with only one local relapse at 1 year (59). However, complications like skin burns (4/21 patients) and limitations in treating lobular carcinomas were noted. Grotenhuis et al. emphasize that RFA is best suited for cT1-T2N0 ductal carcinomas with clear margins, but long-term oncologic outcomes compared to surgery remain uncertain (60).

HIFU and other ablative therapies are less established (55), with HIFU’s ablative rate being the lowest (47.6%) due to depth limitations. Laser ablation, while minimally invasive, has poor ablative rates (52.2%) and carries risk of skin burns (55).

Key challenges include the lack of randomized trials in older adults and unclear long-term recurrence risks. While cryoablation and RFA offer minimally invasive, outpatient alternatives, their adoption outside clinical trials require further validation. For now, they represent viable options for carefully selected older patients with early-stage, low-risk tumours.

Percutaneous excision

Percutaneous excision techniques, such as vacuum-assisted excision (VAE), are also being investigated as potential alternatives for small, screen-detected breast cancers. The ongoing UK-based SMALL trial (Open Surgery versus Minimally Invasive-Vacuum Assisted Excision for Small Screen-Detected Breast Cancer) is a phase III randomized study comparing VAE with standard surgery in patients with biologically favorable tumors ≤15 mm (61). With coprimary endpoints evaluating re-excision rates and local recurrence at 5 years, this trial aims to determine whether VAE can safely reduce surgical burden while maintaining oncologic outcomes. The trial also explores the omission of SLNB in low-risk patients undergoing VAE. When completed, this study will provide crucial evidence to guide the potential integration of VAE into clinical practice for early-stage disease management.

Axillary surgery

Axillary management in older breast cancer patients requires careful consideration of both oncologic outcomes and quality of life implications. The meta-analysis by Lai et al. provides critical insights into this debate, synthesizing real-world evidence from 44 studies involving over 100,000 older patients (aged ≥65 years) (9). Their findings support the safety of omitting SLNB in clinically node-negative patients, as it did not significantly impact OS (HR =1.41, 95% CI: 0.93–2.16) or BCSS (HR =1.34, 95% CI: 0.73–2.46). Similarly, ALND omission in node-positive patients showed comparable OS (5-year OS: OR =0.97, 95% CI: 0.79–1.19) and even improved BCSS (5-year BCSS: OR =0.59, 95% CI: 0.42–0.82), while reducing complications such as lymphedema (excess risk of 3.1% with ALND).

Recent randomized trials have further refined axillary management strategies. The SOUND trial demonstrated that omitting axillary surgery was noninferior to SLNB in patients with small (≤2 cm) breast cancers and negative preoperative axillary ultrasonography, with 5-year distant disease-free survival rates of 97.7% (SLNB group) and 98.0% (no axillary surgery group) (log-rank P=0.67) (62). Similarly, the INSEMA trial confirmed the noninferiority of omitting SLNB in clinically node-negative patients with tumors ≤5 cm, reporting 5-year invasive disease-free survival rates of 91.9% (no SLNB) and 91.7% (SLNB) (63). Both trials highlight the feasibility of sparing suitable patients axillary surgery when nodal staging would not alter adjuvant therapy decisions.

For clinically node-negative patients, Lai et al. (9) reported low complication rates with SLNB (lymphedema: 2.6–4.9%), making it a reasonable option when nodal staging is needed to guide adjuvant therapy decisions. However, for frail patients with limited life expectancy or significant comorbidities, omitting SLNB altogether may be justified, as it avoids unnecessary morbidity without compromising survival. In node-positive patients, de-escalation to SLNB alone (without ALND) appears viable, particularly for those with micrometastases or low nodal burden, as aggressive axillary surgery did not confer additional survival benefits in this population.

These findings align with recent guidelines from EUSOMA and SIOG (4), which recommend individualized axillary management based on life expectancy, comorbidities, and tumour biology. Future research should further refine selection criteria for axillary surgery de-escalation in older adults, particularly in the context of modern systemic therapies.

Strengths and limitations of this review

This narrative review provides a synthesis of current evidence regarding surgical management of breast cancer in older adults, with several notable strengths. First, it encompasses a broad range of surgical approaches, from conventional techniques to emerging therapies, offering clinicians a holistic perspective on treatment options. The review specifically highlights the importance of individualized decision-making through geriatric assessments, addressing a critical gap in current practice. By evaluating both oncologic outcomes and quality of life considerations, it provides balanced insights for clinical decision-making. The inclusion of evolving techniques such as oncoplastic surgery and local ablation therapies ensures relevance to contemporary practice. Furthermore, the review identifies key knowledge gaps, paving the way for future research directions in this understudied population.

While this review synthesizes a broad range of studies, it is important to acknowledge variations in evidence quality. For instance, the comparative outcomes of upfront surgery versus PET are supported by RCTs and large cohort studies (8,9), which provide robust evidence but may still be subject to selection bias in observational data. Conversely, data on emerging techniques like cryoablation such as ICE3 trial (56) are promising but limited by smaller sample sizes and shorter follow-up periods. Similarly, studies on oncoplastic surgery in older adults often involve retrospective designs or single-center experiences (37), which may limit generalizability. We have highlighted these limitations throughout the review to ensure readers can weigh the evidence appropriately when making clinical decisions.

However, several limitations should be acknowledged. While the review extensively covers breast surgery techniques, it also includes a dedicated section on axillary surgery. The narrative design, while allowing for comprehensive discussion of complex topics, may be subject to selection bias compared to systematic review methodologies. Additionally, the heterogeneity of older adult populations in terms of functional status and comorbidities makes direct comparisons between studies challenging. The review also faces inherent limitations from the primary studies themselves, including the underrepresentation of older adults in clinical trials and the lack of long-term outcome data for newer techniques like cryoablation. Despite these limitations, this review provides valuable insights to guide surgical decision-making while highlighting areas requiring further investigation.

Conclusions

The surgical management of breast cancer in older adults requires a tailored approach that considers age-related physiological changes, comorbidities, life expectancy, patient preferences, and individual wishes. It demands a nuanced approach that accounts for the profound heterogeneity within this population. For healthy older patients with a life expectancy exceeding five years, upfront surgery with breast conservation or mastectomy remains the gold standard, while PET with AIs or tamoxifen is a reasonable alternative for frail patients and those with hormone-responsive tumours, particularly when life expectancy is limited. BCS with adjuvant radiotherapy provides survival outcomes equivalent to mastectomy in early-stage disease, though radiotherapy omission may be considered in selected low-risk cases with adherence to endocrine therapy. Oncoplastic surgery and reconstruction, though underutilized in older women, can significantly improve aesthetic and psychosocial outcomes, with autologous techniques like DIEP flaps offering durable results. Emerging minimally invasive techniques show promise for carefully selected patients with small, low-risk tumours. Axillary surgery decisions should be individualized, with SLNB omission being safe for clinically node-negative patients and ALND de-escalation considered for selected node-positive cases to reduce morbidity without compromising survival.

Clinical decision-making should be guided by personalized strategies incorporating frailty assessments, patient preferences, and quality of life considerations. Multidisciplinary team discussions remain crucial to ensure treatment plans align with individual goals, functional status, and values regarding aesthetics, recovery, and long-term well-being. By integrating comprehensive geriatric evaluations, shared decision-making, and evolving surgical techniques, clinicians can better address the diverse needs of this growing patient population.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-25-21/rc

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-25-21/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-25-21/coif). A.K. serves as an unpaid editorial board member of Annals of Breast Surgery from September 2023 to August 2025. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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