A new study has reported that although surgery remains the treatment of choice, older patients with estrogen receptor-rich tumors tend to do equally well when treated solely by hormonal therapy (aromatase inhibitors or tamoxifen). The study was designed to compare the survival outcomes of older breast cancer patients who received surgery as part of their treatment with those who did not. A review of seven randomized trials with a total of 1,571 participants comparing surgery with primary endocrine therapy found no difference in overall survival. The present study included 1,065 women at least 70 years of age (median age 78) with estrogen receptor positive (ER+) early stage invasive breast cancer. All of the participants had either surgery (499 women) or primary endocrine therapy (616) between 1973 and 2009 as initial treatment. The women were followed for a median of 49 months (longest 230 months).

The five-year breast cancer-specific survival was 90% in the study group and overall survival was 62%. The majority (74.2%) of the women who did die, died from causes other than breast cancer. The annual rate of locoregional recurrence (recurrence in the breast, chest wall, or lymph nodes) was less than 1% following surgery. The annual rates of contralateral breast cancer (<1%) and distant metastases (<3%) were similarly low. For patients using endocrine therapy only, 97.9% achieved clinical benefit (partial/complete response and/or stable disease) at six months. Median time to progression in this group was of 49 months (longest 132 months). All participants with strongly ER+ tumors (defined as having an H-score > 250, where H-score is a measure of estrogen receptor expression based on cell staining) achieved clinical benefit and had better breast cancer-specific survival. Patients with strongly ER+ tumors were found to have equivalent breast cancer-specific survival regardless of treatment (surgery or primary endocrine therapy, whereas surgery produced better outcome for those with less strongly ER+ tumors. The authors conclude that older women with ER+ breast cancer appear to have excellent long-term outcome regardless of initial treatment. The majority die from non-breast cancer causes. These findings should be taken into account when treatment decisions are made for older women.