Factors impacting decision for reconstructive surgery in breast cancer in older women: a narrative review

Background and Objective: Lower breast reconstruction rates persist in older women (aged ≥65 years) with breast cancer despite clinical guidelines recommending that chronological age alone should not preclude access. Quantitative and qualitative evidence was reviewed to identify patient, physician, and systemic factors influencing this disparity. Greater understanding of these factors is essential to improving care. Methods: A search of English studies published between 2010 and 2025 was conducted in PubMed and Google Scholar from April to August 2025 with the terms “older women with breast cancer” and “breast reconstruction in older women”. Key articles and recent systematic reviews were supplemented by reference chaining to identify relevant studies, including those published before 2010. Both quantitative and qualitative evidence addressing factors affecting reconstruction uptake in older women were included. Key Content and Findings: A total of 78 studies are included in this review. Factors relating to uptake of breast reconstruction in older women can be categorised as patient-associated, physician-associated and systemic factors. Direct age-stratified evidence was identified for certain patient-associated factors (chronological age, comorbidity burden and functional status, disease characteristics, adjuvant therapy, and sociodemographic status), physician-related factors (physician framing and dynamics), and systemic factors (healthcare infrastructure, finance and socioeconomic status). However, most available studies were not age-specific, included few older women, and were often of low levels of evidence. Other reported influences such as patient anxiety, surgical fatigue, logistical and caregiving barriers, ageism, conflation of chronological and physiological age, were extrapolated from mixed-age data or non-age specific data. Notably, there remains a significant gap in age-specific research, particularly regarding oncoplastic breast surgery (OBS) uptake and qualitative insight into older women’s experiences. Conclusions: The underutilisation of breast reconstruction in older women reflects a complex interplay of patient-associated, physician-associated, and systemic factors. Few high quality, age-stratified studies with adequate representation of older women exist. Addressing this gap requires greater research focus on older populations, improved shared decision-making practices that prioritise physiological age over chronological, and health system reforms to mitigate structural barriers. Enhanced understanding and tailored can guide the future of reconstruction decision-making and practices, promoting equitable, patient-centred care.