Breast surgery in stage IV breast cancer: impact of staging and patient selection on overall survival

Identification of the optimal candidates to benefit from surgery and chemotherapy among elderly female breast cancer patients with bone metastases

Breast cancer is currently the most common malignant tumor affecting women's health worldwide. The rise in breast cancer metastases among patients is attributed to the inherent variability in metastatic behavior. In breast cancer, bones are the primary location for distant metastases, significantly impacting the survival rates of elderly (≥ 65) patients. The use of surgery and chemotherapy in this population is controversial. This study seeks to create a tool for forecasting overall survival (OS) in older breast cancer patients with bone metastases and to determine the optimal candidates for surgery and chemotherapy. Elderly female breast cancer patients with bone metastases from the Surveillance, Epidemiology, and End Results (SEER) database were included in this study and categorized into a training cohort and a validation cohort using R software. To identify independent predictors of OS in this population, both univariate and multivariate Cox regression analyses were conducted. Subsequently, a prognostic nomogram was created to estimate OS at 12, 24, and 36 months. The nomogram's accuracy and practical value were assessed using a calibration curve, area under the curve (AUC), and decision curve analysis (DCA). At the same time, a mortality risk classification system based on the nomogram was created to divide the population into high and low mortality risk categories, and subgroups were analyzed to determine the optimal candidates for surgery and chemotherapy. This study encompassed 2257 elderly female breast cancer patients with bone metastases, divided into 1581 participants for the training cohort and 676 for the validation cohort. Both univariate and multivariate Cox regression analyses validated those variables such as age, race, marital status, histological type, tumor grade, ER status, PR status, breast subtype, distant metastases (lung, liver, and brain), and treatment methods (surgery and chemotherapy) independently predicted OS in elderly female breast cancer patients with bone metastases (p < 0.05). Utilizing these independent predictors, a prognostic nomogram was developed to estimate OS at 12, 24, and 36 months. The calibration curves indicated that the nomogram's predictions closely matched the observed outcomes. The nomogram's AUC for forecasting OS at 12, 24, and 36 months was 0.753, 0.748, and 0.745 in the training cohort, and 0.744, 0.723, and 0.723 in the validation cohort. Additionally, the nomogram's AUC surpassed that of any individual independent predictor. DCA showed that the nomogram could achieve more net clinical benefit over a broader range of threshold probabilities. The nomogram-based risk classification system effectively sorted patients into two categories: low risk (≤ 820) and high risk (> 820). Subgroup analysis indicated that individuals classified as low-risk experienced the greatest advantage from surgery and chemotherapy (p < 0.05), whereas the high-risk group did not exhibit a statistically significant difference (p > 0.05). Drawing from the clinicopathological characteristics of elderly female breast cancer patients with bone metastases, this study developed a novel prognostic nomogram to forecast OS at 12, 24, and 36 months, enabling precise survival predictions. In addition, this study also constructed a mortality risk classification system, which can effectively help clinicians screen out the optimal candidates to benefit from surgery and chemotherapy and rationalize the allocation of medical resources.

Radiation therapy of the primary tumour and oligometastatic sites in patients with breast cancer with synchronous metastases: A literature review

De novo metastatic breast cancer represents 5 to 8% of all breast cancers (2500 new cases per year in France). Systemic treatment is the cornerstone of treatment, whereas radiation therapy usually has a palliative intent. Advances in systemic and local treatments (surgery and radiation therapy) have substantially improved overall survival. In the recent breast cancer statistics in the United States, the 5-year relative survival for patients diagnosed during 2012-2018 was 29% for stage IV (Breast Cancer Statistics). Thus, an increasing proportion of metastatic breast cancers present a prolonged complete response to systemic therapy, which raises the question of the impact of local treatment on patient survival. Radiation therapy has shown its value for early breast cancer, but its place in the local management of the primary tumour or oligometastatic sites for de novo metastatic breast cancer remains under debate. This article is a literature review assessing the role of radiation therapy directed to the primary tumour and oligometastatic sites of breast cancer in patients with synchronous metastases, in order to highlight clinicians in their therapeutic decision.

Locoregional treatment of de novo stage IV breast cancer in the era of modern oncology

Approximately 6% of metastatic breast cancers arise de novo. While systemic therapy (ST) remains the treatment backbone as for patients with metachronous metastases, locoregional treatment (LRT) of the primary tumor remains a controversial method. The removal of the primary has an established role for palliative purposes, but it is unclear if it could also determine a survival benefit. Retrospective evidence and pre-clinical studies seem to support the removal of the primary as an effective approach to improve survival. On the other hand, most randomized evidence suggests avoiding LRT. Both retrospective and prospective studies suffer several limitations, ranging from selection bias and outdated ST to a small sample of patients. In this review we discuss available data and try to identify subgroups of patients which could benefit the most from LRT of the primary, to facilitate clinical practice decisions, and to hypothesize future studies design on this topic.

Radiotherapy of the Primary Disease for Synchronous Metastatic Cancer: A Systematic Review

In the case of synchronous metastatic disease, the local treatment of primary tumors by radiotherapy has long been reserved for palliative indications. The emergence of the concept of oligometastatic and oligopersistent diseases, the advent of new systemic therapies enabling longer overall survival with an enhanced quality of life, a better understanding of the biologic history of metastatic spread, and technical advances in radiation therapy are revolutionizing the management of patients with de novo metastatic cancer. The prognosis of these patients has been markedly improved and many studies have investigated the survival benefits from the local treatment of various primary tumors in cases of advanced disease at the time of diagnosis or in the case of oligopersistence. This article provides an update on the place of irradiation of the primary tumor in cancer with synchronous metastases, and discusses its interest through published or ongoing trials.

Local treatment improves survival in patients with stage IVB cervical cancer

OBJECTIVE

To evaluate the value of local treatment in stage IVB cervical cancer (CC).

METHODS

Patients diagnosed with stage IVB CC between 2010 and 2015 were included using the data from the Surveillance, Epidemiology, and End Results program. Propensity score matching (PSM) was used to balance the clinicopathological variables of patients. Multivariate Cox regression analyses were performed to analyze the risk factors associated with cause-specific survival (CSS).

RESULTS

We identified 960 patients in this study, all patients had received chemotherapy. Of these patients, 818 patients were treated with local treatment (85.2%), including 724 (88.5%) and 94 (11.5%) patients receiving radiotherapy (RT) alone and surgery ± RT, respectively. Local treatment was the independent prognostic factor associated with better CSS. Before PSM, patients who received RT (hazard ratio [HR] 0.633, 95% confidence interval [CI] 0.517-0.775, P < 0.001) or surgery (HR 0.391, 95% CI 0.277-0.552, P < 0.001) were independently associated with a better CSS compared to those with no local treatment. The 3-years CSS rate was 14.4%, 32.4%, and 54.8% in no local treatment, RT alone, and surgery groups, respectively (P < 0.001). Similar results were found after PSM. Patients receiving RT (HR 0.643, 95% CI 0.436-0.947, P = 0.025) and surgery (HR 0.146, 95% CI 0.052-0.410, P < 0.001) had better CSS compared to patients with no local treatment after PSM. While similar CSS was shown between RT alone cohort and the surgery cohort (HR 0.756, 95% CI 0.454-1.260, P = 0.284).

CONCLUSIONS

The addition of local surgery or RT to chemotherapy appears to confer improved survival outcomes in patients with stage IVB CC.

Early Local Therapy for the Primary Site in De Novo Stage IV Breast Cancer: Results of a Randomized Clinical Trial (EA2108)

PURPOSE

Distant metastases are present in 6% or more of patients with newly diagnosed breast cancer. In this context, locoregional therapy for the intact primary tumor has been hypothesized to improve overall survival (OS), but clinical trials have reported conflicting results.

METHODS

Women presenting with metastatic breast cancer and an intact primary tumor received systemic therapy for 4-8 months; if no disease progression occurred, they were randomly assigned to locoregional therapy for the primary site (surgery and radiotherapy per standards for nonmetastatic disease) or continuing sysmetic therapy. The primary end point was OS; locoregional control and quality of life were secondary end points. The trial design provided 85% power to detect a 19.3% absolute difference in the 3-year OS rate in randomly assigned patients. The stratified log-rank test and Cox proportional hazards model were used to compare OS between arms. Cumulative incidence of locoregional progression was compared using Gray's test. Quality-of-life assessment used standard instruments.

RESULTS

Of 390 participants enrolled, 256 were randomly assigned: 131 to continued systemic therapy and 125 to early locoregional therapy. The 3-year OS was 67.9% without and 68.4% with early locoregional therapy (hazard ratio = 1.11; 90% CI, 0.82 to 1.52; P = .57). The median OS was 53.1 months (95% CI, 47.9 to not estimable) in the systemic therapy arm and 54.9 months (95% CI, 46.7 to not estimable) in the locoregional therapy arm. Locoregional progression was less frequent in those randomly assigned to locoregional therapy (3-year rate: 16.3% v 39.8%; P < .001). Quality-of-life measures were largely similar between arms.

CONCLUSION

Early locoregional therapy for the primary site did not improve survival in patients presenting with metastatic breast cancer. Although it was associated with improved locoregional control, this had no overall impact on quality of life.

Surgery No More? Managing the Primary Tumor in Stage IV Breast Cancer

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

OUP accepted manuscript

Purpose

About 10% of breast cancer (BC) is diagnosed in stage IV. This study sought to identify factors associated with time to progression (TTP) and overall survival (OS) in a cohort of patients diagnosed with de novo metastatic breast cancer (MBC), from a single cancer center in Colombia, given that information on this aspect is limited.

Methodology

An observational, analytical, and retrospective cohort study was carried out. Time to progression and OS rates were estimated using the Kaplan–Meier survival functions. Cox models were developed to assess association between time to progression and time to death, using a group of fixed variables.

Results

Overall, 175 patients were included in the study; 33.7% of patients had luminal B HER2-negative tumors, 49.7% had bone involvement, and 83.4% had multiple metastatic sites. Tumor biology and primary tumor surgery were the variables associated with TTP and OS. Patients with luminal A tumors had the lowest progression and mortality rates (10 per 100 patients/year (95% CI: 5.0-20.0) and 12.6 per 100 patients/year (95% CI: 6.9-22.7), respectively), and patients with triple-negative tumors had the highest progression and mortality rates (40 per 100 patients/year (95% CI: 23.2-68.8) and 44.1 per 100 patients/year (95% CI: 28.1-69.1), respectively). Across the cohort, the median TTP was 2.1 years (95% CI: 1.6; the upper limit cannot be reached) and the median OS was 2.4 years (95% CI: 2-4.3).

Conclusions

In this cohort, patients with luminal A tumors and those who underwent tumor surgery given that they presented clinical benefit (CB) after initial systemic treatment, had the lowest progression and mortality rates. Overall, OS was inferior to other series due to high tumor burden and difficulties in accessing and continuing oncological treatments.

Impact of surgery on survival in breast cancer with bone metastases only: a SEER database retrospective analysis

BACKGROUND

It was controversial to operate on the primary site of breast cancer (BC) with bone metastasis only. We investigated the impact of surgery on BC patients with bone metastases via a SEER database retrospective analysis.

METHODS

A total of 2917 BC cases with bone metastasis, first diagnosed between 2010 and 2015 in the Surveillance, Epidemiology, and Results Database (SEER) of National Cancer Institute were selected. We assessed the effect of different surgical procedures on survival and prognosis.

RESULTS

Compared with the non-surgical group, the primary tumor surgical group showed longer median survival time (χ2 = 146.023, P < 0.001), and the breast-conserving subgroup showed the highest median survival time of 70 months (χ2 = 157.117, P < 0.001). Compared with the non-surgery group, the median overall survival (OS) of primary surgery group was longer (HR = 0.525, 95%CI = 0.467-0.590, P < 0.001), and the breast-conserving subgroup showed the longest median operative OS (HR = 0.394, 95%CI = 0.325-0.478, P < 0.001).

CONCLUSION

This study showed that primary surgery could improve the median survival time and OS of BC patients with bone metastasis. Moreover, under the condition of low tumor burden, breast conserving surgery was a better choice.

Primary tumor resection in patients with stage IV breast cancer: 10-year experience

The role of surgery in the management of stage IV breast cancer is controversial. Existing studies in Stage IV breast cancer have not closely evaluated the role of patient response to induction systemic therapy (IST) in its relationship to survival outcomes. We identified all patients with a diagnosis of de novo stage IV breast cancer who underwent surgery of their primary tumor from January 2008 to December 2018. Patients were grouped according to their response in the primary disease site into progression (progressive primary disease) or no progression (nonprogressive primary; comprising complete, partial and stable response). We identified a total of 45 stage IV breast cancer patients who underwent operative intervention of their primary breast tumor. Prior to surgical intervention, progression in the primary site during IST was identified in 13/42 patients (31%), of whom four patients also had progression in the distant disease. The 5-year survival was higher in the nonprogressive primary (74%) than the progressive primary disease group (52%) which did not reach statistical significance (p = 0.08). Age, pathologic tumor size, clinical nodal status, number of positive lymph nodes, and distant disease response to systemic therapy were significantly associated with survival. In this single institution experience, select patients with stage IV breast cancer at initial diagnosis who underwent resection of the primary tumor following systemic therapy achieved favorable overall and distant progression-free survival. Surgery is reasonable to consider for local palliation or in selected patients who have excellent response to systemic therapy and good performance status.

Primary Surgery with Systemic Therapy in Patients with de Novo Stage IV Breast Cancer: 10-year Follow-up; Protocol MF07-01 Randomized Clinical Trial

BACKGROUND

The aim of this randomized clinical trial was to evaluate the overall survival (OS) data of patients diagnosed with de novo stage IV breast cancer (BC) who received locoregional treatment (LRT) over a 10-year follow-up.

STUDY DESIGN

The MF07-01 is a 1:1 multicenter, randomized clinical trial comparing the LRT with systemic therapy (ST), where ST was given to all patients either immediately after randomization or after surgical resection of the intact primary tumor.

RESULTS

A total of 278 patients were randomized and 265 patients were in the final analysis. At 10-year follow-up, survivals were 19% (95% CI 13%-28%) and 5% (95% CI 2%-12%) in the LRT group and ST group, respectively. Median survival was 46 months for the LRT group and 35 months for the ST group, and hazard of death was 29% lower in the LRT group compared with the ST group (hazard ratio [HR] 0.71; 95% CI 0.59-0.86; p = 0.0003).

CONCLUSIONS

Patients with a diagnosis of de novo stage IV BC who underwent LRT followed by ST had a 14% higher chance of OS by the end of the 10-year follow-up compared with the patients who received only ST. The longer study follow-up revealed that LRT should be presented to patients when discussing treatment options.

The Effect of Primary Surgery in Patients with De Novo Stage IV Breast Cancer with Bone Metastasis Only (Protocol BOMET MF 14-01): A Multi-Center, Prospective Registry Study

BACKGROUND

More evidence shows that primary surgery for de novo metastatic breast cancer (BC) prolongs overall survival (OS) in selected cases. The aim of this study was to evaluate the role of locoregional treatment (LRT) in BC patients with de novo stage IV bone only metastasis (BOM).

METHODS

The prospective, multicenter registry study BOMET MF14-01 was initiated in May 2014. Patients with de novo stage IV BOM BC were divided into two groups: those receiving systemic treatment (ST group) and those receiving LRT (LRT group). Patients who received LRT were further divided into two groups: ST after LRT (LRT + ST group) and ST before LRT (ST + LRT group).

RESULTS

We included 505 patients in this study; 240 (47.5%) patients in the ST group and 265 (52.5%) in the LRT group. One hundred and thirteen patients (26.3%) died in the 34-month median follow-up, 85 (35.4%) in the ST group and 28 (10.5%) in LRT group. Local progression was observed in 39 (16.2%) of the patients in the ST group and 18 (6.7%) in the LRT group (p = 0.001). Hazard of death was 60% lower in the LRT group compared with the ST group (HR 0.40, 95% CI 0.30-0.54, p < 0.0001).

CONCLUSION

In this prospectively maintained registry study, we found that LRT prolonged survival and decreased locoregional recurrence in the median 3-year follow-up. Timing of primary breast surgery either at diagnosis or after ST provided a survival benefit similar to ST alone in de novo stage IV BOM BC patients.

The role of loco-regional treatment in long-term quality of life in de novo stage IV breast cancer patients: protocol MF07-01Q

BACKGROUND/OBJECTIVE

Since more solid evidence has emerged supporting the effectiveness of loco-regional treatment (LRT), clinicians consider LRT a treatment option for selected de novo stage IV breast cancer (BC) patients. This is the first report on long-term quality of life (QoL) in a cohort of patients who were randomized to receive either LRT and then systemic treatment (ST) or ST alone in the protocol MF07-01. We aimed to evaluate QoL in patients living at least 3 years since randomization using scores from the SF-12 health survey.

METHODS

SF-12 (V2) forms were completed during visits of patients who were living 36 months after the randomization. We first calculated PCS-12 (Physical Health Composite Scale) and MCS-12 (Mental Health Composite Scale) scores from de novo stage IV BC patients and compared them with the scores of patients diagnosed with stage I-III BC who lived more than 3 years. Further, PCS-12 and MCS-12 scores were compared between the LRT and ST groups with de novo stage IV BC. Additionally, general health, physical functioning, role functioning, bodily pain, vitality, mental health, and social functioning were evaluated and compared between the groups. Considering age-related changes in QoL, we also compared PCS-12 and MCS-12 scores of patients below or above 55 and 65 years of age. Responses to four additional questions (compare your physical health, mental health, daily activities, and energy currently vs. at diagnosis of BC) were recorded, considering cultural differences.

RESULTS

There were 81 patients in this analysis; 68% of patients (n = 55) had LRT, and 32% (n = 26) received ST. General health was good or very good in 62% (n = 34) in the LRT group and 66% (n = 17) in the ST-only group (p = 0.63). Mean PCS-12 score was 40.8 + 1.6, and mean MCS-12 score was 43.4 + 2.0 (p = 0.34 and p = 0.54, respectively). PCS-12 and MCS-12 score difference was lower than that of the general Turkish population (PCS-12 = 49.3 + 12.8 and MCS-12 = 46.8 + 13.0) and stage I-III BC patients (PCS-12 = 51.1 ± 0.5, MCS-12 = 45.7 ± 0.6). PCS-12 and MCS-12 scores were similar between the LRT and ST-only groups in patients younger and older than 55 and 65, but QoL scores were much better in stage I-III BC patients younger than 65 when compared to the scores of those with de novo stage IV BC. Although treatment with or without LRT did not affect physical health, mental health, daily activities, and energy at 3 years vs. at diagnosis of BC in de novo stage IV BC patients (p > 0.05), these variables were significantly better in stage I-III BC patients (p < 0.001).

CONCLUSION

The current MF07-01Q study demonstrates that patient who had LRT has similar physical and mental health outcomes compared to ST only in a cohort of patients who lived longer than 3 years. Trial registration This study is registered on clinicaltrials.gov with identifier number NCT00557986.

De novo Stage IV Luminal Breast Cancer: Yes or No for Local Treatment? Serial Cases and Review

BACKGROUND: Primary stage IV breast cancer accounts about of 3–5% of newly diagnosed breast cancer cases. The management of this patient subset mostly comprises systemic therapy, with additional surgery or radiotherapy to control locoregional symptoms. Some of the retrospective studies showed the benefit of locoregional treatment as the first treatment of choice for overall survival (OS), but the efficacy of primary site surgery remains controversial for OS in prospective, controlled trials. AIM: We aimed to presents series of cases with primary metastatic breast cancer with diffuse bone metastasis. MATERIALS AND METHODS: This study was serial of cases with primary metastatic breast cancer with diffuse bone metastasis and a review of the literature. All of the cases were treated with upfront surgical resection of the primary in the breast. RESULTS: During the follow-up period of 36 months, all of our patients were still alive. CONCLUSION: Retrospective studies about resection of primary tumor as the first treatment of choice are with conflicting results, which may be related to randomization bias, including different biological types of breast cancer, different metastatic sites, and patients with different menopausal status. On the other hand, prospective studies did not show any powerful results that would lead the treatment in de novo stage IV breast cancer because of few limitations such a short follow-up period (between 23 and 40 months), younger patients, ER-positive/HER2 negative tumors, and type of chemotherapy given or not upfront. The effect of upfront surgery in newly metastatic breast cancer patients is still challenging, so there is a need to identify the exact cohort of patients who could benefit from surgery.

Is Surgical Management of Primary Beneficial in Metastatic Breast Cancer??

Metastatic breast cancer is not a curable disease, but women with metastatic disease are living longer. Although the relative survival has improved in recent years still patients who present with metastatic disease have a less than 30% 5-year survival. Historically, removal of the primary breast tumor has been offered to these patients only for palliation. However, there have been recent reports that removal of the primary tumor may improve survival. These are mostly retrospective studies limited by selection bias. Prospective and randomized trials have not shown a clear survival advantage. Although the definitive role of removal of the primary tumor in metastatic breast cancer is not settled, it is critical to understand the complexities of this debate in order to make further gains in breast cancer survivorship.

Large Breast Tumor Ulceration and Quality of Life in an 80-Year-Old Woman

Advanced breast cancer with skin ulceration, bleeding, and odor is associated with impaired quality of life (QoL). In patients with metastatic breast cancer, treatment aims to relieve symptoms, improve QoL, and slow the progression of cancer. Occasionally, it is extremely difficult to alleviate symptoms and improve QoL in patients with breast cancer and skin ulceration, especially elderly patients. Since patient age, patient preferences, and the expected survival benefit from treatment are factors that influence the selection of therapy, physicians should provide an optimal treatment for patients with metastatic disease depending on the situation. In this study, we report the case of an elderly patient with metastatic breast cancer who had substantial skin ulceration. In this patient, multidisciplinary treatment including chemotherapy, radiotherapy, and surgery resulted in significantly improved QoL.

Impact of Primary Site Surgery on Survival of Patients with de novo Stage IV Breast Cancer

Purpose

The efficacy of primary site surgery in patients with de novo stage IV breast cancer remains controversial. However, few real-world studies have evaluated the benefits of local surgery on the primary site of stage IV breast cancer in China. The purpose of this study was to investigate the role of local surgery in the de novo stage IV breast cancer.

Materials and Methods

Women with metastatic breast cancer at diagnosis were identified from Guangxi medical university cancer hospital (China) database from 2009 to 2017. The clinical and tumor features, surgical treatment, and survival rates were compared between surgical and non-surgical patients.

Results

Two hundred forty-three patients were included, of whom 125 underwent primary site surgery. Patients who underwent surgery were more often had small primary tumors, fewer lymph node metastases, and had less visceral involvement. Patients in the surgery group had dramatically longer OS (median 35 vs 22 months, log-rank P=0.006). Stratified survival analysis showed that patients with bone metastasis alone or ≤3 metastasis benefit from surgery, while patients with visceral metastasis did not benefit from surgery. In multivariate analysis, surgical treatment, estrogen receptor status, progesterone receptor status and visceral metastases remained independent factors for survival.

Conclusion

Surgical resection of the primary site can improve survival in selected de novo stage IV breast cancer patients.

Different Breast Cancer Subtypes Show Different Metastatic Patterns: A Study from A Large Public Database

BACKGROUND

Receptor status in breast cancer is known to be related to survival. However, the relationship between breast cancer subtype, preferential sites of metastasis, and overall survival is not clear.

METHODS

A total of 414,528 patients from the National Cancer Database (2010-2013) were examined. All patients received surgery and systemic treatments. Breast cancer was subtyped based on hormonal receptor (HR) and HER2 status.

RESULTS

HR-/HER2+ breast cancer patients had the highest overall rate of metastasis while HR+/HER2- had the lowest. HR+/HER2+ cancer had the most frequent metastasis to the bone, and HR-/HER2+ to brain, liver, lung and multiple sites. Generally, patients with brain or multiple metastasis had the worst overall survival (OS) across different subtypes.  Patients with bone oligometastasis tend to have better OS than patients with metastasis to other site but significantly worse OS than patients without any metastasis.

CONCLUSIONS

This large study exhibits how breast cancer subtype plays a role in the rate and site of metastasis as well as in overall survival.  Surveillance and treatment strategies should be tailored on the risk and potential site of metastases based upon receptor subtype.

Is there a role for locoregional treatment of the primary tumor in de novo metastatic breast cancer in the era of tailored therapies?: Evidences, unresolved questions and a practical algorithm

Improvements in systemic therapies have changed the face of de novo metastatic breast cancer (dnMBC), with a 5-year survival rate exceeding 25 %. Increasing evidence suggests that a subset of patients could benefit from a locoregional treatment (LRT) with prolonged survival, although the diversity of publications on the subject make it difficult to draw any conclusions. In this review, we summarize the available data on retrospective, prospective and current ongoing clinical trials. Since factors such as tumor biology, pattern of metastatic dissemination and the timing of the treatment are closely linked to the therapeutic strategy, we focus on papers which include these aspects. We discuss recent studies indicating that exclusive radiotherapy provides results comparable with those obtained by surgery. We will then discuss the biological rationale for LRT. Finally, we propose a decision-tree to select the optimal candidates for LRT in dnMBC patients.

Role of locoregional surgery in patients with de novo stage IV breast cancer: analysis of real-world data from China

Stage IV breast cancer is metastatic breast cancer (MBC). Because real-world data are lacking in China, our research attempts to explore the effect of locoregional surgery on the prognosis of patients with MBC. A total of 987 patients from 10 hospitals and 2 databases in East China (2004–2018) were included in this study. Overall, 47% of patients underwent locoregional surgery, and 53% did not. Surgeons tended to perform surgery on patients with small tumours (T1/T2), positive hormone receptor (HR) markers, and metastatic sites confined to a single organ and non-visceral sites (bone only/others) (each p < 0.05). Kaplan–Meier survival curves and the log-rank test showed that median survival was longer for patients who had locoregional surgery than for those who did not (45.00 vs. 28.00 months; p < 0.001). Patients who underwent surgery after systemic treatment had better survival than those who underwent surgery immediately (p < 0.001). In most subgroups, overall survival (OS) was significantly longer in the surgery group than in the no-surgery group (each p < 0.05), except for brain metastases and triple negative breast cancer. Therefore, we concluded that locoregional surgery for the primary tumour in MBC patients was associated with a marked reduction in risk of dying except for patients with brain metastases or triple-negative subtype.

A nomogram for predicting survival in patients with de novo metastatic breast cancer: a population-based study

BACKGROUND

5-10% of patients are diagnosed with metastatic breast cancer (MBC) at the initial diagnosis. This study aimed to develop a nomogram to predict the overall survival (OS) of these patients.

METHODS

de novo MBC patients diagnosed in 2010-2016 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. They were randomly divided into a training and a validation cohort with a ratio of 2:1. The best subsets of covariates were identified to develop a nomogram predicting OS based on the smallest Akaike Information Criterion (AIC) value in the multivariate Cox models. The discrimination and calibration of the nomogram were evaluated using the Concordance index, the area under the time-dependent receiver operating characteristic curve (AUC) and calibration curves.

RESULTS

In this study, we included 7986 patients with de novo MBC. The median follow-up time was 36 months (range: 0-83 months). Five thousand three-hundred twenty four patients were allocated into the training cohort while 2662 were allocated into the validation cohort. In the training cohort, age at diagnosis, race, marital status, differentiation grade, subtype, T stage, bone metastasis, brain metastasis, liver metastasis, lung metastasis, surgery and chemotherapy were selected to create the nomogram estimating the 1-, 3- and 5- year OS based on the smallest AIC value in the multivariate Cox models. The nomogram achieved a Concordance index of 0.723 (95% CI, 0.713-0.733) in the training cohort and 0.719 (95% CI, 0.705-0.734) in the validation cohort. AUC values of the nomogram indicated good specificity and sensitivity in the training and validation cohort. Calibration curves showed a favorable consistency between the predicted and actual survival probabilities.

CONCLUSION

The developed nomogram reliably predicted OS in patients with de novo MBC and presented a favorable discrimination ability. While further validation is needed, this may be a useful tool in clinical practice.

Primary tumor removal improves the prognosis in patients with stage IV breast cancer: A population-based study (cohort study)

Adjuvant therapy including chemotherapy, hormonal therapy, and radiotherapy were often used as a common stereotypy for female stage IV breast cancer rather than surgery. This study aimed to define the role of local surgery in metastatic breast cancer. Female metastatic breast cancer patients were identified in the Surveillance, Epidemiology, and End Results (SEER) program data (2010-2013). We compared survival time between patients who received primary tumor removal (PTR) versus those who did not. Multivariate Cox regression models and competitive risk models were built to adjust potential confounders. Of 7669 female stage IV breast cancer patients, 2704 (35.3%) had surgery on their breast tumor and 4965 (64.7%) did not. In the entire cohort, women who underwent PTR had a 45% reduced risk of breast cancer-related death (multi-adjusted hazard ratio [HR], 0.55; 95% CI, 0.50 to 0.60) compared with women who did not undergo PTR (P < 0.001). In a cause-specific hazard model (CS model), the multivariable HRs (95% CI) for the association of PTR with breast cancer related-death were 0.54 (0.50-0.60) in the multivariate-adjusted analysis. Similar results were also observed in the sub-distribution hazard function model (SD model) with corresponding multivariate HRs (95%CI) of 0.57 (0.52-0.63). Our study suggested that PTR was associated with improved survival in female stage IV breast cancer patients. The role of PTR in these patients needs to be re-evaluated.

Breast Reconstruction in the Setting of Stage 4 Breast Cancer: Is It Worthwhile?

BACKGROUND

The role of reconstruction after primary tumor surgery for metastatic breast cancer remains controversial. This report describes the outcomes for patients undergoing mastectomy with and without reconstruction in the setting of de novo stage 4 breast cancer.

METHODS

Using a prospectively maintained institutional breast surgery database, this study identified all patients who presented with de novo stage 4 breast cancer from January 2008 to December 2018. Patients were included if they had undergone mastectomy with or without reconstruction. Patient, surgical characteristics, and survival outcomes were abstracted and analyzed.

RESULTS

The study identified 29 patients: 8 patients (28%) who underwent reconstruction (R) and 21 patients (72%) who did not (NR). Complete clinical response to induction systemic therapy was more frequent among patients in the R group than among those in the NR group for the primary disease (50% in R, 5% in NR), and to a lesser degree for distant disease (63% in R, 39% in NR). No difference in complication rates between the two groups was identified [n = 1 (13%) in R; n = 2 (10%) in NR; p = 1.0]. Overall survival from surgery was longer in the R group (100% at 2 and 5 years) than in the NR group [85%; 95% confidence interval (CI), 68-100% at 2 years vs 50%; 95% CI 27-91% at 5 years] (p = 0.046).

CONCLUSION

Breast reconstruction after mastectomy may be reasonable to consider for appropriately selected patients with de novo stage 4 breast cancer who have excellent responses to systemic therapy and anticipated durable survival.

[Treatment of primary disease with irradiation in case of de novo metastatic breast cancer]

Synchronous metastatic breast cancer accounts for 5 to 6% of all breast cancers in Western countries, which corresponds to nearly 2500 new cases per year in France. Irradiation of the primary tumour in cases of metastatic disease at diagnosis was historically reserved for palliative indications. However, progress in systemic treatments, a better understanding of the biological basis of metastatic dissemination, the genesis of the concept of oligometastatic disease and ablative treatments directed towards metastases are revolutionizing the management of patients with de novo stage IV breast cancer. Survival of these patients has improved markedly over the years, and several studies have investigated the carcinological benefit of local treatment of the breast tumour in patients with advanced diseases at diagnosis. This article provides an update on the role of irradiation of the primary tumour in breast cancer with synchronous metastases, and discusses its interest through published or ongoing trials.

Early Death Incidence and Prediction in Stage IV Breast Cancer

BACKGROUND The early death of patients is a global cancer issue. We aimed to identify the risk factors for early death in stage IV breast cancer. Predictive nomograms for early death evaluation were generated based on the risk factors. MATERIAL AND METHODS Based on the Surveillance, Epidemiology, and End Results (SEER) database, patients diagnosed with IV breast cancer were selected. The risk factors for early death (survival time ≤1 year) were identified using logistic regression model analysis. Predictive nomograms were constructed and internal validation was performed. RESULTS A total of 5998 (32.6%) breast cancer patients were diagnosed as early death in the construction cohort. Age older than 50 years, unmarried status, black race, uninsured status, triple-negative type, grade (II and III), tumor size >5 cm, and metastasis to lung, liver, and brain were risk factors for total early death, while Luminal B subtype, N1 stage, and surgical interventions were associated with lower risk of early death. As for cancer-specific and non-cancer-specific early death, several factors were not consistent between the 2 groups. Nomograms for all-cause, cancer-specific, and non-cancer-specific early death were constructed. The calibration curve showed satisfactory agreement. The areas under the ROC curve (AUC) were 78.3% (95% CI: 77.7-78.9%), 75.8% (75.1-76.4%), and 72.3% (71.6-72.9%), respectively. In the validation cohort, a total of 689 (19.3%) patients were diagnosed as early death and the calibration curve showed satisfactory agreement. The AUCs of the all-cause, cancer-specific, and non-cancer-specific early death prediction were 74.0% (95% CI: 72.5-75.4%), 73.5% (72.0-74.9%), and 68.6% (67.0-70.1%), respectively. CONCLUSIONS Nomograms were generated to predict early death, with good calibration and discrimination. The predictive model can provide a reference for identifying cases with high risk of early death among stage IV breast cancer patients and play an auxiliary role in guiding individual treatment.

Microwave ablation of primary breast cancer inhibits metastatic progression in model mice via activation of natural killer cells

Surgery is essential for controlling the symptoms and complications of stage IV breast cancer. However, locoregional treatment of primary tumors often results in distant progression, including lung metastasis, the most common type of visceral metastasis. As a minimally invasive thermal therapy, microwave ablation (MWA) has been attempted in the treatment of breast cancer, but the innate immune response after MWA has not yet been reported. Using two murine models of stage IV breast cancer, we found that MWA of primary breast cancer inhibited the progression of lung metastasis and improved survival. NK cells were activated after MWA of the primary tumor and exhibited enhanced cytotoxic functions, and the cytotoxic pathways of NK cells were activated. Depletion experiments showed that NK cells but not CD4+ or CD8+ T cells played a pivotal role in prolonging survival. Then, we found that compared with surgery or control treatment, MWA of the primary tumor induced completely different NK-cell-related cytokine profiles. Macrophages were activated after MWA of the primary tumor and produced IL-15 that activated NK cells to inhibit the progression of metastasis. In addition, MWA of human breast cancer stimulated an autologous NK-cell response. These results demonstrate that MWA of the primary tumor in metastatic breast cancer inhibits metastatic progression via the macrophage/IL-15/NK-cell axis. MWA of the primary tumor may be a promising treatment strategy for de novo stage IV breast cancer, although further substantiation is essential for clinical testing.

Primary tumor resection in de novo stage IV breast cancer patients

Breast and axillary surgery in Stage IV disease is outside current national guidelines but has been a topic of ongoing debate. A single institution retrospective study identified women with de novo stage IV BC from 2011-2016 to evaluate the rate and goals of primary site surgery. Only 10.2% (n = 27/265patients) had primary site surgery. The goal of surgery was most often treatment intent (n = 23, 85.1%) not palliation (n = 4, 14.8%). There was no 30-day mortality and low (n = 1, 3.7%) 30-day morbidity. Multi-disciplinary patient care pathways based on modern evidence may help identify patients potentially suitable for primary site surgery.

Primary Tumor Surgery for Patients with De Novo Stage IV Breast Cancer can Decrease Local Symptoms and Improve Quality of Life

BACKGROUND

It was unknown whether surgery for primary tumor would affect the occurrence of local symptoms caused by tumor progression in patients with de novo stage IV breast cancer (BC). Our work attempted to probe the effect of local resection on controlling local symptoms and improving the quality of life in de novo stage IV BC patients.

METHODS

Our study included patients presenting with de novo stage IV BC at the Cancer Hospital of the Chinese Academy of Medical Sciences from January 2008 to December 2014. In this study, we defined a new term called "local progress/recurrence of symptoms" (LPRS) to refer to the local problems caused by tumor progression/recurrence. All the patients were grouped into surgery and non-surgery groups. The characteristics of the two groups were analyzed by Chi square and Fisher's test. Univariate and multivariate Cox regression models were designed to evaluate independent prognostic factors.

RESULTS

This study contained 177 patients. The follow-up deadline was April 1, 2019. The median follow-up time was 33 months (range 1-135 months). In included patients, 77 (43.5%) underwent surgery for primary tumors. Primary tumor surgery could reduce the occurrence of LPRS (relative risk/risk ratio (RR = 0.440; 95% CI 0.227-0.852; p = 0.015)) and patients without LPRS had longer OS (45 months vs 29 months, p < 0.001). In addition, patients who had only one symptom had better OS than those who had two or three symptoms (p = 0.0175).

CONCLUSIONS

The quality of life in patients with de novo stage IV breast cancer can be improved by reducing the incidence of local symptoms through primary tumor surgery.

The Impact of Primary Tumor Surgery on Survival in HER2 Positive Stage IV Breast Cancer Patients in the Current Era of Targeted Therapy

OBJECTIVE

We sought to examine the impact of primary tumor resection on survival in HER2+ stage IV breast cancer patients in the era of HER2 targeted therapy.

METHODS

We conducted a retrospective cohort study of women with HER2+ stage IV breast cancer in the National Cancer Database from 2010 to 2012 comparing those who did and did not undergo definitive breast surgery.

RESULTS

Of 3231 patients, treatment included primary site surgery in 35.0%; chemo/targeted therapy in 89.4%; endocrine therapy in 37.7%; and radiation in 31.8%. Surgery was associated with Medicare/other government (OR 1.36, 95% CI 1.03-1.81) or private insurance (OR 1.93, 95% CI 1.53-2.42) versus none/Medicaid, radiation (OR 2.10, 95% CI 1.76-2.51), chemo/targeted therapy (OR 1.99, 95% CI 1.47-2.70), and endocrine therapy (OR 1.73, 95% CI 1.40-2.14). Non-Hispanic Black versus White patients (OR 0.68, 95% CI 0.53-0.87) were less likely to have surgery. Overall mortality was associated with insurance (Medicare/other government versus none/Medicaid, HR 0.36, p < 0.0001), receipt of chemo/targeted therapy (HR 0.76, p = 0.008), endocrine therapy (HR 0.70, p = 0.0006), and radiation therapy (HR 1.33, p = 0.0009), NH Black versus White race/ethnicity (HR 1.39, p = 0.002), visceral versus bone-only metastases (HR 1.44, p = 0.0003), and lowest versus highest income quartile (HR 1.36, p = 0.01). Propensity score analysis showed surgery was associated with improved survival versus no surgery (HR 0.56, 95% CI 0.40-0.77).

CONCLUSIONS

Surgery of the primary site for metastatic HER2+ breast cancer is associated with improved overall survival in selected patients.

Locoregional therapy of the primary tumour in de novo stage IV breast cancer in 216 066 patients: A meta-analysis

Patients presenting with de novo stage IV metastatic breast cancer have a complex disease which is normally treated with palliative intent and systemic therapy. However, there is mounting evidence that resection of the primary tumour and/or localised radiotherapy (locoregional therapy; LRT) could be associated with overall survival improvements. We aimed to conduct a meta-analysis to inform decision making. Using the PubMed, Cochrane and Ovid SP databases, a literature review and meta-analysis were conducted to assess the effect of LRT on overall survival. Studies were analysed for the impact of LRT on survival. All forms of LRT resulted in a significant 31.8% reduction in mortality (N = 42; HR = 0.6823 (95% CI 0.6365; 0.7314)). Surgical resection resulted in a significant 36.2% reduction in mortality (N = 37; HR = 0.6379 (95% CI 0.5974; 0.6811)). The prospective trials reported a 19.23% reduction in mortality which was not statistically significant (N = 3, HR = 0.8077 (95% CI 0.5704; 1.1438). 216 066 patients were included. This is the largest meta-analysis regarding this question to date. Our meta-analysis shows that LRT of the primary tumour seems to improve overall survival in de novo stage IV disease. Therefore, this therapeutic option should be considered in selected patients after a careful multidisciplinary discussion.

The Impact of Locoregional Treatment on Survival in Patients With Metastatic Breast Cancer: A National Cancer Database Analysis

BACKGROUND

Although systemic therapy is the standard treatment for metastatic breast cancer, the value of locoregional treatment (LRT) of the primary tumor and its impact on survival is controversial. This study evaluates survival outcomes in patients with metastatic breast cancer after receiving LRT (surgery and/or radiation therapy) of the primary tumor.

MATERIALS AND METHODS

The National Cancer Database was used to identify 16,128 qualifying cases of metastatic breast cancer who received systemic therapy with or without LRT from 2004 to 2013. Treatment modality was divided into surgery (Sx), radiation therapy (RT), surgery followed by RT (Sx + RT), and no LRT. The median survival and 3-year actuarial survival rates (OS) were analyzed for each treatment group. On multivariate analyses, adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using Cox regression modeling to adjust for patient and clinicopathologic characteristics.

RESULTS

Overall, the median follow-up was 28.3 months, and the median survival for all patients was 37.2 months. With 9761 deaths reported, the estimated 3-year OS was 51.3%. The Sx + RT group (n = 2166) had the highest 3-year OS of 69.4%, followed by the Sx group (n = 4293) with 57.6%, the no LRT group (n = 8955) with 44.3%, and the RT group (n = 714) with 41.5% (P < .0001). On multivariate analysis, compared with the no LRT group, a decreased HR was noted in patients receiving Sx (adjusted HR, 0.68; 95% CI, 0.65-0.71; P < .0001) and Sx + RT (adjusted HR, 0.46; 95% CI, 0.43-0.49; P < .0001).

CONCLUSION

LRT, especially surgery followed by RT, in addition to systemic therapy, was associated with improved survival in patients with metastatic breast cancer.

Establishing a predicted model to evaluate prognosis for initially diagnosed metastatic Her2-positive breast cancer patients and exploring the benefit from local surgery

BACKGROUND

For patients initially diagnosed with metastatic Her2-positive breast cancer (MHBC), we intended to construct a nomogram with risk stratification to predict prognosis and to explore the role of local surgery.

METHODS

We retrieved data from the Surveillance, Epidemiology, and End Results (SEER) database. Kaplan-Meier (KM) method and log-rank test were used for the selection of significant variables. Cox regression analysis and Fine-Gray test were utilized to confirm independent prognostic factors of overall survival (OS) and breast cancer-specific survival (BCSS). A nomogram predicting 1-year, 3-year, and 5-year OS was developed and validated. Patients were stratified based on the optimal cut-off values of total personal score. KM method and log-rank test were used to estimate OS prognosis and benefit from local surgery and chemotherapy.

RESULTS

There were 1680 and 717 patients in the training and validation cohort. Age, race, marriage, T stage, estrogen receptor (ER) status, visceral metastasis (bone, brain, liver and lung) were identified as independent prognostic factors for OS and BCSS, while histology was also corelated with OS. C-indexes in the training and validation cohort were 0.70 and 0.68, respectively. Calibration plots indicated precise predictive ability. The total population was divided into low- (<141 points), intermediate- (142-208 points), and high-risk (>208 points) prognostic groups. Local surgery and chemotherapy brought various degrees of survival benefit for patients with diverse-risk prognosis.

CONCLUSIONS

We constructed a model with accurate prediction and discrimination. It would provide a reference for clinicians' decision-making. Surgery on the primary lesion was recommended for patients with good physical performance status, while further study on optimal surgical opportunity was needed.

Surgical Resection of the Primary Tumor in Women With De Novo Stage IV Breast Cancer: Contemporary Practice Patterns and Survival Analysis

OBJECTIVE

We evaluated patterns of surgical care and their association with overall survival among a contemporary cohort of women with stage IV breast cancer.

BACKGROUND

Surgical resection of the primary tumor remains controversial among women with stage IV breast cancer.

METHODS

Women diagnosed with clinical stage IV breast cancer from 2003 to 2012 were identified from the American College of Surgeons National Cancer Database. Those with intact primary tumors who were alive 12 months after diagnosis were categorized by treatment sequence: (1) surgery before systemic therapy, (2) systemic therapy before surgery, and (3) systemic therapy alone. Multivariate logistic regression was used to estimate the association of treatment sequence with surgery type. Overall survival was estimated using multivariate Cox proportional hazards models.

RESULTS

Among 24,015 women, 56.2% (13,505) underwent systemic therapy alone and 43.8% (10,510) underwent surgical resection. Rates of surgery decreased slightly over time (43.1% in 2003 to 41.9% in 2011). Treatment with systemic therapy before surgery was associated with larger tumor size (median 4.5 vs 3.1 cm, P < 0.001) and receipt of mastectomy (81.4% vs 52.2%, P < 0.001) when compared to those who underwent surgery first. Receipt of surgery, whether before or after systemic therapy (Hazard Ratio, 0.68; 95% confidence interval, 0.62-0.73; Hazard Ratio, 0.56; 95% confidence interval, 0.52-0.61; P < 0.001), was independently associated with improved adjusted overall survival when compared to systemic therapy alone.

CONCLUSIONS

Surgical resection of the primary tumor occurs in almost half of women with stage IV breast cancer alive 1 year after diagnosis, and is increasingly occurring after systemic therapy. Coordinated multidisciplinary care remains highly relevant in the setting of metastatic breast cancer, where surgical decisions should be made on an individual basis and may affect survival in select women.

Surgery and survival in patients with stage IV breast cancer

BACKGROUND

Retrospective studies have shown some improvement in survival for patients receiving surgical management of the intact primary tumor in patients with presenting with Stage IV disease, while prospective studies have revealed mixed results.

METHODS

An examination of the NCDB from 2004-2013 was undertaken to examine factors related to the utilization of surgery and overall survival in patients with de novo Stage IV disease. Univariate and multivariable analyses were conducted to determine factors related to survival. Propensity score matching method was implemented to balance patients' baseline characteristics.

RESULTS

A total of 11 694 patients with Stage IV breast cancer at diagnosis met inclusion criteria. Surgical intervention occurred in 5202 patients (44.5%), with the use of surgery decreasing throughout the study period (53.6% surgery 2004-2006; 31.8% surgery 2011-2013). Selection for surgical intervention was associated with small tumors (T1) and a higher nodal burden (N2/3). Uninsured patients, those treated at academic centers, those treated in the Northeast, and those with hormone receptor positive tumors were less likely to undergo surgery. Surgery was independently associated with a better overall survival. Propensity score matching revealed a persistent survival advantage for surgical patients receiving surgery, regardless of the receipt of systemic therapy.

CONCLUSIONS

Surgery on the intact primary tumor for patients presenting with de novo Stage IV breast cancer is associated with improved overall survival. Surgical resection in patients with Stage IV breast cancer should be considered for well-selected patients as a part of multimodality therapy.

Treatment Patterns Among De Novo Metastatic Cancer Patients Who Died Within 1 Month of Diagnosis

BACKGROUND

Little is known about patterns of and factors associated with treatment for de novo metastatic cancer patients who die soon after diagnosis. In this study, we examine treatment patterns for patients newly diagnosed with metastatic lung, colorectal, breast, or pancreatic cancer who died within 1 month of diagnosis.

METHODS

We identified 100 848 adult patients in the National Cancer Database with de novo metastatic lung, colorectal, breast, and pancreatic cancer, diagnosed between 2004 and 2014 and who died within 1 month. We performed descriptive and multivariable logistic regression analyses to examine receipt of surgery, chemotherapy, radiation, and hormonal therapy by cancer type, adjusting for sociodemographic and clinical variables.

RESULTS

Treatment substantially varied by cancer type, over time, age, insurance, and facility type. Surgery ranged from 0.4% in pancreatic to 28.3% in colorectal cancer (CRC) patients, chemotherapy from 5.8% among CRC to 11% in lung and breast cancer patients, and radiotherapy from 1.3% in pancreatic to 18.7% in lung cancer patients. Use of some treatments (eg, surgery for CRC and breast cancer) progressively declined between 2004 and 2014. Compared with lung cancer patients treated at National Cancer Institute-designated cancer centers, those treated at community cancer centers had 48% lower odds of radiation.

CONCLUSIONS

Treatment of patients diagnosed with imminently fatal de novo metastatic cancer varied markedly by cancer type and patient/facility characteristics. These variations warrant more research to better identify patients with imminently fatal de novo metastatic cancer who may not benefit from aggressive and expensive therapies.

Locoregional surgical treatment improves the prognosis in primary metastatic breast cancer patients with a single distant metastasis except for brain metastasis

BACKGROUND

We aimed to validate the clinical significance of locoregional surgery in improving the prognosis of primary metastatic breast cancer (pMBC).

METHODS

We conducted a population-based retrospective study by analyzing clinical data obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database. Stratification analysis was employed to assess the effect of breast surgery on breast cancer-specific survival and overall survival. Then propensity score matching and COX regression models were employed to evaluate the survival advantages of breast surgery, if any in patients with pMBC.

RESULTS

The median BCSS and OS in the surgery group were almost twice of that in the group without surgery. Breast surgery provided a survival advantage for patients with a single metastasis in the bone, liver or lung, but not in the brain. We found that axillary lymph node dissection performed in combination with specific breast surgical procedures did not result in a significant improvement in survival. Additionally, when combined with radiotherapy and/or chemotherapy, surgery significantly improved the survival and was not influenced by the molecular subtype and tumor size. Finally, using COX regression models before and after propensity score matching, breast surgery was found to reduce the risk of mortality in patients with MBC by more than 40%.

CONCLUSIONS

The effect of locoregional surgery has been underestimated in pMBC patients. Surgical procedures should be seriously considered when planning combination treatments for pMBC patients with a single metastasis except for brain metastasis.

Survival impact of primary site surgery on metastatic breast cancer patients at diagnosis

BACKGROUND

Stage IV breast cancer was considered to be an incurable disease. Primary site surgery used to be reserved to control local complications. In the present study, we compared the survival of women who received therapeutic breast surgery for stage IV breast cancer at initial diagnosis to the survival of those who did not.

METHODS

Two French hospitals databases were retrospectively screened from 2005 to 2012. We identified all women with metastatic breast cancer at diagnosis. Patients' data were obtained by a review of their medical history. Data were analyzed according the four breast cancer subtypes (luminal A, luminal B, her 2 and triple negative).

RESULTS

One hundred thirty nine women were included, of whom 69 had primary site surgery. TNM stage and phenotypes of breast cancer were comparable in the two groups but operated women were younger than women who did not (p<0.0001). Average follow-up was 31±23.3 months [1-97]. Through logistic regression, we observed that tumor resection decreased death hazard ratio vs no surgery: HR 0.33, 95% CI [0.16-0.66] p=0.001. In the surgery group, there was no survival difference if women received chemotherapy (p=0.23). There were more patients with only one metastatic site in the surgery group (p=0.002) and they had been more treated with systemic therapy. When we compared tumor phenotypes individually, surgery increased survival on luminal A breast cancer patients (p<.0001).

CONCLUSION

Women with luminal A breast cancer and synchronous metastasis seemed to benefit from surgery. The development of a national reporting system or registers for outcomes would facilitate the investigation of the disease across a multitude of aspects of stage IV breast cancer.

Primary tumor resection in stage IV breast cancer: A systematic review and meta-analysis

OBJECTIVE

The impact of primary tumor resection (PTR) on survival is still controversial in stage IV breast cancer. This systematic review and meta-analysis aimed to evaluate the impact of PTR on overall survival (OS) in stage IV breast cancer.

METHODS

Comprehensive literature search was conducted to identify studies comparing PTR with no PTR for stage IV breast cancer. The quality of the studies was assessed using Cochrane risk of bias tool and Newcastle-Ottawa Scale. We used subgroup and meta-regression analysis to assess the contribution of demographic and clinical factors to heterogeneity.

RESULTS

Data on 714 patients in 3 randomized controlled trials (RCTs) and 67,272 patients in 30 observational studies were included. One RCT was terminated early due to poor recruitment, and the remaining two RCTs' design were different, thus RCTs were only performed systematic review without meta-analysis. The pooled outcomes of 30 observational studies showed PTR significantly improved OS (HR = 0.65; 95%CI, 0.61 to 0.70, P < 0.001, I2 = 80%). Additionally, PTR was associated with better distant progression-free survival (HR = 0.42; 95%CI, 0.29 to 0.60) but did not impact progression-free survival. Subgroup analysis showed PTR benefit in patients who had only one metastatic site (HR = 0.62, 95%CI. 0.48 to 0.81), bone-only metastasis (HR = 0.61, 95%CI. 0.37 to 1.00), with negative margin (HR = 0.61, 95%CI. 0.58 to 0.65).

CONCLUSIONS

PTR should not be part of routine clinical practice in stage IV breast cancer but might be performed in selected patients. Our findings highlight PTR might be valuable in patients with limited disease burden or attaining clear margin.

Role of Operative Management in Stage IV Breast Cancer

The role of operative therapy in stage IV breast cancer continues to evolve with advances in therapy and improvements in survival among this population. Traditionally surgery was performed with palliative intent to alleviate symptoms related to the intact breast primary. Several retrospective studies have challenged this paradigm, demonstrating survival advantage with surgery in de novo metastatic disease. Prospective studies are ongoing and maturing data. A comprehensive approach to local therapy following systemic therapy may be beneficial to achieve improved survival outcome associated with stage IV- no evidence of disease and to decrease local failure in inflammatory breast cancer.