Oncoplastic surgery and breast reconstruction in the elderly: an unsolved conundrum

Breast cancer incidence has been steadily increasing manly in high income countries as is life expectancy. The majority of newly diagnosed breast cancer cases will occur in post -menopausal women with an increasing in the older age group. As in younger women oncoplastic surgery and post mastectomy breast reconstruction should also be viable options, when needed, in older women. However, this is not the case in most centres and chronological age alone seems to be a barrier to these surgical alternatives. We evaluated the most relevant and recently published literature on the topic to analyse the available evidence in favour and against the use of oncoplastic breast surgery and post mastectomy breast reconstruction in this age group. Older women are not significantly represented in randomized clinical trials. There is minimal published evidence on oncoplastic breast surgery. Regarding post mastectomy breast reconstruction, although there are more publications, most studies are retrospective, present an evident selection bias and are very heterogeneous. Regarding oncoplastic surgery and post mastectomy breast reconstruction, there is no evidence that, compared to younger age groups, higher rates of complications should lead to the denial of these choices to older women, especially in the absence of associated comorbidities. Patient reported outcomes are not sufficiently explored in older women but, based on the limited available evidence, older women report higher rates of satisfaction when compared to younger women regarding oncoplastic surgery and post mastectomy breast reconstruction. Decisions in older women proposed for breast surgery and in need of oncoplastic breast surgery or post mastectomy breast reconstruction should always integrate, patients preference, a geriatric assessment and a life expectancy estimation. In case of unfavourable geriatric assessment and low estimation of life expectancy, a higher complication rate should be anticipated. It is not likely that randomized controlled trials will happen in this age group not only due to ethical concerns (as oncoplastic surgery and post mastectomy reconstruction are already standard of care in other age groups) but also to the difficulties in obtaining meaningful numbers. However, well designed prospective cohorts can be a valuable alternative to the scarce available retrospective evidence.