Breast cancer incidence and mortality increase with advancing age. In spite of this, screening for breast cancer by physical examination and mammography is underutilized in older women compared with their younger counterparts. Studies suggest that even for elderly women with mild to moderate co-existing illnesses, the use of screening mammography reduces breast cancer mortality. The local therapy of breast cancer is well tolerated by the majority of elderly women. Mastectomy has a 30-day operative mortality of less than 1% in women older than age 65 and provides excellent local control. However, mastectomy has no survival advantage over lumpectomy and radiotherapy. If breast preservation is undertaken, radiotherapy is an important part of the treatment. Local failure in the breast in the absence of radiotherapy usually occurs in the first 4 postoperative years and is likely to become a problem during the patient's lifetime. Radiation to the breast is well tolerated, and the incidence of complications does not appear to be age related. Many older women are anxious to preserve their breasts and should be offered this treatment option. In the older woman with severe co-morbid conditions in whom the risk of operative morbidity and mortality is high, tamoxifen, 20 mg daily, may be used as an alternative to surgical therapy. Complete and partial response rates of 50% to 80% are reported with tamoxifen therapy, and this often results in control of local disease during the patient's lifetime. However, this should not be considered standard therapy for the otherwise healthy older woman. The majority of older women benefit from tamoxifen therapy postoperatively, and cytotoxic chemotherapy, when indicated, can be delivered with acceptable toxicity. The failure to use adjuvant therapy when indicated is one of the most frequently identified problems in the management of breast cancer in the elderly. Breast cancer in older women carries a significant mortality, even in spite of the presence of concurrent diseases. In a number of studies, old age is noted to be a negative prognostic factor. Whether this is due to the biology of the disease or the undertreatment of older women is unclear, but it is evident that breast cancer in the elderly should not be considered an indolent disease. Breast cancer therapy should be determined by a woman's physiologic age and psychological needs rather than her chronologic age.
