Approach to a suspicious breast lesion in an older woman

Confirm the diagnosis fully, then match treatment to fitness, frailty and the woman's wishes rather than to her age. Age-related variation in treatment is common, and many older women receive primary endocrine therapy, which may worsen survival and local control.

Discuss options with her (and her family if she wishes), using decision tools where available.

Clinical assessment: history and physical examination.

Imaging: mammography and/or ultrasound. Adding ultrasound to mammography improves the accuracy of radiological grading.

Tissue diagnosis: needle biopsy, either fine-needle aspiration cytology or core biopsy. Core biopsy confirms invasive cancer and gives the information needed to plan treatment; cytology can show oestrogen and progesterone receptor status but not HER2.

The three together are more accurate than any one alone. In one clinic series, a positive triple assessment had a positive predictive value of 100% and a sensitivity of 94.7% against core biopsy.

Pathology: classify the tumour by the WHO system, stage it by TNM (8th edition), and record oestrogen receptor, progesterone receptor and HER2 status.

Staging scans for high-risk disease: CT and bone scan, with PET–CT only if these are inconclusive.

Comprehensive geriatric assessment: SIOG/EUSOMA (2021) advocate it in older women with breast cancer. It helps predict survival and quality of life and guides treatment decisions, though the best set of tools is uncertain.

Surgery, with endocrine therapy for oestrogen-receptor-positive disease, is oncologically superior to primary endocrine therapy for most older women with early ER-positive cancer.

In women aged 70 or over who were fit for surgery, tamoxifen alone gave similar overall survival to surgery but worse local control and progression-free survival (Cochrane review).

In less fit women (median age 81, with more comorbidity and functional impairment), breast-cancer-specific survival did not differ between primary endocrine therapy and surgery for 4–5 years. With a predicted life expectancy under 5 years (over 90, or over 85 with comorbidity or frailty), primary endocrine therapy may be a reasonable individual choice.

Quality of life: surgery brought more psychosocial morbidity at 3 months, which resolved by 2 years; in the Age Gap study, global health status was similar over 24 months after adjusting for baseline differences.

The Pan-Asian adaptation of the ESMO guideline recommends mammography every 2 years from 45 to 69, with possible benefit from 40–44 and 70–74. Once a suspicious lesion has been found, the question is diagnosis rather than screening, so complete the assessment above.