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

Inflammatory breast cancer, best practice in the community setting

Inflammatory breast cancer (IBC) is a rare and aggressive form of breast cancer typically diagnosed at advanced stages. Although many cases initially respond to conventional therapies, IBC remains refractory, with high risk of recurrence due to early dissemination, tumor heterogeneity, and complex microenvironmental factors. Despite advancements in treatment, IBC poses unique challenges, particularly in community healthcare settings, where implementation of current guidelines is often limited by disease complexity and evidence gaps. Multidisciplinary care is essential and should include education on therapeutic options, lymphedema management, financial navigations, and ongoing support. To support diagnostic consistency, a consensus-driven IBC Scoring System has been developed to help clinicians identify IBC more accurately using clinical features This paper reviews best practices for managing IBC in community settings, emphasizing practical, multidisciplinary strategies that improve outcomes and presenting a framework aligns with the realities of community healthcare to ensure patients receive the highest possible standard of care.

Overall survival of patients with de Novo HER2-positive metastatic breast cancer in the Netherlands from 2008 to 2017: A population-based cohort study of systemically treated patients

AIM

This study aims to determine whether real-world overall survival (OS) of patients with de Novo HER2-positive (HER2 +) metastatic breast cancer (MBC) in the Netherlands improved over time.

METHODS

Data of patients diagnosed with de Novo HER2 + MBC in 2008-2017 were retrieved from the Netherlands Cancer Registry. OS was estimated per two-year period using the Kaplan-Meier method and compared using the log-rank test for trend and the multivariable Cox proportional hazards analysis, adjusted for baseline characteristics and local therapy. First-given systemic and local therapy use was determined per two-year period.

RESULTS

Among 1458 patients included, 99 % (1452/1458) were female and 53 % (775/1458) aged 50-74 years at diagnosis. Comparing patients diagnosed with de Novo HER2 + MBC in 2008-2009 versus 2016-2017, the median OS improved from 30·9 months (95 %CI:25·0-35·4) to 57·3 months (95 %CI:46·7-68·1) (p-value for trend<0·001) (adjusted hazard rate ratio =0·49, 95 %CI:0·40-0·59). The use of any HER2-targeted therapy increased from 64 % (178/279) to 84 % (287/340), while the use of pertuzumab-based therapy increased from 0 % to 67 % (227/340) over the same period. The use of surgery remained stable over time, while radiotherapy use for both the primary tumour and metastases increased in recent years, from 16 % (44/279) and 15 % (42/279) in 2008-2009-22 % (76/340) and 26 % (88/340) in 2016-2017, respectively.

CONCLUSION

OS has doubled over ten years, for patients diagnosed with de Novo HER2 + MBC in the Netherlands between 2008 and 2017. No change in metastatic presentation was observed over time, suggesting the improved OS is most likely explained by treatment improvements.

Effect of locoregional surgery in primary tumors on overall survival in patients with de novo stage IV breast cancer: a systematic review and meta-analysis

Background

Due to the controversy in the therapeutic effect of locoregional surgery in primary tumors for patients with de novo stage IV breast cancer, the aim of this study was to evaluate the effect of locoregional surgery on overall survival in patients with de novo stage IV breast cancer.

Methods

A computer-based search of PUBMED, Embase, and American Society of Oncology (ASCO) annual meetings abstracts was conducted to identify the prospective trials of the combination of locoregional surgery in primary tumors and systemic therapy in comparison with standard systemic therapy alone for patients with de novo stage IV breast cancer. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated by universal inverse variance and combined across articles. Random-effects model and subgroup analyses were performed to ascertain the origin of this heterogeneity.

Results

A total of 2029 patients from 8 studies were included, with 1014 patients (49.98%) underwent locoregional surgery in primary tumors (surgery group) and 1015 ones (50.02%) with standard systemic therapy alone (no surgery group). Compared to patients in the no surgery group, participants with ER/PR positive breast cancer in the surgery group had improved overall survival (OS) (HR=0.77, 95%CI 0.55-0.93, P=0.01), and improved locoregional progression-free survival (HR=0.36, 95%CI 0.14-0.95, P=0.04) for all participants in the surgery group. And patients with bone-only metastases in the surgery group had insignificantly favorable OS than those in no surgery group (HR=0.70, 95%CI, 0.47-1.04, P=0.08).

Conclusion

Our study demonstrated that locoregional surgery in primary tumors was associated with improved OS for participants with ER/PR positive de novo stage IV breast cancer, and locoregional surgery in primary tumors could be worthy of clinical recommendation for patients with ER/PR positive de novo stage IV breast cancer.

Adding Metastasis-Directed Therapy to Standard-of-Care Systemic Therapy for Oligometastatic Breast Cancer (EXTEND): A Multicenter, Randomized Phase 2 Trial

PURPOSE

Prior evidence suggests a progression-free survival (PFS) benefit from adding metastasis-directed therapy (MDT) to standard-of-care (SOC) systemic therapy for patients with some oligometastatic solid tumors. Randomized trials testing this hypothesis in breast cancer have yet to be published. We sought to determine whether adding MDT to SOC systemic therapy improves PFS in oligometastatic breast cancer.

METHODS AND MATERIALS

External Beam Radiation to Eliminate Nominal Metastatic Disease is a multicenter phase 2 randomized basket trial testing the addition of MDT to SOC systemic therapy in patients with ≤5 metastases (NCT03599765). Patients were randomly assigned 1:1 to MDT (definitive local treatment to all sites of disease, plus SOC systemic therapy) or to SOC systemic therapy-only. Primary endpoint was PFS, and secondary endpoints included overall survival, time to subsequent line of systemic therapy, and time to the appearance of new metastases. Exploratory analyses included quality of life and systemic immune response measures.

RESULTS

From September 2018 through July 2022, 22 and 21 patients were randomly assigned to the MDT and no-MDT arms, respectively. At a median follow-up of 24.8 months, PFS was not improved with the addition of MDT to SOC systemic therapy (median PFS 15.6 months MDT vs 24.9 months no-MDT [hazard ratio, 0.91; 95% CI, 0.34-2.48; P = .86]). Similarly, MDT did not improve overall survival, time to subsequent line of systemic therapy, or time to the appearance of new metastases (all P > .05). No significant differences were found in quality of life measures, systemic T-cell activation, or T-cell stimulatory cytokine concentration.

CONCLUSIONS

Among patients with oligometastatic breast cancer, the addition of MDT to SOC systemic therapy did not improve PFS. These findings suggest that MDT may have no systemic benefit in otherwise unselected patients with oligometastatic breast cancer, although this trial was limited by a heterogeneous and small sample size and overperformance of both treatment arms.

The impact of breast surgery and systemic therapy on the survival of patients with de novo stage IV breast cancer

BACKGROUND

Systemic therapy (ST) is essential for de novo stage IV breast cancer (BC). Stage IV BCs are highly heterogeneous, and it seems inappropriate to treat all de novo stage IV BCs equally. The survival benefit of surgery for primary sites in patients with de novo stage IV BC remains inconclusive.

PATIENTS AND METHODS

We investigated 220 patients with clinical de novo stage IV BC. The relationship between primary site surgery and overall survival (OS) was analyzed. Factors such as tumor subtype, timing of surgery, and efficacy of ST were also evaluated.

RESULTS

The median follow-up time was 37.9 (0.5-201.7) months. In the total cohort, the median OS of the patients with and without primary site surgery was 70.5 months (95% confidence interval [CI] 58.4-107.3) and 42.7 months (95% CI 35.7-48.8), respectively. The OS was significantly longer in patients who underwent primary site surgery, especially in the hormone receptor (HR) + /HER2- and HER2 + subtypes, but not in the triple-negative subtype. OS prolongation was significant in patients who underwent surgery ≥ 24 months after the first diagnosis and in whom the first-line ST was effective for ≥ 24 months. Primary site surgery was a good prognostic factor in both univariate and multivariate analyses.

CONCLUSIONS

The OS was significantly longer in patients with de novo stage IV BC who underwent primary site surgery than in those who did not undergo surgery. Our results suggest that the tumor subtypes, efficacy of ST, and timing of surgery influenced the benefits of surgery.

Quality of Life After Locoregional Treatment in Women with De Novo Metastatic Breast Cancer: A Systematic Review and Meta-Analysis

INTRODUCTION

Primary site locoregional treatment (LRT) of metastatic breast cancer has been performed and evaluated with the aim to improve survival, prevent complications, and alleviate local symptoms. As some studies fail to show a survival benefit, the quality of life is important to consider when deciding on LRT. The aim of this study was to evaluate and quantify the impact of LRT on the quality of life of patients with de novo metastatic breast cancer (dnMBC) through a systematic review of the literature and a meta-analysis.

METHODS

Multiple databases were searched on May 2024 with the following keywords: (i) dnMBC; (ii) LRT, including surgery +/- radiotherapy; and (iii) QOL.

RESULTS

Six studies were included in the qualitative synthesis and four in meta-analysis (481 women, n = 251 in the LRT and n = 230 in the control groups). There was a significant QOL decrease in the LRT group at 18 months (standardized mean difference [SMD] = -0.63; 95% confidence interval [CI] -0.98--0.26; p < 0.001, low heterogeneity I2 = 33%) and after 30 months (SMD -0.82; 95%CI -1.58--0.06; p = 0.034, high heterogeneity I2 = 93%), while no statistically significant difference was observed at short term (6 months, p = 0.333).

CONCLUSIONS

This study shows that there is lacking evidence regarding the QOL benefits after LRT in this population, and even a numerical deterioration in global QOL several months after the treatment. Future and ongoing research may provide additional insights into this question on dnMBC and specifics subgroups.

Case report: Unraveling a unique case of male occult breast cancer with axillary intricacies and a comprehensive literature dive

Male breast cancer is a rare neoplasm, accounting for approximately 1% of all breast cancer cases. It typically presents as a painless, retroareolar mass. An exceedingly rare variant is male occult breast cancer, which is primarily characterized by axillary lymph node enlargement without an identifiable primary breast tumor. We report an intriguing case of a septuagenarian patient diagnosed with male occult breast cancer. The patient presented with both axillary lymph node enlargement and an associated axillary skin ulcer, and was subsequently diagnosed with male occult breast cancer with metastases to the axillary and clavicular lymph nodes, as well as more distant sites. His treatment involved a multidisciplinary approach, including HER2-targeted therapy, chemotherapy, axillary lymph node dissection, and radiotherapy. Regular follow-ups have shown that his condition remains stable. Notably, this is the first documented case of male occult breast cancer with distant metastasis that was successfully treated with surgery and radiotherapy following systemic therapy. This case highlights the complex clinical presentation and management of male occult breast cancer. Our findings suggest that surgical intervention may be a feasible option post-downstaging by systemic therapy, even in the presence of distant metastases.

Therapeutic strategies for fungating and ulcerating breast cancers: A systematic review and narrative synthesis

BACKGROUND

To identify optimal therapeutic strategies for managing fungating, large or ulcerating breast tumors and highlight existing gaps in the literature.

METHODS

We conducted a systematic search of Medline, Embase, APA, PsycInfo, CAB abstracts, Scopus, and Web of Science from inception to June 30, 2024, including studies on patients with fungating, large, or ulcerating breast cancers.

RESULTS

The search identified 7917 studies, with 79 meeting the inclusion criteria: 62 case reports, 7 case series, and 10 cohort studies. Owing to high heterogeneity, a narrative synthesis was performed, categorizing treatment by year, molecular subtype, histology, and staging. We found that treatment modalities increased, from an average of two in luminal-B cancers to three in HER2-positive cases, with over half achieving complete response. Triple-negative breast cancers averaged two modalities, with around half showing only partial response. Cohort analysis revealed a significant positive correlation between metastasis rate and radiotherapy use (Spearman's rho = 0.828, p = 0.042) and between chemotherapy and hormonal therapy use (rho = 0.69, p = 0.04). Median survival was positively correlated with surgical treatment (rho = 0.82, p = 0.046).

CONCLUSIONS

Local treatment is crucial for symptomatic palliation in fungating or ulcerating breast tumors, and histology should guide therapeutic choices. While local treatments remain primary, emerging systemic therapies show promise and may soon become first-line options. As the first systematic review on this topic, our study faced considerable source heterogeneity, precluding a meta-analysis. Instead, we analyzed treatment trends by demographics and tumor characteristics, providing a comprehensive overview and encouraging further research in this area.

Local Control of Advanced Breast Cancer-Debate in Multidisciplinary Tumor Board

Background/Objectives: In Romania, breast cancer is the second most common cancer, the third leading cause of cancer death, and the most prevalent cancer overall. De novo advanced-stage breast cancer often presents in clinical practice, and treatment decisions are best made in a multidisciplinary tumor board (MTD) involving surgeons, radiotherapists, and medical oncologists. Significant advances in systemic therapies, particularly in progression-free survival (PFS) and overall survival (OS), have surpassed traditional palliative mastectomy and radiotherapy for local control. Therefore, the purpose of this study is to emphasize the importance of the initial choice of treatment for patient prognosis. Methods: We expose two cases of patients with de novo severe, advanced-stage, hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative breast cancer and their management and outcome using cyclin-dependent kinase (CDK) 4/6 inhibitor and radiotherapy. An extensive review of the literature from the past five years was also conducted. Results: The role of palliative mastectomy is diminishing, as many patients are opting for novel therapies, including cyclin-dependent kinase (CDK) 4/6 inhibitors, which may improve quality of life. Conclusions: First-line therapy for locally advanced breast cancer has suffered changes due to the implementation of systemic targeted therapy. However, drug resistance-either de novo or acquired-remains a critical consideration. MTD discussions and informed patient decisions are essential to achieving a personalized, evidence-based treatment outcome.

Machine learning-based prognostic modeling and surgical value analysis of de novo metastatic invasive ductal carcinoma of the breast

Whether primary lesion surgery improves survival in patients with de novo metastatic breast cancer (dnMBC) is inconclusive. We aimed to establish a prognostic prediction model for patients with de novo metastatic breast invasive ductal carcinoma (dnMBIDC) based on machine learning algorithms and to investigate the value of primary site surgery. The data used in our study were obtained from the Surveillance, Epidemiology, and End Results database (SEER, 2010-2021) and the First Affiliated Hospital of Nanchang University (1st-NCUH, June 2013-June 2023). We used COX regression analysis to identify prognostic factors. We divided patients into training and validation groups and constructed Extreme Gradient Boosting (XGBoost) prognostic prediction model. In addition, we used propensity score matching (PSM), K-M survival analysis, and COX regression analysis to explore the survival benefit of patients undergoing primary lesion surgery. A total of 13,383 patients were enrolled, with 13,326 from SEER and 57 from 1st-NCUH. The results showed that XGboost had good predictive ability (training set C-index = 0.726, 1 year AUC = 0.788, 3 year AUC = 0.774, 5 year AUC = 0.774; validation set C-index = 0.723, 1 year AUC = 0.785.1, 3 year AUC = 0.770, 5 year AUC = 0.764), which has better predictive power than the Coxph model. We used Shiny-Web to make our model easily available. Furthermore, we found that surgery was associated with a better prognosis in dnMBIDC patients. Based on the XGboost, we can accurately predict the survival of dnMBIDC patients, which can provide a reference for clinicians to treat patients. In addition, surgery may bring survival benefits to dnMBIDC patients.

Survival Impact of Postoperative Primary Area Radiotherapy on De Novo Metastatic Breast Cancer: A Retrospective Study

IntroductionThe role of radiotherapy (RT) in de novo metastatic breast cancer (dnMBC) patients undergoing surgery remains controversial due to limited evidence. This study aimed to evaluate the impact of postoperative radiotherapy on survival outcomes in this population.Materials and methodsWe retrospectively analyzed 102 dnMBC patients who underwent surgery at a provincial cancer hospital. Patients were grouped based on whether they received postoperative RT. Baseline characteristics were compared using the chi-square test. Kaplan-Meier analysis and Cox proportional hazards models were used to assess the prognostic impact of postoperative radiotherapy on local recurrence-free survival (LRFS), progression-free survival (PFS), and overall survival (OS).ResultsKM survival analysis showed that postoperative RT significantly improved LRFS (HR = 0.3634, 95%CI 0.1552-0.8508, p = .0197) and PFS (HR = 0.4903, 95%CI 0.3061-0.7855, p = .003) but had no significant effect on OS (HR = 0.7337, 95%CI 0.3514-1.508, p = .5395). Multivariate analysis identified postoperative RT as an independent protective factor for LRFS (HR = 0.265, 95%CI 0.088-0.795, p = .018) and PFS (HR = 0.525, 95%CI 0.313-0.882, p = .015). Subgroup analysis showed that for LRFS, RT had no significant interaction with different subgroup classification variables (all interaction p > .05). However, RT had a significant interaction with N stage for PFS (p = .016), specifically in N1-3 patients (HR = 0.384, 95% CI 0.221-0.668).ConclusionRT may improve disease control in selected dnMBC patients undergoing surgery, particularly those with lymph node metastasis. However, these findings still require further validation in larger, multicenter cohorts.

Unlocking survival benefits: primary tumor resection in de novo stage IV breast cancer patients

BACKGROUND

For patients with de novo stage IV breast cancer (BC), the conditions under which the primary tumor resection (PTR) may offer benefit remain unclear.

METHODS

The SEER database provides treatment data for patients with de novo stage IV BC. We screened cases of metastatic BC diagnosed from 2010 to 2015, with primary endpoints of overall survival (OS) and cancer-specific survival (CSS).

RESULTS

9252 patients with stage IV de novo BC were enrolled. For OS, median survival time (MST) was 38 months with systematic treatment (ST) compared to 52 months with ST plus PTR (p < 0.001). For CSS, MST was 38 months for ST versus 54 months for ST plus PTR (p < 0.001). The results of the Cox proportional hazards regression analysis regarding PTR, for OS: bone metastasis (aHR 0.664, 95%CI 0.583-0.756, p < 0.001); liver-lung metastasis (aHR 0.528, 95%CI 0.327-0.853, p = 0.009). For CSS: bone metastasis (aHR 0.655, 95%CI 0.571-0.751, p < 0.001); liver-lung metastasis (aHR 0.549, 95%CI 0.336-0.889, p = 0.017). Kaplan-Meier analysis indicated that in patients with bone metastases and liver-lung metastases, PTR could improve survival outcomes.

CONCLUSION

Liver-lung metastases and bone metastases in patients with de novo stage IV BC could enhance both OS and CSS through PTR.

Outcomes of De Novo Oligometastatic Breast Cancer Treated With Surgery of Primary and Metastasis Directed Radiotherapy

OBJECTIVES

With sensitive imaging for breast cancer, the question arises whether present-day oncologists treat dOMBC with palliative systemic therapy (ST), which, a few years earlier, would have been treated with curative intent. We retrospectively analyzed outcomes of dOMBC treated with curative intent using a combination of surgery, metastasis-directed radiotherapy (RT), and adjuvant/neoadjuvant ST and have also explored the possible role of total lesional glycolysis of metastases and p53 immunohistochemistry in predicting outcomes.

METHODS

Data were collected from a prospectively maintained database using electronic medical records and Radiation Oncology Information System. In the study, dOMBC was defined as up to 3 metastatic sites, all amenable to treatment with ablative RT and primary and axillary disease amenable to curative surgery. Patients were treated with surgery, ST, and RT.

RESULTS

Patients underwent either breast conservation surgery or modified radical mastectomy. Patients were treated with 6 to 8 cycles of chemotherapy in the neoadjuvant and/or adjuvant setting. Hormone receptor-positive patients received either tamoxifen or aromatase inhibitors. Trastuzumab was offered to Her-2-neu receptor-positive patients. RT included locoregional RT and metastases-directed ablative body RT. The median progression-free survival was 39 months (95% CI: -28.7 to 50.1 mo). Two and 3 year estimated disease-free survival (DFS) was 79% and 60.5%, respectively. The median overall survival was not reached. The estimated 3-year overall survival was 87.3%. Total lesional glycolysis of metastases score and p53 status did not affect DFS.

CONCLUSION

Combination treatment of surgery, metastases-directed ablative RT, and ST may provide prolonged DFS in dOMBC.

The effective duration of systemic therapy and the neutrophil-to-lymphocyte ratio predict the surgical advantage of primary tumor resection in patients with de novo stage IV breast cancer: a retrospective study

BACKGROUND

The primary tumor resection (PTR) of de novo stage IV breast cancer (DnIV BC) is controversial, and previous studies have suggested that the neutrophil-to-lymphocyte ratio (NLR) could be a poor-prognosis factor for BC. We investigated PTR's surgical advantage related to clinical outcomes, the surgery timing in responders to systemic therapy, and whether the NLR can predict the benefit of surgery for DnIV BC.

PATIENTS AND METHODS

We retrospectively analyzed the cases of the DnIV BC patients who received systemic therapies and/or underwent PTR at our institution between January 2004 and December 2022. Blood tests and NLR measurement were performed before and after each systematic therapy and/or surgery.

RESULTS

Sixty patients had undergone PTR local surgery (Surgery group); 81 patients had not undergone surgical treatment (Non-surgery group). In both groups, systemic treatment was performed as chemotherapy (95%) and/or endocrine therapy (92.5%) (p < 0.0001). The groups' respective median progression-free survival (PFS) durations were 88 and 30.3 months (p = 0.004); their overall survival (OS) durations were 100.1 and 31.8 months (p = 0.0002). The Surgery-group responders to systemic therapy lasting > 8.1-months showed significantly longer OS (p = 0.044). The PFS and OS were significantly associated with the use of postoperative systemic therapy (p = 0.0012) and the NLR (p = 0.018). A low NLR (≤ 3) was associated with significantly better prognoses (PFS and OS; p < 0.0001).

CONCLUSIONS

A longer effective duration of systemic therapy (> 8.1 months) and a low pre-surgery NLR (≤ 3.0) could predict PTR's surgical advantage for DnIV BC. These variables may help guide decisions regarding the timing of surgery for DnIV BC.

Deep neural network provides personalized treatment recommendations for de novo metastatic breast cancer patients

Background: It has long been controversial whether surgery should be performed for de novo metastatic breast cancer (dnMBC). The choice and timing of the primary tumor resection for dnMBC patients need to be individualized, but there was no tool to assist clinicians in decision-making. Methods: A 1:1:2 propensity score matching (PSM) was applied to examine the prognosis of dnMBC patients who underwent neoadjuvant systemic therapy followed by surgery (NS), surgery followed by chemotherapy (SC), and chemotherapy without surgery (CW). Then, two deep feed-forward neural network models were constructed to conduct personalized treatment recommendations. Results: The PSM-adjusted data showed that not all the dnMBC patients could benefit from surgery, and the advantages of NS and SC were different among various subgroups. Patients with stage T1-2, and pathological grade II tumors can be operated on directly, whereas those with stage T3-4, pathological grade III/IV diseases require NS. However, patients with grade I diseases, over 80 years of age, or with brain metastases could not benefit from surgery, regardless of whether they received neoadjuvant systemic therapy. Our deep neural network models exhibited high accuracy on both the train and test sets, one model can assist in deciding whether surgery is requested for dnMBC patient, if the surgery is necessary, another model can determine whether neoadjuvant systemic therapy is needed. Conclusion: This study investigated the prognosis of dnMBC patients, and two artificial intelligence (AI) assisted surgery decision-making models were developed to assist clinicians in delivering precision medicine while improving the survival of dnMBC patients.

Self-Reported Management of Inflammatory Breast Cancer Among the American Society of Breast Surgeons Membership: Consensus and Opportunities

BACKGROUND

Inflammatory breast cancer (IBC) is rare and biologically aggressive. We sought to assess diagnostic and management strategies among the American Society of Breast Surgeons (ASBrS) membership.

PATIENTS AND METHODS

An anonymous survey was distributed to ASBrS members from March to May 2023. The survey included questions about respondents' demographics and information related to stage III and IV IBC management. Agreement was defined as a shared response by >80% of respondents. In areas of disagreement, responses were stratified by years in practice, fellowship training, and annual IBC patient volume.

RESULTS

The survey was administered to 2337 members with 399 (17.1%) completing all questions and defining the study cohort. Distribution of years in practice was 26.0% 0-10 years, 26.6% 11-20 years and 47.4% > 20 years. Overall, 51.2% reported surgical oncology or breast fellowship training, 69.2% maintain a breast-only practice, and 73.5% treat < 5 IBC cases/year. Agreement was identified in diagnostic imaging, trimodal therapy, and mastectomy with wide skin excision for stage III IBC. Lack of agreement was identified in surgical management of the axilla; respondents with < 10 years in practice or fellowship training were more likely to perform axillary dissection for cN0-N2 stage III IBC. Locoregional management of stage IV IBC was variable.

CONCLUSIONS

Among ASBrS members, there is consensus in diagnostic evaluation, treatment sequencing and surgical approach to the breast in stage III IBC. Differences exist in surgical management of the cN0-2 axilla with uptake of de-escalation strategies. Clinical trials are needed to evaluate oncologic safety of de-escalation in this high-risk population.

Subdivision of M1 category and prognostic stage for de novo metastatic breast cancer to enhance prognostic prediction and guide the selection of locoregional therapy

BACKGROUND

Although de novo metastatic breast cancer (dnMBC) is acknowledged as a heterogeneous disease, the current staging systems do not distinguish between patients within the M1 or stage IV category. This study aimed to refine the M1 category and prognostic staging for dnMBC to enhance prognosis prediction and guide the choice of locoregional treatment.

METHODS

We selected patients with dnMBC from the SEER database (2010-2019), grouping them into training (N = 8048) and internal validation (N = 3450) cohorts randomly at a 7:3 ratio. An independent external validation cohort (N = 660) was enrolled from dnMBC patients (2010-2023) treated in three hospitals. Nomogram-based risk stratification was employed to refine the M1 category and prognostic stage, incorporating T/N stage, histologic grade, subtypes, and the location and number of metastatic sites. Both internal and external validation sets were used for validation analyses.

RESULTS

Brain, liver, or lung involvement and multiple metastases were independent prognostic factors for overall survival (OS). The nomogram-based stratification effectively divided M1 stage into three groups: M1a (bone-only involvement), M1b (liver or lung involvement only, with or without bone metastases), and M1c (brain metastasis or involvement of both liver and lung, regardless of other metastatic sites). Only subtype and M1 stage were included to define the final prognostic stage. Significant differences in OS were observed across M1 and prognostic subgroups. Patients with the M1c stage benefited less from primary tumor surgery in comparison with M1a stage.

CONCLUSION

Subdivision of the M1 and prognostic stage could serve as a supplement to the current staging guidelines for dnMBC and guide locoregional treatment.

The Role of Surgery for Stage IV Breast Cancer

Surgery for the management metastatic breast cancer has traditionally been considered a palliative procedure. However, some retrospective publications indicated that there may be a survival benefit to surgery in the presence of metastatic disease. Recent randomized trials will be reviewed for both management of the intact primary tumor in de novo breast cancer and systemic secondary metastases.

The role of locoregional surgery in de novo stage IV breast cancer: A meta-analysis of randomized controlled trials

BACKGROUND

We performed an updated meta-analysis to explore the value of locoregional surgery in de novo stage IV breast cancer patients.

METHODS

A literature search was conducted to identify randomized controlled trials comparing primary tumor resection with systemic therapy in de novo stage IV breast cancer. The hazard ratio (HR) of overall survival (OS), local relapse-free survival (LRFS), and distant relapse-free survival (DRFS) were estimated and pooled.

RESULTS

Six studies were eligible, including a total of 1368 patients. Both OS (HR = 0.86; 95 %CI: 0.77-0.96; p = 0.01; I2 = 45 %) and LRFS (HR = 0.35; 95 %CI: 0.20-0.62; p = 0.0003; I2 = 83 %) were significantly improved with locoregional surgery compared with systemic therapy alone. There was no significant difference in terms of DRFS (HR = 0.96; 95 %CI: 0.41-2.22; p = 0.92; I2 = 86 %). The OS benefit was more pronounced in hormone receptor-positive patients (HR = 0.79; p = 0.003) and HER2-negative patients (HR = 0.80; p = 0.003).

CONCLUSIONS

This study demonstrated that locoregional surgery conferred significant OS and LRFS benefits in de novo stage IV breast cancer patients and may serve as an alternative choice for selected patients.

PTX-RPPR, a conjugate of paclitaxel and NRP-1 peptide inhibitor to prevent tumor growth and metastasis

Paclitaxel, a potent anti-tumor drug widely recognized for its therapeutic efficacy, has faced limitations in clinical application due to its poor solubility. The use of Cremophor EL (CrEL) as a cosolvent in paclitaxel injections has been associated with hypersensitivity reactions in some patients. To overcome these challenges, we have developed a novel conjugate by linking a neuropilin-1 targeting peptide, RPPR, to paclitaxel, resulting in PTX-RPPR. This innovative approach has significantly enhanced the solubility of paclitaxel, achieving a 3.8 mg/mL concentration, a remarkable 90-fold increase over the native drug. PTX-RPPR has shown potent anti-tumor activity, inhibiting tumor cell proliferation with an IC50 ranging from 0.26 to 1.64 μM and effectively suppressing migration, invasion, and angiogenesis at a concentration of 75 nM. Notably, in a 4T1 mammary carcinoma model, PTX-RPPR administered at a dose of 0.7 μmol/kg exhibited tumor growth inhibition comparable to that of paclitaxel at a higher dose of 3.5 μmol/kg, with superior efficacy in preventing lung metastasis. Furthermore, PTX-RPPR effectively reduced NRP-1 expression in both tumors and lungs post-treatment. In contrast to paclitaxel formulated with CrEL, PTX-RPPR did not induce IL-6 expression, suggesting a safer profile in terms of immunological response. Characterized by a particle size of 200 nm and a zeta potential of +30 mV, the nano-formulation of PTX-RPPR demonstrated remarkable stability over seven days. This study introduced PTX-RPPR as a promising peptide-drug conjugate that addresses the solubility and hypersensitivity issues associated with paclitaxel, offering a safer therapeutic strategy for cancer treatment.

BMP4-Induced Suppression of Breast Cancer Metastasis Is Associated with Inhibition of Cholesterol Biosynthesis

We reported previously that in preclinical models, BMP4 is a potent inhibitor of breast cancer metastasis and that high BMP4 protein levels predict favourable patient outcomes. Here, we analysed a breast cancer xenograft with or without enforced expression of BMP4 to gain insight into the mechanisms by which BMP4 suppresses metastasis. Transcriptomic analysis of cancer cells recovered from primary tumours and phosphoproteomic analyses of cancer cells exposed to recombinant BMP4 revealed that BMP4 inhibits cholesterol biosynthesis, with many genes in this biosynthetic pathway being downregulated by BMP4. The treatment of mice bearing low-BMP4 xenografts with a cholesterol-lowering statin partially mimicked the anti-metastatic activity of BMP4. Analysis of a cohort of primary breast cancers revealed a reduced relapse rate for patients on statin therapy if their tumours exhibited low BMP4 levels. These findings indicate that BMP4 may represent a predictive biomarker for the benefit of additional statin therapy in breast cancer patients.

A nomogram and risk stratification system for predicting survival in T1-2N0-1 breast cancer patients with liver metastasis in females: a population-based study

PURPOSE

Liver was one of the most common distant metastatic sites in breast cancer. Patients with distant metastasis were identified as American Joint Committee on Cancer (AJCC) stage IV indicating poor prognosis. However, few studies have predicted the survival in females with T1-2N0-1 breast cancer who developed liver metastasis. This study aimed to explore the clinical features of these patients and establish a nomogram to predict their overall survival.

RESULTS

1923 patients were randomly divided into training (n = 1154) and validation (n = 769) cohorts. Univariate and multivariate analysis showed that age, marital status, race, estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor-2 (HER2), chemotherapy, surgery and bone metastasis, brain metastasis were considered the independent prognostic indicators. We developed a nomogram according to these ten parameters. The consistency index (c-index) was 0.72 (95% confidence interval CI 0.70-0.74) in the training cohort, 0.72 (95% CI 0.69-0.74) in the validation cohort. Calibration plots indicated that the nomogram-predicted survival was consistent with the recorded 1-, 3- and 5-year prognoses. Decision curve analysis curves in both the training and validation cohorts demonstrated that the nomogram showed better prediction than the AJCC TNM (8th) staging system. Kaplan Meier curve based on the risk stratification system showed that the low-risk group had a better prognosis than the high-risk group (P < 0.001).

CONCLUSIONS

A predictive nomogram and risk stratification system were constructed to assess prognosis in T1-2N0-1 breast cancer patients with liver metastasis in females. The risk model established in this study had good predictive performance and could provide personalized clinical decision-making for future clinical work.

Associations amongst genes, molecules, cells, and organs in breast cancer metastasis

This paper is a cross fertilization of ideas about the importance of molecular aspects of breast cancer metastasis by basic scientists, a pathologist, and clinical oncologists at the Henry Ford Health symposium. We address four major topics: (i) the complex roles of lymphatic endothelial cells and the molecules that stimulate them to enhance lymph node and systemic metastasis and influence the anti-tumor immunity that might inhibit metastasis; (ii) the interaction of molecules and cells when breast cancer spreads to bone, and how bone metastases may themselves spread to internal viscera; (iii) how molecular expression and morphologic subtypes of breast cancer assist clinicians in determining which patients to treat with more or less aggressive therapies; (iv) how the outcomes of patients with oligometastases in breast cancer are different from those with multiple metastases and how that could justify the aggressive treatment of these patients with the hope of cure.

Palliative Radiotherapy for Symptomatic Primary Tumors in Patients With Locally Advanced Breast Cancer

Breast cancer remains a significant health concern for women, with a significant number of women facing unresectable, symptomatic, and advanced disease that severely affects their quality of life. Palliative radiotherapy (RT) is a well-established modality for managing such cases and alleviating symptoms. Recent advancements in systemic therapies and the resulting increase in long-term survival rates have not only heightened the need for retreatment in certain patients, but have also emphasized the importance of achieving durable local control. Additionally, inconsistencies in RT referral timing and variations in disease severity and extent contribute to diverse RT objectives and expected outcomes. The optimal dose fractionation for RT remains underexplored. Furthermore, a deeper understanding of breast radiobiology, along with the introduction of ultra- and moderately hypofractionated regimens and the widespread adoption of conformal techniques such as intensity-modulated RT, has diversified the approaches in RT dose and target volume. This review aimed to provides a comprehensive summary of the current evidence on the efficacy, outcomes, and toxicity profiles of palliative RT for symptomatic breast cancer. It highlights the need for more optimized regimens and further research to address the evolving treatment landscape and differing expectations of patients and physicians regarding RT.

Axillary lymph node removal in de novo metastatic breast cancer

Background

Several prospective studies have found that local surgical resection did not improve the survival of patients with de novo metastatic breast cancer (dnMBC). However, a significant portion of dnMBC patients still undergo local surgery, and the role of axillary lymph node dissection (ALND) in dnMBC patients remains unclear. This study aimed to investigate the effect of ALND in patients with dnMBC.

Methods

We included patients diagnosed with dnMBC between 2010 and 2020 using the data from the Surveillance, Epidemiology, and End Results program. The Chi-square test, binomial logistic regression, propensity score matching (PSM), Kaplan-Meier method, and multivariate Cox proportional models were employed for statistical analysis.

Results

A total of 6,838 patients were identified, with 5,562 (81.3%) in the ALND group and 1,276 (18.7%) in the non-ALND group. Being diagnosed in later years emerged as an independent predictive factor related to the receipt of ALND (P=0.003). Before PSM, the 5-year breast cancer-specific survival (BCSS) was 51.1% and 38.2% in those with and without ALND, respectively (P<0.001). The 5-year overall survival (OS) was 45.9% and 32.3% in those with and without ALND, respectively (P<0.001). ALND was identified as an independent prognostic factor related to better BCSS (P<0.001) and OS (P<0.001) compared to the non-ALND group. Similar findings were observed after PSM. The outcomes were significantly better in the ALND group than in the non-ALND group in most subgroups. However, the number of removed lymph nodes did not show a significant association with BCSS (P=0.27) and OS (P=0.29).

Conclusions

Our study suggests that ALND is associated with improved survival outcomes in dnMBC patients. These findings advocate for a re-evaluation of the role of surgical interventions in dnMBC, emphasizing the need for personalized treatment strategies that consider the potential benefits of ALND.

Locoregional Radiotherapy in Patients with Advanced Breast Cancer Treated with Cyclin-Dependent Kinase 4/6 Inhibitors Based on Real-World Data

BACKGROUND

The use of locoregional radiotherapy (RT) in patients with advanced ER-positive, HER2-negative breast cancer remains a topic of ongoing debate. In this study, we aimed to evaluate the efficacy of locoregional RT in advanced breast cancer patients treated with cyclin-dependent kinase 4/6 inhibitors (CDK4/6i) in a first-line setting.

METHODS

We conducted a retrospective analysis of patients diagnosed with advanced breast cancer between 2018 and 2023 who received treatment with CDK4/6i and underwent locoregional radiotherapy.

RESULTS

Among the 371 patients treated with CDK4/6i as part of their first-line therapy, 23 received locoregional RT either concurrently or sequentially with CDK4/6 inhibitors. Disease progression within the breast occurred in 19 patients (5.1%). Among these cases, five patients had previously undergone breast RT (5/23, 21.7%), while 14 did not (14/348, 4.0%, p = 0.004). All cases of local progression after RT followed palliative doses and were accompanied by early systemic progression. The 2-year PFS in the entire cohort of patients treated with locoregional RT was 65.7% (95% CI: 40.5-82.3%). Notably, patients who received higher RT doses had longer 2-year PFS (83.3%, 95% CI: 27.3-97.5%) than those with palliative RT doses (59.3%, 95% CI: 30.7-79.3%); however, the results were not statistically significant (p = 0.58). Furthermore, the 2-year local control in the entire cohort with locoregional RT was 73.0% (95% CI: 46.5-87.9%). Importantly, no local progression was observed after RT when using high doses.

CONCLUSIONS

The addition of locoregional radiotherapy to first-line CDK4/6 inhibitors warrants further investigation across various clinical scenarios in advanced breast cancer. Palliative radiation regimens delivered early in breast oligoprogression may not always suffice, emphasizing the need for comprehensive studies in this context.

Should breast surgery be considered for patients with de novo metastatic inflammatory breast cancer?

INTRODUCTION

We aimed to identify factors predicting surgery for de novo stage IV inflammatory breast cancer (IBC) and determine the association of surgery with overall survival (OS).

METHODS

Female patients with unilateral AJCC clinical stage IV IBC treated 2010-2018 in the NCDB were identified. Logistic regression and multivariable proportional Cox hazards regressions determined factors associated with treatment and OS.

RESULTS

Of 1049 patients, 29.1% underwent breast surgery (BS) and 70.9% had no surgery (NS). Increasing age and more recent treatment year were significantly associated with NS. 2-Year OS was superior in BS patients (71% vs 38% NS). Single-site and bone-only metastasis had no association with treatment type or OS.

CONCLUSION

Contrary to guidelines, 1/3 of de novo stage IV IBC patients underwent BS, and had an independent OS benefit irrespective of extent or site of metastasis. Further research is needed to determine which patients with stage IV IBC should undergo BS.

Palliative surgery versus non-surgery of the solitary metastatic lesion in De novo metastatic breast cancer: A SEER based study

This study aimed to evaluate whether palliative surgery for metastatic lesion could provide a survival benefit in metastatic breast cancer (MBC) patients with solitary metastasis. De novo MBC patients with solitary distant lesions were enrolled utilizing the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was conducted to form matched pairs of the surgery group and the non-surgery group. The breast cancer-specific survival (BCSS) and overall survival (OS) outcomes between the 2 groups were compared in the following 3 sample models: the entire cohort of MBC (7665 cases); subgroups of patients with different isolated metastatic organs; and subgroups of patients with different molecular subtypes for each isolated metastatic organ. Compared with the Non-surgery group, the surgery group showed better BCSS and OS before PSM (HR = 0.88, 95% CI = 0.79-0.99, P = .04 and HR = 0.85, 95% CI = 0.76-0.95, P = .006, respectively). After PSM, palliative surgery still provided an OS benefit in patients with brain metastasis and lung metastasis (HR = 0.59, 95% CI = 0.37-0.95, P = .01 and HR = 0.64, 95% CI = 0.45-0.90, P = .02, respectively). Likewise, a better BCSS benefit was also found in the subset of patients with brain metastasis (HR = 0.61, 95% CI = 0.38-1.00, P = .01). Further stratification analysis indicated that patients with the luminal A subtype with brain metastasis have a better BCSS (HR = 0.36, 95% CI = 0.16-0.79, P = .04) and OS (HR = 0.37, 95% CI = 0.18-0.75, P = .03) after undergoing palliative surgery than nonsurgical treatment. Our study originality showed that palliative surgery for metastatic lesion could improve survival prognosis in patients with special single-organ metastasis and specific molecular subtypes. More clinical studies are needed to determine whether palliative surgery should be performed in MBC patients.

Enhancing Early-Stage Breast Cancer Survivorship: Evidence-Based Strategies, Surveillance Testing, and Imaging Guidelines

Addressing the challenges of survivorship necessitates a comprehensive, patient-centered approach, focusing on mitigating risk through lifestyle modification, identifying distant recurrence, and optimization of breast imaging. This article will discuss the current and emerging clinical strategies for the survivorship period, advocating a multidisciplinary and comprehensive approach. In this manner, early-stage breast cancer survivors are empowered to navigate their journey with enhanced knowledge, facilitating a transition to life beyond cancer.

Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy

The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.

Navigating Breast Cancer Oligometastasis and Oligoprogression: Current Landscape and Future Directions

PURPOSE

We examine the potential for curative approaches among metastatic breast cancer (MBC) patients by exploring the recent literature on local ablative therapies like surgery and stereotactic body radiation therapy (SBRT) in patients with oligometastatic (OM) breast cancer. We also cover therapies for MBC patients with oligoprogressive (OP) disease.

KEY FINDINGS

Surgery and SBRT have been studied for OM and OP breast cancer, mainly in retrospective or non-randomized trials. While many studies demonstrated favorable results, a cooperative study and single-institution trial found no support for surgery/SBRT in OM and OP cases, respectively.

CONCLUSION

While there is interest in applying local therapies to OM and OP breast cancer, the current randomized data does not back the routine use of surgery or SBRT, particularly when considering the potential for treatment-related toxicities. Future research should refine patient selection through advanced imaging and possibly explore these therapies specifically in patients with hormone receptor-positive or HER2-positive disease.

Nanotechnology for the theranostic opportunity of breast cancer lung metastasis: recent advancements and future challenges

Lung metastasis of breast cancer is rapidly becoming a thorny problem in the treatment of patients with breast cancer and an obstacle to long-term survival. The main challenges of treatment are the absence of therapeutic targets and drug resistance, which promotes the development of nanotechnology in the diagnosis and treatment process. Taking advantage of the controllability and targeting of nanotechnology, drug-targeted delivery, controlled sustained release, multi-drug combination, improved drug efficacy, and reduced side effects can be realized in the process of the diagnosis and treatment of metastatic breast cancer (MBC). Several nanotechnology-based theranostic strategies have been investigated in breast cancer lung metastases (BCLM): targeted drug delivery, imaging analysis, immunotherapy, gene therapy, and multi-modality combined therapy, and some clinical applications are in the research phase. In this review, we present current nanotechnology-based diagnosis and treatment approaches for patients of incurable breast cancer with lung metastases, and we hope to be able to summarize more effective and promising nano-drug diagnosis and treatment systems that aim to improve the survival of patients with advanced MBC. We describe nanoplatform-based experimental studies and clinical trials targeting the tumor and the tumor microenvironment (TME) for BCLM to obtain more targeted treatment and in the future treatment steps for patients to provide a pioneering strategy.

Primary Tumor Resection Before Systemic Therapy in Patients With Colon Cancer and Unresectable Metastases: Combined Results of the SYNCHRONOUS and CCRe-IV Trials

PURPOSE

Chemotherapy is established as primary treatment in patients with stage IV colorectal cancer and unresectable metastases. Data from nonrandomized clinical trials have fueled persistent uncertainty if primary tumor resection (PTR) before chemotherapy prolongs survival. We investigated the prognostic value of PTR in patients with newly diagnosed stage IV colon cancer who were not amenable to curative treatment.

PATIENTS AND METHODS

Patients enrolled in the multicenter, randomized SYNCHRONOUS and CCRe-IV trials were included in the analysis. Patients with colon cancer with synchronous unresectable metastases were randomly assigned at 100 sites in Austria, Germany, and Spain to undergo PTR or up-front chemotherapy (No PTR group). The chemotherapy regimen was left at discretion of the local team. Patients with tumor-related symptoms, inability to tolerate surgery and/or systemic chemotherapy, and history of another cancer were excluded. The primary end point was overall survival (OS), and the analyses were performed with intention-to-treat.

RESULTS

A total of 393 patients were randomly assigned to undergo PTR (n = 187) or no PTR (n = 206) between November 2011 and March 2017. Chemotherapy was not administered to 6.4% in the No PTR group and 24.1% in the PTR group. The median follow-up time was 36.7 months (95% CI, 36.6 to 37.3). The median OS was 16.7 months (95% CI, 13.2 to 19.2) in the PTR group and 18.6 months (95% CI, 16.2 to 22.3) in the No PTR group (P = .191). Comparable OS between the study groups was further confirmed on multivariate analysis (hazard ratio, 0.944 [95% CI, 0.738 to 1.209], P = .65) and across all subgroups. Patients with serious adverse events were more common in the No PTR group (10.2% v 18.0%; P = .027).

CONCLUSION

Among patients with colon cancer and synchronous unresectable metastases, PTR before systemic chemotherapy was not associated with prolonged OS.

Patterns of distant metastasis and survival outcomes in de novo metastatic breast cancer according to age groups

Background

Is de novo metastatic breast cancer (dnMBC) the same disease in the elderly as in younger breast cancer remains unclear. This study aimed to determine the metastatic patterns and survival outcomes in dnMBC according to age groups.

Methods

We included patients from the Surveillance Epidemiology and End Results program. Chi-square test, multivariate logistic regression analyses, and multivariate Cox regression models were used for statistical analyses.

Results

A total of 17719 patients were included. There were 3.6% (n=638), 18.6% (n=3290), 38.0% (n=6725), and 39.9% (n=7066) of patients aged <35, 35-49, 50-64, and ≥65 years, respectively. Older patients had a significantly higher risk of lung metastasis and a significantly lower risk of liver metastasis. There were 19.1%, 25.6%, 30.9%, and 35.7% of patients with lung metastasis in those aged <35, 35-49, 50-64, and ≥65 years, respectively. Moreover, the proportion of liver metastasis was 37.6%, 29.5%, 26.3%, and 19.2%, respectively. Age was the independent prognostic factor associated with breast cancer-specific survival (BCSS) and overall survival (OS). Those aged 50-64 years had significantly inferior BCSS (P<0.001) and OS (P<0.001) than those aged <35 years. Patients aged ≥65 years also had significantly lower BCSS (P<0.001) and OS (P<0.001) than those aged <35 years. However, similar outcomes were found between those aged 35-49 and <35 years.

Conclusion

Our study suggests that different age groups may affect the metastatic patterns among patients with dnMBC and the survival of younger patients is more favorable than those of older patients.

Five-Fraction High-Conformal Ultrahypofractionated Radiotherapy for Primary Tumors in Metastatic Breast Cancer

PURPOSE

To report on the local control and toxicity of 5-fraction, high-conformal ultrafractionated radiation therapy (RT) for primary tumors in patients with metastatic breast cancer (MBC) who did not undergo planned surgical intervention.

METHODS

We retrospectively reviewed 27 patients with MBC who underwent 5-fraction high-dose ultrafractionated intensity-modulated RT for their primary tumors between 2017 and 2022 at our institution. A median dose of 66.8 Gy (range, 51.8-83.6 Gy) was prescribed to the gross tumor, calculated in 2-Gy equivalents using an α/β ratio of 3.5, along with a simultaneous integrated boost of 81.5%. The primary endpoint of this study was local control.

RESULTS

The median tumor size and volume were 5.1 cm and 112.4 cm3, respectively. Treatment was generally well tolerated, with only 15% of the patients experiencing mild acute skin toxicity, which resolved spontaneously. The best infield response rate was 82%, with the objective response observed at a median time of 10.8 months post-RT (range, 1.4-29.2), until local progression or the last follow-up. At a median follow-up of 18.3 months, the 2-year local control rate was 77%. A higher number of prior lines of systemic therapy was significantly associated with poorer 2-year local control (one-two lines, 94% vs three or more lines, 34%; p = 0.004). Post-RT, 67% of the patients transitioned to the next line of systemic therapy, and the median duration of maintaining the same systemic therapy post-RT was 16.3 months (range, 1.9-40.3).

CONCLUSION

In our small dataset, 5-fraction, high-conformal ultrahypofractionated breast RT offered promising 2-year local control with minimal toxicity. Further studies are warranted to investigate the optimal dose and role in this setting.

The Canadian Breast Cancer Symposium 2023 Meeting Report

On 15-16 June 2023, healthcare professionals and breast cancer patients and advocates from across Canada met in Toronto, Ontario, for the 2023 Canadian Breast Cancer Symposium (CBSC.). The CBSC. is a national, multidisciplinary event that occurs every 2 years with the goal of developing a personalized approach to the management of breast cancer in Canada. Experts provided state-of-the-art information to help optimally manage breast cancer patients, including etiology, prevention, diagnosis, experimental biology, and therapy of breast cancer and premalignant breast disease. The symposium also had the objectives of increasing communication and collaboration among breast cancer healthcare providers nationwide and providing a comprehensive and real-life review of the many facets of breast cancer. The sessions covered the patient voice, the top breast cancer papers from different disciplines in 2022, artificial intelligence in breast cancer, systemic therapy updates, the management of central nervous system metastases, multidisciplinary management of ductal carcinoma in situ, special populations, optimization-based individual prognostic factors, toxicity management of novel therapeutics, survivorship, and updates in surgical oncology. The key takeaways of these sessions have been summarized in this conference report.

The Current and Future Roles of Precision Oncology in Advanced Breast Cancer

Breast cancer is a common but heterogeneous disease characterized by several biologic features, including tumor grade, hormone receptor status, human epidermal growth factor receptor 2 status, and gene expression assays. These biologic and genomic features drive treatment decisions. In the advanced disease setting, inter- and intrapatient tumor heterogeneity is increasingly recognized as a challenge for optimizing treatment. Recent evidence and the recent approval of novel radiopharmaceuticals have increased recognition and acceptance of the potential of molecular imaging as a biomarker to impact and guide management decisions for advanced breast cancer.

Locoregional therapy containing surgery in metastatic breast cancer: Systematic review and meta-analysis

INTRODUCTION

The role of locoregional therapy (LRT) containing surgery and systematic therapy in metastatic breast cancer patients remains controversial. This study investigated the effect of LRT in patients who were initially diagnosed with metastatic breast cancer (MBC) on overall survival (OS), locoregional progression-free survival (PFS), and distant systemic PFS.

METHODS

The related keywords were searched in MEDLINE/PubMed, SCOPUS, and Web of Science databases up to August 15th, 2022. Hazard ratios (HR) with 95% confidence intervals (CIs) were pooled by the random-effects model.

RESULTS

Seven articles with 1626 participants compared LRT with only systemic therapy (ST) for patients with de novo MBC. LRT did not improve (p = 0.28) OS compared to ST (HR: 0.83, 95% CI: 0.60, 1.16). LRT significantly improved locoregional PFS outcomes compared to ST (HR: 0.31, 95% CI: 0.15, 0.60, p = 0.001). LRT significantly (p = 0.001) improved OS in patients with solitary bone metastases (HR: 0.48; 95% CI: 0.35-0.67).

CONCLUSION

LRT improves locoregional PFS. Furthermore, LRT improves OS in patients with solitary bone metastases.

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.

Primary site surgery of de novo stage IV HER2-positive breast cancer in the era of new drug treatments

Objective

The surgical treatment of the primary site has been a subject of controversy in patients with de novo metastatic breast cancer. In recent years, studies using large databases and retrospective analyses have provided evidence of the survival benefits of localized surgery for these patients. However, due to the improved prognosis associated with novel antitumor agents and the widespread use of anti-HER2 therapy, it is important to investigate the role of primary site surgery in the context of new drug treatments for stage IV HER2-positive breast cancer.

Methods

This retrospective analysis included patients with metastatic breast cancer at diagnosis who were consulted at the First Hospital of Jilin University between 2016 and 2022. We compared the patients' clinical and pathological characteristics, treatment regimens, and prognosis between the surgery and non-surgery groups.

Results

A total of 96 patients with stage IV HER2-positive breast cancer were included in the study, with 24 patients (25%) undergoing surgery for the primary lesion. Patients with lower Eastern Cooperative Oncology Group (ECOG) scores, earlier T-stage, metastases confined to one organ/site, and fewer metastases were more likely to undergo surgery. Patients in the surgical group had longer progression-free survival (median 25.7 vs. 15.9 months, p=0.073) and overall survival (median 79.1 vs. 48 months, p=0.073) compared to patients in the non-surgical group, however, there was no statistical difference. Univariate and multivariate Cox regression analysis suggested that the choice of first-line targeted therapy regimens rather than surgical treatment influenced the patients' prognoses. In the subgroup of patients receiving first-line targeted therapy with trastuzumab plus pertuzumab, the decision to undergo surgery on the primary site did not have a statistically significant effect on prognosis.

Conclusion

Primary site surgery does not improve the prognosis of de novo stage IV HER2-positive breast cancer. In the era of anti-HER2 therapy, primary surgery is not recommended, except in exceptional circumstances.

The impact of histologic subtype on primary site surgery in the management of metastatic lobular versus ductal breast cancer: a population based study from the National Cancer Database (NCDB)

PURPOSE

Primary site surgery for metastatic breast cancer improves local control but does not impact overall survival. Whether histologic subtype influences patient selection for surgery is unknown. Given differences in surgical management between early-stage lobular versus ductal disease, we evaluated the impact of histology on primary site surgery in patients with metastatic breast cancer.

METHODS

The National Cancer Database (NCDB, 2010-2016) was queried for patients with stage IV HR-positive, HER2-negative invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC). We compared clinicopathologic features, primary site surgery rates, and outcomes by histologic subtype. Multivariable Cox proportional hazard models with and without propensity score matching were used for overall survival (OS) analyses.

RESULTS

In 25,294 patients, primary site surgery was slightly but significantly less common in the 6,123 patients with ILC compared to the 19,171 patients with IDC (26.9% versus 28.8%, p = 0.004). Those with ILC were less likely to receive chemotherapy (41.3% versus 47.4%, p < 0.0001) or radiotherapy (29.1% versus 37.9%, p < 0.0001), and had shorter OS. While mastectomy rates were similar, those with ILC who underwent lumpectomy had significantly higher positive margin rates (ILC 15.7% versus IDC 11.2%, p = 0.025). In both groups, the odds of undergoing surgery decreased over time, and were higher in younger patients with T2/T3 tumors and higher nodal burden.

CONCLUSION

Lobular histology is associated with less primary site surgery, higher positive margin rates, less radiotherapy and chemotherapy, and shorter OS compared to those with HR-positive HER2-negative IDC. These findings support the need for ILC-specific data and treatment approaches in the setting of metastatic disease.

Breast surgery for patients with de novo metastatic breast cancer: A meta-analysis of randomized controlled trials

The role of breast surgery in the treatment of patients with de novo metastatic breast cancer(dnMBC) remains controversial, with conflicting trial results. We did a meta-analysis to comprehensively investigate and assess whether breast surgery is associated with survival and quality of life outcomes in patients with dnMBC.We systematically searched PubMed, Embase, Google Scholar, Scopus, and Web of Science, from database inception to March 30, 2022, for randomized controlled trials(RCTs) that compared breast surgery or locoregional therapy with non-surgical treatment based on systemic therapy for managing dnMBC.We also reviewed abstracts and presentations from major conference proceedings. We excluded non-randomised trials and considered only papers published in English. The primary outcomes were overall survival(OS),locoregional progression-free survival(LPFS), distant progression-free survival(DPFS), and quality of life(QoL). The quality of RCTs was appraised with the Cochrane Collaboration risk of bias tool. Random-effects model or fixed effects model were used to calculate the effect sizes of included RCTs.Quality of evidence was assessed with GRADE criteria. Data analysis was performed with STATA 17.0. A total of 1018 women from seven randomized clinical trials were included in the analysis. Pooled analyses revealed that compared with systemic therapy, breast surgery was not associated with beneficial outcomes in OS(hazard ratio [HR],0.87; 95%CI,0.68 to 1.11; I2 = 53.08 %; p = 0.265),DPFS(HR,1.20; 95%CI,0.94 to 1.54; I2 = 86.45 %; p = 0.136), or QoL-global health status (standardized mean difference[SMD],0.08; 95%CI,-0.15 to 0.32; I2 = 79.45 %; p = 0.478) and QoL-mental-physical functionality(SMD,-0.19; 95%CI,-0.50 to 0.13; I2 = 0.00 %; p = 0.255), but was associated with a benefit in LPFS(HR,0.27; 95%CI,0.19 to 0.38; I2 = 84.16 %; p < 0.001). These findings were consistent in subgroup analyses of the timing of surgery, site and number of metastases and tumor molecular subtype. The evidence grade was moderate because of the substantial heterogeneity among studies. Based on the RCTs evidence, we found that breast surgery may benefit locoregional control but does not prolong OS and improve QoL in patients with dnMBC. The Prospero registration number: CRD42020206460.

Surgery of the primary tumor in patients with de novo metastatic breast cancer: a nationwide population-based retrospective cohort study in Belgium

PURPOSE

We aimed to assess the impact of surgery of primary tumor in overall survival (OS) of women with de novo metastatic breast cancer.

METHODS

Nationwide, population-based retrospective cohort study of women diagnosed with de novo metastatic breast cancer in Belgium, between Jan/2010-Dec/2014. Data was obtained from the Belgian Cancer Registry and administrative databases. "Surgery" group was defined by surgery of primary tumor up to nine months after diagnosis. We excluded women who did not receive systemic treatment or did not complete nine months follow-up after diagnosis. All the subsequent analyses reporting on overall survival and the stratified outcome analyses were performed based on this nine-month landmark cohort. OS was estimated using Kaplan-Meier method and compared using adjusted Cox proportional hazards models controlling for confounders with 95% confidence intervals (CI). We performed a stratified analysis according to surgery timing and a propensity score matching analysis.

RESULTS

1985 patients, 534 (26.9%) in the "Surgery" and 1451 (73.1%) in the "No Surgery" group. Patients undergoing surgery were younger (p < 0.001), had better performance status (PS) (p < 0.001), and higher proportion of HER2-positive and triple-negative breast cancer (p = 0.012). Median follow-up was 86.0 months (82.6-88.5). Median OS was 60.1 months (57.1-68.2) in the "Surgery" vs. 41.9 months (39.8-44.2) in the "No Surgery" group (adjusted HR 0.56; 0.49-0.64). OS was similar when surgery was performed upfront or after systemic treatment. Propensity score matching analysis confirmed the same findings.

CONCLUSION

Among patients receiving systemic treatment for de novo metastatic breast cancer and surviving nine months or more, those who received surgery of the primary tumor within nine months of diagnosis have longer subsequent survival than those who did not.

Systemic Treatment of Patients With Metastatic Breast Cancer: ASCO Resource-Stratified Guideline

PURPOSE

To guide clinicians and policymakers in three global resource-constrained settings on treating patients with metastatic breast cancer (MBC) when Maximal setting-guideline recommended treatment is unavailable.

METHODS

A multidisciplinary, multinational panel reviewed existing ASCO guidelines and conducted modified ADAPTE and formal consensus processes.

RESULTS

Four published resource-agnostic guidelines were adapted for resource-constrained settings; informing two rounds of formal consensus; recommendations received ≥75% agreement.

RECOMMENDATIONS

Clinicians should recommend treatment according to menopausal status, pathological and biomarker features when quality results are available. In first-line, for hormone receptor (HR)-positive MBC, when a non-steroidal aromatase inhibitor and CDK 4/6 inhibitor combination is unavailable, use hormonal therapy alone. For life-threatening disease, use single-agent chemotherapy or surgery for local control. For premenopausal patients, use ovarian suppression or ablation plus hormone therapy in Basic settings. For human epidermal growth factor receptor 2 (HER2)-positive MBC, if trastuzumab, pertuzumab, and chemotherapy are unavailable, use trastuzumab and chemotherapy; if unavailable, use chemotherapy. For HER2-positive, HR-positive MBC, use standard first-line therapy, or endocrine therapy if contraindications. For triple-negative MBC with unknown PD-L1 status, or if PD-L1-positive and immunotherapy unavailable, use single-agent chemotherapy. For germline BRCA1/2 mutation-positive MBC, if poly(ADP-ribose) polymerase inhibitor is unavailable, use hormonal therapy (HR-positive MBC) and chemotherapy (HR-negative MBC). In second-line, for HR-positive MBC, Enhanced setting recommendations depend on prior treatment; for Limited, use tamoxifen or chemotherapy. For HER2-positive MBC, if trastuzumab deruxtecan is unavailable, use trastuzumab emtansine; if unavailable, capecitabine and lapatinib; if unavailable, trastuzumab and/or chemotherapy (hormonal therapy alone for HR-positive MBC).Additional information is available at www.asco.org/resource-stratified-guidelines. It is ASCO's view that healthcare providers and system decision-makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

The Japanese Breast Cancer Society Clinical Practice Guidelines for surgical treatment of breast cancer, 2022 edition

The 2022 revision of the Japanese Breast Cancer Society (JBCS) Clinical Practice Guidelines for surgical treatment of breast cancer was updated following a systematic review of the literature using the Medical Information Network Distribution Service (MINDS) procedure, which focuses on the balance of benefits and harms for various clinical questions (CQs). Experts in surgery designated by the JBCS addressed five areas: breast surgery, axillary surgery, breast reconstruction, surgical treatment for recurrent and metastatic breast cancer, and other related topics. The revision of the guidelines encompassed 4 CQs, 7 background questions (BQs), and 14 future research questions (FRQs). A significant revision in the 2022 edition pertained to axillary management after neoadjuvant chemotherapy in CQ2. The primary aim of the 2022 JBCS Clinical Practice Guidelines is to provide evidence-based recommendations to empower patients and healthcare professionals in making informed decisions regarding surgical treatment for breast cancer.

A Nomogram and Risk Classification System Predicting the Prognosis of Patients with De Novo Metastatic Breast Cancer Undergoing Immediate Breast Reconstruction: A Surveillance, Epidemiology, and End Results Population-Based Study

Background The lifespan of patients diagnosed with de novo metastatic breast cancer (dnMBC) has been prolonged. Nonetheless, there remains substantial debate regarding immediate breast reconstruction (IBR) for this particular subgroup of patients. The aim of this study was to construct a nomogram predicting the breast cancer-specific survival (BCSS) of dnMBC patients who underwent IBR. Methods A total of 682 patients initially diagnosed with metastatic breast cancer (MBC) between 2010 and 2018 in the Surveillance, Epidemiology, and End Results (SEER) database were included in this study. All patients were randomly allocated into training and validation groups at a ratio of 7:3. Univariate Cox hazard regression, least absolute shrinkage and selection operator (LASSO), and best subset regression (BSR) were used for initial variable selection, followed by a backward stepwise multivariate Cox regression to identify prognostic factors and construct a nomogram. Following the validation of the nomogram with concordance indexes (C-index), receiver operating characteristic (ROC) curves, calibration curves, and decision curve analyses (DCAs), risk stratifications were established. Results Age, marital status, T stage, N stage, breast subtype, bone metastasis, brain metastasis, liver metastasis, lung metastasis, radiotherapy, and chemotherapy were independent prognostic factors for BCSS. The C-indexes were 0.707 [95% confidence interval (CI), 0.666-0.748] in the training group and 0.702 (95% CI, 0.639-0.765) in the validation group. In the training group, the AUCs for BCSS were 0.857 (95% CI, 0.770-0.943), 0.747 (95% CI, 0.689-0.804), and 0.700 (95% CI, 0.643-0.757) at 1 year, 3 years, and 5 years, respectively, while in the validation group, the AUCs were 0.840 (95% CI, 0.733-0.947), 0.763 (95% CI, 0.677-0.849), and 0.709 (95% CI, 0.623-0.795) for the same time points. The calibration curves for BCSS probability prediction demonstrated excellent consistency. The DCA curves exhibited strong discrimination power and yielded substantial net benefits. Conclusions The nomogram, constructed based on prognostic risk factors, has the ability to provide personalized predictions for BCSS in dnMBC patients undergoing IBR and serve as a valuable reference for clinical decision making.

Cost-effectiveness analysis of elacestrant versus standard endocrine therapy for second-/third-line treatment of patients with HR+/HER2- advanced or metastatic breast cancer: a US payer perspective

Background

This study evaluated the cost-effectiveness of elacestrant (ELA) and standard-of-care (SOC) as second-/third-line treatment for pretreated estrogen receptor (ER)- positive/human epidermal growth factor receptor 2 (HER2)-negative advanced or metastatic breast cancer (A/MBC) in the US.

Methods

The 3 health states partitioned survival model (PSM) was conducted from the perspective of the US third-party payers. The time horizon for the model lasted 10 years. Effectiveness and safety data were derived from the EMERALD trial (NCT03778931). Costs were derived from the pricing files of Medicare and Medicaid Services, and utility values were derived from published studies. One-way sensitivity analysis as well as probabilistic sensitivity analysis were performed to observe model stability.

Result

ELA led to an incremental cost-effectiveness ratio (ICER) of $8,672,360/quality-adjusted life year (QALY) gained compared with SOC in the overall population and $2,900,560/QALY gained compared with fulvestrant (FUL) in the ESR1(estrogen receptor 1) mutation subgroup. The two ICERs of ELA were significantly higher than the willingness-to-pay (WTP) threshold values of $150,000/QALY.

Conclusions

ELA was not cost-effective for the second-/third-line treatment of patients with ER+/HER2-A/MBC compared with SOC in the US.

De Novo Oligometastatic Breast Cancer

De novo oligometastatic breast cancer, a unique disease needing new treatment paradigms.

Understanding breast cancer complexity to improve patient outcomes: The St Gallen International Consensus Conference for the Primary Therapy of Individuals with Early Breast Cancer 2023

The 18th St Gallen International Breast Cancer Conference held in March 2023, in Vienna, Austria, assessed significant new findings for local and systemic therapies for early breast cancer with a focus on the evaluation of multimodal treatment options. The emergence of more effective, innovative agents in both the preoperative (primary or neoadjuvant) and post-operative (adjuvant) settings has underscored the pivotal role of a multidisciplinary approach in treatment decision making, particularly when selecting systemic therapy for an individual patient. The importance of multidisciplinary discussions regarding the clinical benefits of interventions was explicitly emphasized by the consensus panel as an integral part of developing an optimal treatment plan with the 'right' degree of intensity and duration. The panelists focused on controversies surrounding the management of common ductal/no special type and lobular breast cancer histology, which account for the vast majority of breast tumors. The expert opinion of the panelists was based on interpretations of available data, as well as current practices in their professional environments, personal and socioeconomic factors affecting patients, and cognizant of varying reimbursement and accessibility constraints around the world. The panelists strongly advocated patient participation in well-designed clinical studies whenever feasible. With these considerations in mind, the St Gallen Consensus Conference aims to offer guidance to clinicians regarding appropriate treatments for early-stage breast cancer and assist in balancing the realistic trade-offs between treatment benefit and toxicity, enabling patients and clinicians to make well-informed choices through a shared decision-making process.