AIM:To assess oncological outcomes in early-stage, luminal A-like, low-risk, breast cancer patients aged 65 years or more after conserving surgery followed by endocrine therapy (ET) and/or whole breast irradiation (WBI) or no adjuvant therapy. METHODS:Data from patients treated in EUSOMA-certified breast units between 2010 and 2022 were collected. Univariable and multivariable analyses for local, nodal, distant recurrences, breast cancer specific survival (BCSS), and overall mortality were conducted. Potential treatment-related determinants included adjuvant ET alone, WBI alone, ET+WBI or no adjuvant therapy. RESULTS:Breast cancer patients (9660) from 72 Breast Units across 14 European countries were enrolled. Tumours were pT1 in 85.8 % of cases. All tumours were luminal A-like. All patients had negative nodes. Adjuvant ET alone was prescribed for 806 (8.3 %) and WBI alone was delivered to 386 (4.0 %); ET and WBI were combined (ET+WBI) in 8154 (84.4 %) patients. No adjuvant therapy was given to 314 patients (3.3 %). The median follow-up was 1.87 years (first quartile 0.81, third quartile 4.16), and the mean was 2.62 years (range 0.003-13.82 years). Compared with no adjuvant therapy, multivariable analysis showed ET+WBI significantly improved in-breast tumour recurrence-free survival (IBTRFS) (HR 0.28, CI 95 % 0.10 -0.79; p = 0.016) and BCSS (HR 0.12; CI 95 %: 0.03 -0.51; p = 0.004). ET alone (HR 0.57; CI 95 %: 0.35 -0.90; p = 0.017), WBI alone (HR 0.51; CI 95 %: 0.27 -0.95; p = 0.033) and both treatments combined (HR 0.26; CI 95 %: 0.16 -0.42; p < 0.001) significantly lowered mortality. CONCLUSIONS:Despite a short follow-up, results from this large series of low-risk breast cancer patients who had undergone conserving surgery, showed adjuvant treatments impacted positively upon outcomes.

Women aged ≥ 65 with multiple comorbidities are at increased risk of perioperative complications, loco-regional anaesthetic techniques (LRA) may reduce perioperative complications compared to general anaesthesia (GA); however, evidence specific to patients aged ≥ 65 is limited. A systematic search was conducted using Cochrane, Embase, MEDLINE and Web of Science from database inception to 7 April 2025. Studies comparing LRA to GA, with any number of women aged ≥ 65 undergoing primary breast cancer surgeries, were included. Eight studies with a total of 255,088 women, of whom 55,310 were aged ≥ 65, were included. Four studies were prospective and four were retrospective. 192,453 women received GA. Four studies compared local anaesthesia alone (number of women aged ≥ 65, n = 54,852) to GA, and one study each compared local + regional anaesthesia (n ≥ 65 = 389), pectoral nerve blocks (n ≥ 65 = 42), paravertebral block (n ≥ 65 = 26) and thoracic epidural (n ≥ 65 = 1) to GA. Overall, LRA techniques had lower rates of post-operative nausea and vomiting, confusion and operative duration. LRA may have a role in patients who are unfit for or cannot undergo GA for breast cancer surgery; however, data specific to women ≥ 65 years are sparse and there are many confounding factors which impact usability of LRA techniques, for example type of breast and axillary surgery and availability of technique.

The average global life expectancy is predicted to increase to approximately 80 years by 2040 [1]. Cancer is an ageing-related disease, and its prevalence will also increase with this ageing of the population [2]. This rise in older adults living with cancer will demand innovation in service delivery, multidisciplinary collaboration, and a renewed focus on compassionate, patient-centred care. We are therefore compelled to rethink how we approach cancer diagnosis, treatment, and survivorship. This white paper explores the potential realities and challenges through a multidimensional lens, addressing the intersection of demographic shifts, rapid technological advancements, and the evolving needs of older adults living with cancer. Key areas examined include the integration of precision medicine and digital health tools, the adaptation of healthcare delivery models, and the implications for workforce training and resource allocation. The discussion highlights disparities in care, the importance of personalised interventions, and strategies to enhance quality of life for older adults with cancer. By anticipating these developments, the paper offers critical insights for policymakers (who set the rules and goals and allocate funding), health system leaders (who manage the day-to-day operations), clinicians and allied health professionals (who are patient-facing), and patients and caregivers, aiming to promote equity, innovation, quality and resilience in the care of older adults with cancer as we approach the next decade. The paper seeks to consolidate and clarify the diverse issues and opportunities that will emerge as the global population ages and the burden of cancer among older adults rises. With average life expectancy predicted to approach 80 years by 2040, and cancer recognised as a disease closely linked to ageing [3], the paper brings together expert perspectives to provide a sector-wide synthesis of the impending challenges. Its purpose is not to offer a conventional systematic review, but rather to serve as a strategic resource for policymakers, health system leaders, clinicians, allied health professionals, patients, and caregivers, informing the response to demographic shifts, technological advances and evolving patient needs. By consolidating insights on disparities in care, the necessity for personalised interventions, and strategies to enhance quality of life, the paper aims to inform and inspire innovation, equity and resilience in geriatric oncology as we approach the next decade.

PURPOSESERENA-3 is a presurgical window-of-opportunity (WOO) trial exploring the pharmacodynamic effects of camizestrant in postmenopausal women with newly diagnosed estrogen receptor (ER)-positive, human epidermal growth factor receptor 2-negative breast cancer.METHODSThis open-label, parallel-group trial randomly assigned 132 participants to receive camizestrant 75, 150, or 300 mg once daily for 5-7 days or 75 or 150 mg once daily for 12-15 days. The effects of camizestrant on ER expression, activity, and tumor proliferation were assessed in pre- and on-treatment tumor samples by immunohistochemical (IHC) analysis of ER, progesterone receptor (PgR), and Ki67. Exploratory analyses using transcriptomics and mass spectrometry were also performed.RESULTSER expression was reduced by approximately 65% for all camizestrant doses, regardless of treatment duration. Reduction in Ki67 expression was greater after 12-15 days of camizestrant treatment, compared with 5-7 days. Exploratory analyses including mass spectrometry and IHC image analysis aligned with IHC H-score, indicating equivalent, maximal effects of all tested doses of camizestrant on ER expression and activity and Ki67 expression. Of those participants receiving camizestrant 75 mg once daily, 90%-100% reported no treatment-emergent adverse events across all preferred terms; of those reported, all were Grade 1 except one participant with Grade 2 upper respiratory tract infection, not considered related to camizestrant.CONCLUSIONSERENA-3 demonstrates that camizestrant 75 mg once daily (Phase III dose) is well-tolerated and achieves maximal reduction in ER through known mechanisms, that is, antagonism and degradation, by 5-7 days, and proliferation suppression determined by Ki67 expression, by 12-15 days. These data support camizestrant 75 mg once daily as the preferred dose for ongoing clinical development and highlight the importance of presurgical WOO studies in guiding dose selection.

This narrative review explores the evolving role of surgery in older adults with cancer, highlighting non-operative and minimally invasive alternatives, and the integration of geriatric principles to improve selection of treatment and postoperative outcomes. Minimally invasive and non-operative treatments can provide comparable oncological outcomes to traditional surgery with lower morbidity and better functional recovery. Frailty screening tools aid in predicting postoperative outcomes, and geriatric assessment can identify vulnerabilities and assist treatment planning, prehabilitation and rehabilitation. Prehabilitation, early rehabilitation, and multidisciplinary collaboration enhance recovery and align care with patient values and outcomes that matter most. Surgical care in older cancer patients is shifting toward a model focused on preserving quality of life and personalised decision-making. Incorporating geriatric assessments and less invasive approaches can improve outcomes and reduce treatment burden. Further research is needed to integrate these strategies into standard practice.

BACKGROUND:Although the relative proportion of triple-negative breast cancer decreases with age, its prevalence is rising with an aging population. This study examined real-world treatment practices, whether age in older women with triple-negative breast cancer affects therapy and outcomes, focusing on the potentially curable nature of early-stage triple-negative breast cancer. METHODS:A Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PRISMA-compliant search using population, intervention, comparison, outcomes criteria identified literature from 2014 to 2023 across 5 databases (MEDLINE, Embase, PubMed, Web of Science, and Scopus), focusing on women aged 65 years and older with early-stage triple-negative breast cancer. RESULTS:From 7171 records, 37 studies were included. Older women with triple-negative breast cancer exhibited less aggressive features, including lower Ki67, higher androgen receptor, and higher Bcl2 expression. Breast-conserving surgery with radiation therapy (RT) was associated with improved overall survival and breast cancer-specific survival, with fewer recurrences compared with mastectomy with or without RT. Older women with triple-negative breast cancer were more likely to receive RT than systemic therapy, and the lack of RT correlated with worse outcomes. Multivariate analyses showed that systemic treatment improved 5-year overall survival and breast cancer-specific survival. Overall, outcomes did not show significant differences between women aged 70 years and older and women younger than 70 years at a median follow-up of 46 months. CONCLUSIONS:The lack of overall outcome improvements for older women with triple-negative breast cancer following treatment may not solely be due to absent targetable receptors because the intrinsic biology in older patients may be relatively favorable. Instead, treatment selection biases against active treatment due to age-related factors may contribute substantially. Treatment decisions should be biology based and guided by a multidisciplinary, holistic, and patient-centered approach that carefully considers comorbidities, functional status, social support, and patient preferences.

Clinical guidelines recommend surgery for early-stage breast cancer in operable patients; however, primary endocrine therapy (PET) is often used in older women aged ≥ 70. This study aimed to estimate the cost-effectiveness and value of implementation of surgery plus adjuvant endocrine therapy (ET) compared with PET for older women with early breast cancer who are fit for surgery. A partitioned survival analysis model was developed using effectiveness data from the published literature (time horizon: lifetime). Health outcomes were measured as quality-adjusted life years (QALYs; EQ-5D-3L UK tariff). Direct costs were estimated from the perspective of NHS England (discount rate: 3.5

INTRODUCTION:Sentinel lymph node biopsy (SLNB) after neoadjuvant treatment (NAT) is an increasing option for axillary surgery in patients responding to treatment, whether diagnosed as clinically node-negative (cN0) or node-positive (cN + ). This study evaluates SLNB trends in patients with NAT in a large European population. MATERIALS AND METHODS:Data sourced from EUSOMADB, collating prospectively collected data from certified European Breast Units, included 17,321 patients who have undergone NAT between 2010 and 2021. Of those, 9,226 and 8.095 are clinically N0 and cN1, respectively. RESULTS:During the study period, for cN0 patients, there has been a significant increase in the proportion of cases with SLNB, rising from 86% in the 2010-2015 period to 94% in the 2016-2021 period. Consequently, a decline in direct axillary dissection (AD) has been shown in both periods, dropping from 14% to 6% (p < 0.001). Similarly, in cN+ patients, SLNB increased from 25% to 40%, while direct AD decreased from 75% to 60% (p < 0.001). Regarding immunohistochemistry subtypes, higher SLNB rates were reported in triple-negative and HER2-enriched tumors. Nevertheless, SLNB rates rose significantly across all immunohistochemical subtypes (p < 0.001) between both periods. Multivariate analysis identified as statistically significant predictors of SLNB: surgery period (second period), molecular subtype (HER2-positive, triple-negative), breast-conserving surgery and type of NAT. CONCLUSION:This study evidences a substantial shift towards SLNB as the primary axillary surgery following NAT during the study period. This trend emphasizes a preference for less invasive procedures, likely due to the efficacy of neoadjuvant therapy in reducing axillary lymph node involvement.

Background and Objective: Breast cancer management in older women presents challenges due to competing comorbidities and life expectancy concerns. Traditional axillary surgeries as part of treatment of breast cancer are being reconsidered, particularly in two settings (I) early operable disease with positive sentinel lymph node biopsy (SLN+) and (II) cases of early operable clinically node-negative disease (cN0). Current guidelines and emerging evidence suggest that axillary lymph node dissection (ALND) may not always be necessary, especially in patients with low-risk disease. The objective of this study is to offer an updated synthesis of current guidelines and discuss the latest evidence from significant clinical studies. Methods: A literature search was conducted using the PubMed database and articles up to Nov 2023 were included for analysis. Key Content and Findings: Recent trials, including AMAROS and OTOASOR, demonstrate the non-inferiority of radiotherapy compared to ALND in early breast cancer with positive sentinel lymph node biopsy (SLNB), offering a shift towards de-escalation of axillary surgery. Similarly, studies like IBCSG 1093 highlight the potential benefits of omitting axillary surgery in clinically node-negative tumours, showing improved quality of life without compromising oncological outcomes. Despite promising findings from these studies, challenges remain, including disparities between real-world evidence and controlled trials. Variation in clinical management persists, influenced by factors such as trials designs, restricted inclusion criteria, and clinician interpretation. Ongoing trials are still needed to further elucidate the role of axillary surgery, particularly in older women, by assessing quality of life outcomes, the need for comprehensive geriatric assessment tools, and individualised treatment decisions. Conclusions: While evidence supporting the use of radiotherapy or adjuvant systemic therapy for managing axillary lymph nodes continues to grow, the reduction in both ALND and SLNB in older women may be on the horizon, emphasising the importance of tailored treatment approaches based on patient characteristic.

BACKGROUND:The aim of this study was to assess clinicopathologic characteristics, treatment modalities used and outcome of patients with locally advanced breast cancer (LABC). MATERIALS AND METHODS:we searched the European Society of Breast Cancer Specialists (EUSOMA) data warehouse for clinically LABC cT4a-d - in the 2013-2022 timeframe. RESULTS:Of a total of 132269 patients, we identified 2427 patients with cT4abc BC (1.83 %) and 977 with inflammatory (T4d) BCs (0.74 %), of whom 542/2427 (20.1 %) and 251/977 (25.6 %), respectively, had metastatic disease at presentation (p = 0.054. Ninety percent of patients with cT4abcM0 and 88.8 % of patients with cT4dM0 disease had surgery (p = 0.369) and 90.9 % and 88.7 % (p = 0.187) endocrine therapy. Neoadjuvant chemotherapy (CT), adjuvant CT, biological drugs and radiotherapy were given in 33.2 %, 47.0 %, 67.1 % and 61.1 % of cT4abcM0 cases compared to 77.3 %, 80.4 %, 87.7 % and 80.2 % of cT4dM0 cases (all p < 0.001). Multivariable analysis showed that age <70 years, luminal A and HER-2 pure subtype, surgical treatment, radiotherapy, and systemic treatment (all p ≤ 0.034) were determinants of better overall survival (OS). Local recurrence rate (LRR) was significantly lower in patients receiving radiotherapy or endocrine therapy (p ≤ 0.012). Cox analyses showed no difference in OS or LRR between patients with cT4abc and those with T4d BCs, neither at univariable or multivariable analysis. CONCLUSIONS:The current study confirms well-known features of cLABCs and underscores the importance of multimodal treatment, which is often underused in these patients.

The global population is ageing and the risk of breast cancer increases with age. Therefore, we can expect an increase in the number of cases of breast cancer worldwide in the next 20 years. Currently, there are few age-specific guidelines for the management of breast cancer in older women. The International Society of Geriatric Oncology and European Society of Breast Cancer guidelines on this topic were last updated in 2021 and provide some recommendations, although it is worth noting that, generally, the level of evidence pertaining to older women is low. The Nottingham research team on older women with primary breast cancer is working on three main aims in this cohort: (1) understand the unique biological differences between breast cancer in older compared to younger women, (2) explore the unique psycho-social factors that may be present in this population and differ from those found in younger women, as well as how this may influence treatment decisions, and (3) the cost-effectiveness of various treatment strategies in this cohort. This paper will outline key studies published by the Nottingham team in these areas to gather data and highlight future directions for the research group.

INTRODUCTION:Prioritising quality of life (QoL) or length of life is often necessary in the decision-making process for cancer care. This may be complicated in patients with limited life expectancy due to age and comorbidities. Older women with early breast cancer often receive non-standard care (primary endocrine therapy [PET] or omission of chemotherapy or radiotherapy) to reduce treatment morbidity and maintain QoL. We aimed to determine the perceived relative influence of QoL versus length of life in treatment decision making by older women with early (potentially curable) breast cancer. MATERIALS AND METHODS:This was a sub-study of the Age Gap multi-centre, cohort study, which prospectively recruited women >70 yrs. with early breast cancer. Baseline demographics, health characteristics, and QoL scores were analysed alongside a bespoke questionnaire to assess QoL and length of life preferences, including a modified version of the validated quality/quantity questionnaire, in a subset of the main study. RESULTS:The questionnaire was sent to 308 patients and 194 (63 %) were returned by participants with a median age of 75 years (range 70-93). Of these, 14 had PET and 180 had standard treatment (ST) (surgery +/- adjuvant therapy) including 37 who had chemotherapy. The PET group was older (median age 83.5 versus 76 years) and in poorer health (9/14; 64.3 % patients had one or more comorbidities versus 69/144; 47.9 %) with inferior baseline physical domain QoL scores. Patients who received PET valued QoL and length of life equally (Q score 0.87, L score 0.91), and patients who received chemotherapy favoured length of life over QoL (Q score 0.67, L score 0.86). Subgroup analysis showed a small correlation between increasing age and QoL preferences (Spearman's r = 0.2, P < 0.009). There was no correlation between co-morbidities, frailty, or global QoL and length of life/QoL preferences. DISCUSSION:Older women with early breast cancer valued length of life and QoL highly, with an association between preference for QoL and less aggressive treatment choices. Relative QoL preference increased with advancing age. More research is needed to define QoL determinants and outcomes following treatment to help patients make decisions that reflect their priorities. TRIAL REGISTRATION NUMBER:ISRCTN: 46099296.

BACKGROUND:Breast cancer is increasingly prevalent among older adults, who are likely to have numerous comorbidities and unique psychosocial challenges. AIMS:The aim of this study was to measure the prevalence of psychosocial factors in a cohort of older women diagnosed with early-stage operable breast cancer and the influence these factors may have on treatment decisions. METHODS:As part of a prospective study in three UK centres, 199 patients with a new diagnosis of early-stage operable primary breast cancer, aged ≥ 70 years (mean 77, range 68-93) were recruited. A cancer-specific Comprehensive Geriatric Assessment (CGA) was conducted within 6 weeks of diagnosis. Association between treatment decision and psychosocial aspects (as measured by the 'psychosocial support', 'social activity' and 'social support' domains) of the CGA was determined. Treatment decision was not guided by this study and was determined usual conventional methods as per the breast multi-disciplinary team. RESULTS:Scores for 'psychosocial support' averaged 82.1/102, 'social activity' averaged 13.5/24, and 'social support' averaged 43.3/72; with a higher score indicating a more positive outcome. There was no association between total scores in these domains and the type of treatment received. A lower score in three individual questions was associated with a higher likelihood of non-surgical treatment. CONCLUSIONS:While no direct link emerged between overall psychosocial scores and treatment decisions using CGA, specific sub-questions displayed associations with non-surgical treatment. This study is the only one of its kind to our knowledge. This may have implications for the design of a pre-CGA screening tool.

AIMS:We investigated factors related to the type of surgery, i.e. mastectomy versus breast conserving surgery (BCS), in breast cancer (BC) patients with complete pathologic response in the breast (ypT0) after neoadjuvant therapy (NAT). METHODS:A retrospective analysis from the EUSOMA database was performed using data from 55 certified centers across 14 European countries, including ypT0 BC patients (i.e., neither invasive nor in situ residuals), treated between 2017 and 2022. Variables analyzed included year of surgery, age, number and distribution of tumor focality, extent, clinical and pathological stages, and biologic subtype. Logistic regression was used to identify predictors of surgical choice. The Kaplan-Meier method was used for comparison of local recurrence-free survival (LRFS) between surgical groups. RESULTS:Of 1416 BC patients included, 67.5 % underwent BCS and 32.5 % mastectomy. At multivariable analysis, factors increasing the likelihood of mastectomy included: more recent year of surgery [odds ratio (OR) 2.61, 95 % confidence interval (95%CI): 1.51-4.51,p = 0.001], younger age (OR: 0.96, 95%CI: 0.95-0.97,p < 0.001), multifocality (OR: 2.20, 95%CI: 1.61-3.00,p < 0.001) and multicentricity (OR: 12.66, 95%CI: 6.82-23.49,p < 0.001), advanced clinical tumor stage (OR: 14.54, 95%CI: 5.80-36.47,p < 0.001), and baseline axillary nodal involvement (OR: 1.56, 95%CI: 1.12-2.17,p = 0.009). Comparison between groups did not show a significant difference in LRFS (p = 0.389). CONCLUSION:Many BC patients undergo mastectomy despite achieving complete response of primary tumor after NAT. Patients-related and tumor-related features, as well as having surgery in more recent years, seems to influence this choice. Our findings suggest the need for an optimized decision-making to spare unnecessary mastectomies.

Background Breast cancer is the most prevalent cancer globally. Primary treatment commonly involves surgery to the breast and axilla, which can potentially cause a variety of physical impairments, negatively affecting patients’ quality of life. Consequently, effective rehabilitation techniques may help patients recover their physical function following surgery. Therefore, this review aims to identify whether post-operative rehabilitation interventions improve upper limb strength in women following breast cancer surgery and to compare the efficacy of different approaches. Methods The literature search was completed in October 2023 using MEDLINE, EMBASE and Cochrane databases. Eligible studies included full-text English articles of studies performed in patients who have undergone breast cancer surgery and subsequent post-operative rehabilitation to assess the outcome on upper limb strength. Results Nine studies were included with 786 women who underwent breast cancer surgery and subsequent post-operative rehabilitation. Six studies were rated as level-I evidence, whilst three studies represented level-II evidence. Five studies reported an increase in upper limb strength following rehabilitation with multimodal therapy and proprioceptive neuromuscular facilitation. Findings regarding the optimal duration of intervention and the best time to commence rehabilitation following surgery were inconclusive. Conclusion This review has demonstrated heterogeneous findings regarding the impact of post-operative rehabilitation on upper limb strength. Furthermore, the ideal time point to initiate rehabilitation post-surgery, as well as the appropriate length of intervention needs further investigation. Therefore, additional research is necessary to better inform clinical practice in this area.

Background: The aim of the present study was to assess the frequency, clinical and pathologic characteristics and treatment modalities used for clinically locally advanced breast cancers (LABCs). Comparisons were made between cT4d and cT4abc LABCs.

ObjectiveThere is variation in practice in the treatment of older women with breast cancer. International guidelines highlight the importance of patient autonomy in treatment decision-making. The aim of this study is to identify factors which influence decision-making in older women with operable breast cancer, which will enable us to further understand how to support these patients.MethodsSystematic review in accordance with the PRISMA guidelines was performed to identify factors which influence treatment decision-making in older women with operable breast cancer. Medline, Web of Science and SCOPUS were searched.ResultsThe search yielded 5840 results; 13 articles met the inclusion criteria and reported on a total of 1118 women. Thematic analysis identified three key themes in which decision-making factors could be categorised. These were healthcare-related factors, patient-related factors and impact of treatment. Healthcare-related factors included communication with clinicians and provision of information. Patient-related factors were age, pre-existing knowledge, preconceptions of breast cancer and treatment, decision-making style and co-morbidities. The impact of treatment considerations included body image and effect on quality of life. Decision-making style was frequently reported; older women did not demonstrate one preferred style.ConclusionsThe findings have highlighted the complex interplay of factors which influence how older women make breast cancer treatment-decisions. Clinicians should have an awareness of the factors highlighted to maximise their ability to provide support and personalised care to older women with breast cancer whilst treatment decisions are made.