Breast Cancer Res Treat (2012) 132:675–682 Conclusions Despite the remarkable large differences in loco-regional treatment of early breast cancer, this study showed minimal differences in survival at 5 years between older breast cancer patients from seven Western countries. These ﬁndings raise the question whether more or less aggressive treatment of early stage breast cancer in elderly makes a difference. Future research should be focused on the best therapy for elderly women with respect to survival and quality of life. It may well be that the much criticized ‘‘less aggressive therapy’’ for elderly breast cancer patients does not harm patients with early stage disease, particularly women with comorbid illness that may otherwise limit their life expectancy. To properly investigate this, ran- domized controlled trials, speciﬁcally aimed at the elderly, is considered to give the best evidence. RCT’s, however, are costly and time consuming en will not yield practice changing results within years from the start of such a trial. Furthermore, older patients are underrepresented in trials and no direct comparison of different approaches to the local regional treatment of early breast cancer in older women is available. International comparison of speciﬁc treatment protocols could serve as a good alternative to select ‘best practices’ and improve the risk/beneﬁt ratio in the treatment of older breast cancer patients. This com- parative effectiveness research can bridge the knowledge gap speciﬁcally in older cancer patient, who are by nature, heterogeneous in patient characteristics and treatment patterns [28]. Acknowledgments The authors would like to thank the Dutch Cancer Society (KWF 2007-3968), the Netherlands Cancer Registry (NCR) and Geriatric Oncology in the Netherlands (GeriOnNe). Conﬂicts of interest None. 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