Quality of life after breast-conserving surgery in women aged 65 and older: reevaluating age in breast cancer treatment through insights from a prospective Danish cohort study

Introduction

Breast cancer (BC) remains the most common malignancy among women (1). Over the past few decades, survival rates have improved due to earlier detection and advances in multidisciplinary treatment, yet regional and age-related differences persist (2). Breast-conserving surgery (BCS) [breast-conserving therapy BCS + radiotherapy (BCT): lumpectomy followed by radiotherapy] has become a cornerstone in early BC management (3). Compared to mastectomy with reconstruction, BCT offers similar survival rates and, in many studies, better short-term quality of life (QoL) (4). However, in Denmark, the rate of lumpectomy has traditionally been lower than in neighboring countries, especially among older patients (5). An aging population means a growing number of candidates for BCT are ≥65 years. Despite this, older women have historically been underrepresented in clinical trials and may be directed toward mastectomy due to concerns about radiotherapy tolerance, comorbidities, or cosmetic outcomes (6). Given demographic shifts toward an older population, it is necessary to reassess the benefits of BCT for women aged 65 years and above and to evaluate their satisfaction and need for plastic-surgical interventions. International guidelines from the International Society of Geriatric Oncology and the European Society of Breast Cancer Specialists emphasize that treatment decisions should be based on functional rather than chronological age, include geriatric assessment, and incorporate patient preferences (7). Several studies help us understand QoL after BCS. A large general population sample of Rasch-converted BREAST-Q surveys shows normative median scores of 64 for satisfaction with breasts, 69 for psychosocial well-being, 92 for physical well-being, and 59 for sexual well-being (8). Comparing study populations to these benchmarks allows us to determine whether postoperative scores approximate those of the general population. An international cohort of over 1,200 patients found that women aged ≥65 years undergoing BCS had the highest QoL scores among all surgical groups (9). A systematic review of oncoplastic surgery noted that only 10.8% of patients were ≥65 years and called for offering the full range of reconstructive options regardless of age (10). Nonetheless, despite these findings, data on older patients remain limited, and even less is known about the impact of neoadjuvant therapy (NACT) on long-term QoL (11) or on patient demand for postoperative plastic surgical options in this population. While previous studies have shown high QoL in older women after BCS (12), few have used Rasch-adjusted BREAST-Q scores or examined outcomes beyond one year.

The present study aimed to fill this knowledge gap by analysing a prospective Danish cohort of lumpectomy patients with up to three years of follow-up. We hypothesized that older women (≥65 years) would achieve comparable or better early improvements in QoL domains, and that physical and sexual well-being might decline over time, especially among those receiving NACT. A secondary aim was to explore factors associated with the desire for postoperative plastic-surgical consultation regarding possible further surgical options. To our knowledge, no study has applied Rasch-converted BREAST-Q scores to evaluate outcomes specifically among women ≥65 years after BCT or investigated how many of these patients request secondary plastic surgical consultations. We present this article in accordance with the STROBE reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-72/rc).

Methods

Study design and setting

We conducted a prospective observational cohort study of women treated with BCS (lumpectomy) in Denmark from January 2022 to September 2025. Patients were invited to complete the Danish version of the BREAST-Q breast cancer core scale (pre- and postoperative versions 2.0). The Danish translation has been psychometrically validated, demonstrating good reliability and construct validity (13). The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Scientific Ethics Review Committee of Region Zealand, Denmark (No. SJ-914, EMN-2021-01530), and by the Danish Data Protection Agency (No. REG-154-2020). Informed consent was obtained from all individual participants.

Participants

Inclusion criteria were female sex, age ≥18 years, histologically confirmed BC [International Classification of Diseases (ICD)-50] treated with lumpectomy per national guidelines, and completion of the baseline BREAST-Q survey. Patients who underwent mastectomy or reconstruction were excluded. Record numbers allowed linkage of repeated questionnaires across time points.

Data collection and follow-up

Questionnaires were administered at predefined time points: before BCS (baseline), at 13 months if no neoadjuvant chemotherapy (NACT) was given, or at 18 months if NACT was given (both corresponding to one year postoperatively), and at three years postoperatively for all patients. To facilitate analysis, the 13- and 18-month questionnaires were treated as a one-year follow-up. A participant flow diagram (Figure 1) shows inclusion and response rates at each assessment time point. Baseline questionnaires collected demographic information (age, civil status, municipality of residence), anthropometric measures [height, weight, body mass index (BMI)], NACT-status (yes/no), and responses to the BREAST-Q domains: satisfaction with breasts, physical well-being, psychosocial well-being, and sexual well-being (14). Neither the BREAST-Q questionnaires nor the overall study includes detailed operative variables such as resection volume, cavity location, or whether specific oncoplastic techniques were used.

Figure 1 Flow chart of study cohort. Of 950 eligible women, 177 were excluded due to missing baseline BREAST-Q data, leaving 773 patients in the baseline cohort. All patients underwent BCS and completed the 1-year follow-up. At 3 years, 184 patients remained. Of the cohort, 72 received NACT and 701 did not. *, the 1-year follow-up corresponds to 13 months from baseline reporting for patients without NACT and 18 months for patients receiving NACT. Both equal to 12 months from BCS and thus considered 1-year follow-up. BCS, breast-conserving surgery; ICD, International Classification of Diseases; NACT, neoadjuvant chemotherapy.

BREAST-Q scoring and missing data

BREAST-Q responses were coded per the BREAST-Q user guide and converted to raw sum scores. For the physical well-being domain, items were reverse-coded so that higher scores indicated better well-being (15). Within each domain, missing items were imputed using the mean of completed items. Sensitivity analyses using complete-case domain scores without item-level imputation yielded estimates and significance patterns consistent with the primary analyses, indicating robustness to missing-item imputation (16). Raw sum scores were transformed to Rasch scores (0–100) using published conversion tables (17) to ensure interval-level measurement properties, enabling valid comparisons of mean differences across time and between groups, which are not guaranteed with raw ordinal scores (18).

Exposure variables

Age was dichotomized at 65 years, per World Health Organization (WHO) definition (19) to create the groups <65 and ≥65 years. BMI was included as a continuous variable and used as a proxy for body habitus, as detailed operative or cosmetic variables were not collected. BMI was also descriptively used according to WHO classes: <18.5 kg/m² (underweight), 18.5–24.9 kg/m² (normal weight), 25.0–29.9 kg/m² (overweight), and ≥30.0 kg/m² (obesity). NACT status determined whether the 13- or 18-month follow-up questionnaire was administered.

Outcome measures

The primary outcomes were BREAST-Q domain scores at follow-up time points. At the one-year follow-up, patients were also asked whether they wished to be contacted about plastic surgery options (desire for plastic surgery; yes/no).

Statistical analysis

For descriptive statistics, we presented continuous variables as means ± standard deviation and categorical variables as counts and percentages. We calculated mean differences with 95% confidence intervals (CIs) and assessed between-group differences using two-sample t-tests. Formal longitudinal modelling or hypothesis-testing of change scores were not pursued. Thus, the current analyses used observed data for group comparisons at predefined time points, serving descriptive and hypothesis-generating. To aid interpretation, we considered a change of 3–5 points potentially clinically relevant, with ≥4 points as clearly exceeding a commonly used benchmark on the transformed 0–100 BREAST-Q scale (20), a plausible minimal important difference (MID) (21), although published estimates vary by domain. Our primary outcome was Rasch-converted BREAST-Q scores at baseline and follow-up timepoints. Secondary outcomes included differences in scores by age group (<65 vs. ≥65 years) and by NACT (yes/no), as well as predictors of desire for plastic-surgery after treatment. Age and NACT were selected a priori as stratification factors for biological plausibility and guideline relevance (22). Next, we treated BMI as a continuous variable to mitigate information loss and preserve statistical power; WHO categories were used descriptively. To explore predictors of interest in plastic-surgery after treatment (yes/no), we fitted a multivariable logistic regression model including age, BMI, and NACT. Sensitivity analyses addressed missing items in completed questionnaires and did not involve imputation of missing follow-up data. Follow-up completion varied across time points; all analyses were conducted using available data, and participants were included in analyses up to their last completed follow-up. We reported odds ratios (ORs) and 95% CIs. Finally, all analyses were conducted in R 4.2.0 (R Foundation for Statistical Computing), with statistical significance set at P<0.05 (two-sided) (23).

Results

Of 950 eligible women, 773 (81%) completed the baseline survey. The median follow-up time of inclusion was 2.7 years (interquartile range, 2.1–3.4 years). The inclusion flow chart is shown in Figure 1. The mean age at BCS was 59.8±11.2 years (range, 25–88 years); 58% (n=449) were under 65 years, and 42% (n=324) were ≥65 years. NACT was administered to 9% (n=72). The average BMI was 27.4±4.8 kg/m². Civil status was married or cohabiting in 70% of participants, single in 17%, and divorced or widowed in 13%. Patient baseline characteristics are shown in Table 1. At baseline, women ≥65 years reported significantly lower satisfaction with breast (60.7 vs. 63.9, P=0.02) compared to younger women, but had significantly higher physical (88.0 vs. 84.2, P<0.001) and psychosocial well-being (71.1 vs. 68.3, P=0.01). These scores align with reported international pre-operative norms. Baseline and post-treatment Rasch scores by age group are summarized in Table 2 and shown in Figure 2.

Figure 2 Mean BREAST-Q Rasch scores (0–100) by age group and time point. Values represent observed means with corresponding sample sizes (n). The figure illustrates overall descriptive patterns; statistical comparisons between groups at each time point were reported in the Results section.

One-year postoperative women ≥65 years experienced greater early improvements in satisfaction with breasts (+12.0 vs. +4.0, resulting in a 4.8-point statistically significant difference between groups, P<0.001) and psychosocial well-being (+9.2 vs. +4.9, with a 7.0-point statistically significant difference, P=0.01). They also showed a 3.7-point improvement in sexual well-being, compared to a 4.7-point decline among younger women, resulting in an 11.0-point statistically significant difference between groups (P<0.001). All these gains mostly exceeded the 4-point minimal clinically important difference. Although older patients reported significantly higher preoperative physical well-being (by 3.8 points), their decline of 3.7 points one year later resulted in only a 0.6-point difference compared with younger women, which was no longer statistically significant.

The number of respondents decreased over time, with about one-quarter (n=184) of the cohort completing the 3-year follow-up. At three years, satisfaction with breasts in women ≥65 years, although not statistically significant, fell below that of younger women (a 4.2-point difference, P=0.16). While women ≥65 years maintained most of their physical well-being compared to their one-year postoperative reports (a change of −0.2), younger women continued to decline at three years, with a 3.8-point drop leading to a 4.2-point advantage for women ≥65 years (P=0.005). An opposite trend was observed for psychosocial well-being, where women ≥65 years showed an initial improvement of 9.2 points at one-year post-surgery, compared to a more modest 4.9 points in younger women, and these differences converged by three years to show a 3.8-point decline in women ≥65 years vs. a 4.1-point increase in younger women. However, after 3 years, the difference was not statistically significant at 0.7 points, possibly due to the early gains among women ≥65 years. Both groups experienced declines in sexual well-being after three years, contrasting with initial improvements in women aged 65 years and older. Although the declines were similar in magnitude (2.7 vs. 1.4 points), the previously noted 11.0-point difference between groups diminished to 6.9 points and was no longer statistically significant at 3 years (P=0.22).

Women who underwent NACT experienced more rapid declines in satisfaction with breast, physical, and sexual well-being at follow-up year 1. Their sexual well-being decreased by 6.1 points. In contrast, women without NACT experienced only a modest 1.7-point decline. After three years, sexual well-being was markedly lower in the NACT group (46.3±32.7) compared to the non-NACT group (62.1±31.4). Similarly, psychosocial well-being showed the same downward trend in the NACT group. However, physical well-being was similar in both groups after 3 years. Notably, a late increase in patient-reported satisfaction with breasts after 3 years was observed in the NACT group, a trend not observed in the non-NACT group.

Sixteen percent of the cohort (122 women) expressed interest in being contacted about a plastic surgical consultation at year 1 follow-up. The level of interest was age-dependent: 20.8% of women <65 years vs. 9% of women ≥65 years. Among NACT patients, 26.4% (n=19) expressed interest. Figure 3 summarizes these proportions. The logistic regression included 646 women with complete data. Factors considered were age (per year), BMI (per unit), and NACT status. Table 3 shows these results. Age emerged as the only significant predictor: each additional year of age was associated with a 5% decrease in the odds of wanting plastic-surgery after treatment (OR 0.96, 95% CI: 0.94–0.98; P<0.001). To put this into perspective, a 60-year-old woman has approximately a 40% higher likelihood of considering a postoperative plastic-surgical consultation compared to a 70-year-old woman. BMI and NACT were not found to be associated with a desire for further surgery.

Figure 3 Proportion of patients wanting plastic-surgical contact at year 1 of follow-up, left by age <65 years (blue) or ≥65 years (orange), and right by neoadjuvant therapy, no (blue) or yes (orange).

Discussion

This study offers a detailed view of patient-reported outcomes after BCS in older women. Consistent with prior research, we observed that initial satisfaction with breasts and psychosocial well-being improved after lumpectomy across all age groups. Notably, the greatest improvement was seen in women ≥65 years. Although physical well-being is known to decline after surgery, we did not find it to fall more in women ≥65 years; on the contrary, our data suggest that these patients sustain their initial score better than their younger counterparts. Thereby confirming that women in this age group can achieve meaningful improvements. These trends may reflect lower baseline expectations or a greater appreciation of breast preservation among older patients. However, by 3 years, the initial advantage diminishes; satisfaction with breasts in women ≥65 years falls slightly below that of younger women, though they still report higher satisfaction than their baseline scores, and no statistical difference is seen between groups. These findings align with guidelines from the International Society of Geriatric Oncology and the European Society of Breast Cancer Specialists, which emphasize that treatment decisions should focus on functional age rather than chronological age. The observed improvements in QoL post-BCT highlight the importance of offering BCT to older adults based on their functional abilities, aligning with these guidelines and encouraging clinical adoption.

Normative BREAST-Q values from a general population cohort indicate median scores of 64 for satisfaction with breasts, 69 for psychosocial well-being, 92 for physical well-being, and 59 for sexual well-being (24). At three years, both younger women (71.9) and women ≥65 years (67.7) surpassed the normative median for satisfaction with breasts in our cohort. Sexual well-being improved in older women, consistent with recent international studies showing that older women report high long-term QoL after BCT (25). These data challenge the perception that older patients benefit less from BCT and support guidelines recommending that age alone should not determine the surgical strategy (26).

Our analysis highlights the potential impact of NACT on patient-reported outcomes and its delayed effects. NACT patients experienced steeper early declines in physical well-being at one year; by year three, between-group differences were nearly equal. The steep decline in sexual well-being for NACT patients further worsened after three years. In the NACT group an increase in satisfaction with breasts after 3 years was observed, contrasting with the non-NACT group. Although the sample size and exploratory nature require cautious interpretation, these findings align with other studies showing poorer QoL among patients receiving systemic therapy before surgery (27). While our sample sizes were small, the patterns are clinically plausible: tumor downstaging may enable breast conservation and later satisfaction with breast shape, systemic chemotherapy, endocrine effects like treatment-induced menopause, and extended treatment courses can reduce physical and sexual well-being. These results emphasize the importance of surgeons explicitly counselling NACT patients about these trade-offs and integrating rehabilitation and sexual health support into care pathways to address long-term deficits.

Only a minority of women sought plastic surgery, and older women were less likely to do so. Only 9% of women ≥65 years requested postoperative consultation for plastic-surgical options. Our analysis showed that age was the only independent predictor of this interest, suggesting that age reflects a combination of biological, psychosocial, and treatment-related factors central to the research question. BMI did not predict the desire for surgery, despite literature associating high BMI with lower aesthetic satisfaction (28). Although international data show that oncoplastic surgery and reconstruction improve satisfaction and QoL, uptake remains low in women aged 65 and older, who are also less likely to be offered or accept these procedures (29). Our findings suggest that older women may have different cosmetic priorities, lower concern, experience fewer functional impairments, be reluctant to pursue additional procedures, or be less aware of reconstructive options. Our data underscore the importance of shared decision-making that considers all reconstructive options regardless of age. Future qualitative research could examine patient and clinician perspectives on reconstructive choices.

Limitations

This study has limitations. Although the overall cohort was large, 3-year attrition, particularly in the NACT group, reduced the number of evaluable participants compared with clinical trials such as PRIME I. This limitation may affect statistical power and introduce bias, but the study reflects routine clinical practice without intensive follow-up. Therefore, the 3-year findings should be interpreted more exploratively (30). Data on comorbidities, surgical technique, postoperative complications, tumor characteristics, adjuvant radiotherapy, and systemic treatment were unavailable for this analysis and could have influenced QoL reporting. While some studies, like PRIME II (31), have explored omitting postoperative radiotherapy in low-risk older patients, this is not standard in Denmark. The Danish Breast Cancer Group (DBCG) guidelines routinely recommend radiotherapy after BCS, even for low-stage disease. Thus, omitting radiotherapy in this cohort would be rare and based on individual clinical considerations. The observational design restricts causal inferences. Our logistic regression analysis may be underpowered to detect minor effects of BMI and was adjusted only for age, BMI, and NACT; other potential factors were not included and may also affect the desire for reconstruction. As in other longitudinal patient-reported outcome studies, non-responders are more likely to report poorer outcomes, which may inflate absolute BREAST-Q scores. Although missing PROM data are unlikely to be completely random (32), available evidence indicates that non-response is largely non-differential by age. Therefore, although attrition may reduce the precision of long-term estimates, it is unlikely to fully account for the observed age-related differences. In addition, comparisons with normative BREAST-Q data rely on population-based reference values that may not fully align with the present cohort’s age distribution or cultural context. Despite these limitations, the large cohort size, Rasch-transformed scores, and the focus on an older population provide a robust framework for examining age-related differences in patient-reported outcomes after BCS.

Conclusions

In this prospective Danish cohort of lumpectomy patients, women aged ≥65 years showed improvements in satisfaction with breasts, psychosocial well-being, and sexual well-being following BCS. Older women achieved initial QoL scores that were generally similar to or better than those of younger women. These initial significant gains did not continue to improve, and differences between groups diminished over time, although a small late decrease in physical well-being among women aged ≥65 years led to no statistically significant difference between groups at three years. Patients who received NACT faced greater initial declines in QoL, especially in sexual well-being, with their sexual scores remaining lower long term; however, their physical well-being recovered to levels comparable to others after three years. Age alone could predict the desire for a postoperative plastic surgery consult, and only a small proportion of patients sought additional options. Our findings highlight the value of breast-conserving therapy for women aged ≥65 years as a viable option for eligible patients while emphasizing the importance of long-term supportive care, especially for those undergoing NACT. Our future research will focus on tools to identify patients at risk of dissatisfaction and examine survival outcomes to ensure comprehensive, patient-centred care.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-72/rc

Data Sharing Statement: Available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-72/dss

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-72/prf

Funding: This study was supported as part of the HeAT Project by the European Regional Development Fund through the Interreg Deutschland-Danmark Program (No. 01-1-23 2).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-2025-1-72/coif). The 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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Scientific Ethics Review Committee of Region Zealand, Denmark (No. SJ-914, EMN-2021-01530), and by the Danish Data Protection Agency (No. REG-154-2020). Informed consent was obtained from all individual participants.

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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