Role of breast surgery for stage IV breast cancer
- Michael S Sabel, MD
Michael S Sabel, MD
- Associate Professor of Surgery
- University of Michigan Medical School
- Section Editors
- Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
- Section Editor — Breast Surgery
- Associate Professor, Department of Surgery
- Yale University School of Medicine
- Daniel F Hayes, MD
Daniel F Hayes, MD
- Section Editor — Breast Cancer
- Professor of Medicine
- University of Michigan School of Medicine
Patients with metastatic breast cancer are unlikely to be cured of their disease by any means. Complete remissions from systemic chemotherapy are uncommon, and only a fraction of complete responders remain progression-free for a prolonged period. The median survival for patients with stage IV breast cancer is 18 to 24 months, although the range extends from only a few months to many years [1-3]. (See "Systemic treatment for metastatic breast cancer: General principles" and "Tumor, Node, Metastasis (TNM) staging classification for breast cancer".)
Approximately 3 to 4 percent of women with newly diagnosed breast cancer present with synchronous stage IV disease. A major question that arises in such patients is how best to manage the primary tumor. The role of surgical excision of the primary tumor in stage IV breast cancer is discussed here. Surgical intervention for metastatic disease in these patients is discussed elsewhere. (See "The role of local therapies in metastatic breast cancer".)
In the absence of curative treatment for the majority of patients, the goals of therapy typically shift from cure to palliation, focusing on symptom control, improved quality of life (QOL), and prolongation of survival.
The typical approach is to perform a core biopsy of the tumor for histologic confirmation of the diagnosis and proceed directly to systemic therapy. Most oncologists consider that once metastases have occurred, there is no survival benefit to aggressive local therapy. However, resection of the primary tumor in stage IV breast disease can provide palliation of bleeding, ulceration or infection .
UNCLEAR SURVIVAL BENEFIT
Surgical resection of the primary tumor in metastatic breast cancer has not consistently demonstrated improved survival, and therefore, we do not routinely offer this therapy. Although the morbidity and mortality of breast surgery is low, the potential benefits of surgery on local control and survival (if any) must be weighed against the negative aspects of surgery, particularly mastectomy. Prospective trials suggest no survival benefit; however, these studies have limitations and it is unclear whether certain patient and disease characteristics may predict a benefit. Thus, decisions on surgery must be made on a case-by-case basis until further data from additional trials become available . Factors to consider include the potential for local complications after surgery, the patient’s symptoms and desires, the distant disease burden, and the response to systemic therapy, particularly among patients with human epidermal growth factor receptor 2 (HER2)-positive disease who have a brisk and dramatic response to systemic therapy and may experience prolonged disease-free intervals with locoregional treatment.
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