Breast Cancer After 65: Hormone Pills Alone vs. Surgery First

For many older women diagnosed with breast cancer, the first question is whether they need surgery at all. A large review published Nov. 6, 2026, in JAMA Network Open offers some of the clearest information yet, and its message is that the answer depends less on age and more on the tumor itself and a woman's overall health.

Researchers from UPMC Hillman Cancer Center and Brigham and Women's Hospital pooled 29 studies of 22,821 women 65 and older with ER-positive breast cancer that had not spread beyond the breast and nearby area. ER-positive means the cancer cells use the hormone estrogen to grow. The women's median age was 83. The researchers compared two paths: surgery first, or primary endocrine therapy, which means taking hormone-blocking pills instead of having an operation.

How Survival Compared

To compare survival, the team relied on the six randomized trials in the review, which included 813 women. In those trials, women who took hormone pills alone did not have a statistically significant difference in overall survival compared with women who had surgery. The numbers leaned slightly in favor of surgery, but the difference was small enough that it may have been due to chance. There was also no significant difference in deaths from breast cancer specifically.

One finding stands out for families weighing this choice. In the randomized trials, 28.8% of the women died of breast cancer, while 47.3% died of other causes, such as heart disease. For many women in their 80s, other health conditions shape life expectancy more than the breast cancer does.

The Trade-Off: Keeping the Cancer in Check Locally

Surgery did a better job of controlling the cancer in the breast. In one long-running trial, the cancer grew back or progressed in the breast in 38% of women taking hormone pills alone at five years and 43% at 10 years. Many of those women later had surgery to deal with it. In more recent studies of carefully selected women, the time before the cancer progressed was much longer, often more than four years.

It is also worth knowing that all six randomized trials used tamoxifen, an older hormone pill. Today, many older women with ER-positive breast cancer take aromatase inhibitors, such as Arimidex (anastrozole) or Femara (letrozole), which lower estrogen levels after menopause. The randomized evidence doesn't directly test those drugs as a replacement for surgery.

Who Might Do Well Without an Operation

The researchers found that women whose tumors were strongly driven by estrogen, slow-growing (low grade and with a low Ki-67, a marker of how fast cells divide) and smaller were the most likely to have lasting control with pills alone. Frailty, other serious illnesses and difficulty with daily activities were linked to shorter survival, mostly from causes other than breast cancer.

Based on this, the authors suggested that doctors look at tumor biology together with frailty, "rather than age alone, to identify candidates" for hormone therapy without surgery. They were careful to say this approach still needs to be tested in future studies before it becomes routine. The review also had limits: the randomized trials were small and older, and some results had to be estimated from published graphs.

CURE has also reported on research into whether a blood test may help older patients safely avoid surgery and on fewer lymph node biopsies for older women, part of a broader shift toward less treatment when it won't help.

Questions to Bring to Your Oncologist

If you or a parent is weighing surgery versus hormone pills, these questions may help guide the conversation:

• How strongly estrogen-driven and how fast-growing is my tumor, based on my pathology report?
• How do my other health conditions affect the benefit I would get from surgery?
• If I start with hormone pills, how will we check whether they are working, and when would surgery come back on the table?
• What side effects should I expect from the hormone pill you recommend?

Neither path is a shortcut. Both are real treatment, and the right choice is the one that fits the cancer, your health and your goals.

References

1. "Primary Endocrine Therapy vs Upfront Surgery for Older Women With Estrogen Receptor-Positive Breast Cancer: A Systematic Review and Meta-Analysis." JAMA Network Open. Nov. 6, 2026.

For more news on cancer updates, research and education, don't forget to subscribe to CURE®'s newsletters here.