Addressing the Complex Survivorship Landscape for Older Patients With Breast Cancer

With nearly half of the 310,000 annual breast cancer cases in the US occurring in patients 65 years or older, a recent review published in Current Breast Cancer Reports emphasized that this growing demographic faces distinct survivorship challenges that require tailored management to preserve quality of life and independence.

Data Supporting the Findings

The review indicated that 40% to 75% of patients diagnosed with breast cancer have at least 1 comorbidity, most commonly cardiovascular disease or obesity. While survivors may not acquire more comorbidities post-treatment than age-matched controls, the development of a new condition is associated with significantly worse mortality.

Physical and cognitive function represent major areas of concern:

• Physical Function: Older patients demonstrated worse physical recovery than age-matched controls, with up to 87% reporting an impact on musculoskeletal function post-operatively. Those with the greatest musculoskeletal function disruption were from mastectomy and axillary dissection.
• Falls and Bone Health: Treatment-related bone loss affected up to 80% of patients. Survivors of breast cancer had a 1.35 relative risk for osteoporotic fractures, while the study highlighted that the 1-year mortality after a hip fracture is nearly 30%. Additionally, 26% of survivors over age 65 reported a fall within a 12-month period.
• Cognitive Decline: While some declines are transient, survivors are nearly twice as likely to report cognitive problems—often termed "chemotherapy brain", or chemotherapy-induced cognitive impairment—3 years after diagnosis, especially if they received hormone therapy.
• Frailty: The study highlighted work that noted approximately 23% of patients over age 70 are classified as frail. Frailty is associated with reduced survival, functional decline, and increased chemotherapy toxicity.

Treatment and Decision-Making

Treatment strategies for older adults increasingly involve evaluating physiological rather than chronological age. While surgery remains standard, there are significant opportunities for de-escalation of locoregional therapy, particularly in patients aged 70 or older with early-stage disease. Despite evidence that omitting axillary surgery or radiation can be safe in select cases, many patients still undergo these procedures. Qualitative data suggests this may be due to the clinician’s reluctance to de-escalate.

Decision-making in this population is guided by several factors:

• Shared Decision-Making: Older adults who receive more aggressive local therapy often report higher rates of decisional regret. The use of decision aids has been shown to reduce the election of more aggressive therapies.
• Reconstruction: While breast reconstruction is associated with improved well-being, older adults are less likely to undergo the procedure despite having similar complication rates to younger patients with comparable risk profiles.
• Systemic Therapy: Patients over age 75 are approximately 40% less likely to receive guideline-concordant systemic therapy than those aged 66 to 74. Deviations from standard chemotherapy may reduce toxicity but are also associated with worse survival outcomes.
• Geriatric Assessment (GA): Organizations like the American Society of Clinical Oncology (ASCO) and the NCCN support the use of a Comprehensive Geriatric Assessment to identify patients at high risk. The "Practical Geriatric Assessment" is a targeted version designed for clinical workflows. Geriatric assessments can help target interventions such as exercise, which has been shown to mitigate fatigue and improve cognitive function.

Safety

Safety in treating older adults requires careful navigation of treatment toxicities and adherence to the Beers Criteria, which lists medications potentially contraindicated in older populations.

• Pain Management: To minimize narcotics, guidelines recommend nerve blocks and adjuncts like acetaminophen or gabapentin. However, even non-opioid adjuncts may be associated with issues; for example, tramadol must be used with caution due to risks of hyponatremia or central nervous system adverse effects in those with reduced kidney function.
• Insomnia: Over 25% of patients reported sleep disturbances severe enough to require medication, yet most sleep aids are contraindicated in older adults.
• Intervention: The review advocates for the Practical Geriatric Assessment, a targeted version of the Comprehensive Geriatric Assessmentsupported by ASCO and NCCN, to identify patients at high risk for toxicity and to guide appropriate treatment de-escalation.

Reference

Morton CR, Lorentzen EH, Minami CA. Survivorship issues in older adults with breast cancer. Curr Breast Cancer Rep. 2025;17(20):10.1007/s12609-025-00586-1. doi:10.1007/s12609-025-00586-1