BACKGROUND:: Older women are less likely to receive standard management for breast cancer than younger postmenopausal women. Whether differences in general health explain variations in the rates of surgery is not known. METHODS:: In this prospective cohort study, 76 women aged 65 years or more attending breast units in Greater Manchester completed a survey measuring functional status (Elderly Population Health Status Survey's Activity of Daily Living), generic health status (Short Form 12) and health-related quality of life (European Organization for Research on Treatment of Cancer Quality of Life Questionnaire C30). Case-note review assessed co-morbidity (Charlson Index) and management. Primary surgery for operable breast cancer was investigated using logistic regression. RESULTS:: A Charlson Index of 1 or more did not predict the use of surgery (P = 0.363). However, for each point increase on the 1-4 scale indicating worsening functional status, the odds of having surgery decreased by 16 times (odds ratio 0.063). The odds of a woman of 80 years or more having surgery decreased by a factor of 44 (odds ratio 0.023) compared with women aged 65-79 years, accounting for co-morbidity, functional status, pretreatment stage, social deprivation and type of hospital. CONCLUSION:: Older women were less likely to have surgery for operable breast cancer than younger women, even after accounting for differences in general health and co-morbidity. Copyright (c) 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.