The Choosing Wisely Organization and the American College of Surgeons have issued recommendations for patients >70 with breast cancer involving screening and use of radiation therapy (RT) and sentinel lymph node biopsies (SNLB) in early stage tumors. This study evaluated compliance and implementation of these recommendations. A database of patients undergoing breast cancer surgery was retrospectively queried from 2002 to 2017. Patients were divided into cohorts before and after the year of each guideline publication. The rate of presentation on mammography was not different before 2009 (65%) vs. after 2009 (66%). RT was given to 57% of patients with T1 ER + Her2-prior to 2013 vs. 27% after (p=<0.001). SLNB was performed in 91% of patients with T1, grade1/2, ER + Her2-tumors prior to 2016 vs. 56% after (p=<0.001). Rates of mammography detected breast cancer have not decreased but adjuvant RT and SLNB are less frequently performed in low risk breast cancer in the elderly. •There are no defined diagnostic or treatment algorithms for the elderly with breast cancer.•Screening mammogram utilization in the elderly with a life expectancy of less than 10 years has not decreased since 2009.•Radiation therapy in low risk estrogen receptor positive breast cancer can be obviated without compromising outcomes.•Utilization of sentinel lymph node biopsy in low risk elderly breast cancer has decreased over time as per recommendations.