In clinical practice, approximately 50% of new cases of breast cancer occur in women over the age of 65 years, although very few elderly women have been enrolled in the numerous randomized trials conducted so far. Notwithstanding less aggressive biologic features compared with younger patients, breast cancer impacts on mortality of elderly women, especially if not adequately treated. As confirmed by meta-analyses, hormonal therapy is the most effective adjuvant measure for patients with localized disease, whereas the decrease in the benefit of cytotoxic treatment with increased risk of toxicity make the decision on when and how to administer it a major challenge for the medical oncologist. Careful evaluation of biological prognostic factors, performance status and geriatric parameters, such as functional independence, comorbidities and cognitive function of the patient, along with determination of her life expectancy and preferences, represent the relevant information on which the oncologist should ground their decision for integrated treatment with conservative surgery, radiotherapy and hormonochemotherapy in otherwise healthy women, or attenuated or palliative measures for the frail patients, in order to maximize the balance of benefits and toxicities. The aims of this review are to summarize the most relevant concepts for decision making in the clinical practice and discuss the results of recent research concerning the additional needs of elderly women with early breast cancer.