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 "Metastatic breast cancer: Local treatment".)
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.
- Lee CG, McCormick B, Mazumdar M, et al. Infiltrating breast carcinoma in patients age 30 years and younger: long term outcome for life, relapse, and second primary tumors. Int J Radiat Oncol Biol Phys 1992; 23:969.
- Vogel CL, Azevedo S, Hilsenbeck S, et al. Survival after first recurrence of breast cancer. The Miami experience. Cancer 1992; 70:129.
- Leung AM, Vu HN, Nguyen KA, et al. Effects of surgical excision on survival of patients with stage IV breast cancer. J Surg Res 2010; 161:83.
- Singletary SE, Walsh G, Vauthey JN, et al. A role for curative surgery in the treatment of selected patients with metastatic breast cancer. Oncologist 2003; 8:241.
- Harris E, Barry M, Kell MR. Meta-analysis to determine if surgical resection of the primary tumour in the setting of stage IV breast cancer impacts on survival. Ann Surg Oncol 2013; 20:2828.
- Badwe R, Hawaldar R, Nair N, et al. Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial. Lancet Oncol 2015; 16:1380.
- Soran A, Ozmen V, Ozbas S, et al.. Soran A, Ozmen V, Ozbas S, et al. : Early follow up of a randomized trial evaluating resection of the primary breast tumor in women presenting with de novo stage IV breast cancer; Turkish study (protocol MF07–01). abstr S2–03. SABCS 2013.
- Carmichael AR, Anderson ED, Chetty U, Dixon JM. Does local surgery have a role in the management of stage IV breast cancer? Eur J Surg Oncol 2003; 29:17.
- Nieto Y, Cagnoni PJ, Shpall EJ, et al. Phase II trial of high-dose chemotherapy with autologous stem cell transplant for stage IV breast cancer with minimal metastatic disease. Clin Cancer Res 1999; 5:1731.
- Juan O, Lluch A, de Paz L, et al. Prognostic factors in patients with isolated recurrences of breast cancer (stage IV-NED). Breast Cancer Res Treat 1999; 53:105.
- Khan SA, Stewart AK, Morrow M. Does aggressive local therapy improve survival in metastatic breast cancer? Surgery 2002; 132:620.
- Rapiti E, Verkooijen HM, Vlastos G, et al. Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol 2006; 24:2743.
- Babiera GV, Rao R, Feng L, et al. Effect of primary tumor extirpation in breast cancer patients who present with stage IV disease and an intact primary tumor. Ann Surg Oncol 2006; 13:776.
- Gnerlich J, Jeffe DB, Deshpande AD, et al. Surgical removal of the primary tumor increases overall survival in patients with metastatic breast cancer: analysis of the 1988-2003 SEER data. Ann Surg Oncol 2007; 14:2187.
- Fields RC, Jeffe DB, Trinkaus K, et al. Surgical resection of the primary tumor is associated with increased long-term survival in patients with stage IV breast cancer after controlling for site of metastasis. Ann Surg Oncol 2007; 14:3345.
- Blanchard DK, Shetty PB, Hilsenbeck SG, Elledge RM. Association of surgery with improved survival in stage IV breast cancer patients. Ann Surg 2008; 247:732.
- Hazard HW, Gorla SR, Scholtens D, et al. Surgical resection of the primary tumor, chest wall control, and survival in women with metastatic breast cancer. Cancer 2008; 113:2011.
- Ruiterkamp J, Ernst MF, van de Poll-Franse LV, et al. Surgical resection of the primary tumour is associated with improved survival in patients with distant metastatic breast cancer at diagnosis. Eur J Surg Oncol 2009; 35:1146.
- Cady B, Nathan NR, Michaelson JS, et al. Matched pair analyses of stage IV breast cancer with or without resection of primary breast site. Ann Surg Oncol 2008; 15:3384.