The role of local therapies in metastatic breast cancer
- Michael S Sabel, MD
Michael S Sabel, MD
- Associate Professor of Surgery
- University of Michigan Medical School
- Julia White, MD
Julia White, MD
- Professor and Vice Chair
- Department of Radiation Oncology
- Klotz Sister Chair of Cancer Research
- The James CCC, Ohio State University
- Section Editors
- Daniel F Hayes, MD
Daniel F Hayes, MD
- Section Editor — Breast Cancer
- Professor of Medicine
- University of Michigan School of Medicine
- 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
- David E Wazer, MD
David E Wazer, MD
- Section Editor — Radiation Therapy
- Professor of Radiation Oncology
- Tufts University School of Medicine
- Brown University 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".)
Although systemic therapy is the mainstay of treatment for metastatic breast cancer, local management of the primary as well as metastasis-specific local treatment (ie, metastasectomy, radiofrequency ablation, cryotherapy, and radiation therapy) may palliate symptoms and prevent cancer-related complications. Some evidence suggests a potential for prolonging survival, although prospective data are lacking . These approaches and their rationale are discussed here.
Systemic medical therapy for metastatic breast cancer, consisting of chemotherapy, endocrine therapy and/or biologic therapies, and supportive care is discussed elsewhere. (See "Systemic treatment for metastatic breast cancer: General principles".)
LOCAL MANAGEMENT OF THE PRIMARY
The primary role of local treatment to the breast in metastatic breast cancer is palliation. Patients with metastatic disease should be evaluated for possible local management of the primary if it may control local complications from the cancer (eg, bleeding, infection, or wound management). However, in general, for patients who are asymptomatic at the site of their primary, we do not offer local treatment given lack of clear evidence that it improves survival. While retrospective evidence suggests a possible benefit, prospective data have shown no overall survival benefit or only minimal survival benefit, and are limited by methodologic issues. As such, we typically do not offer surgery in such cases.
Deviations to this approach may be rarely made on a case-by-case basis in a multidisciplinary setting, although these instances are exceptional. For example, we have offered local management of the primary to patients with human epidermal growth factor receptor 2 (HER2)-positive disease who have a brisk and dramatic response to systemic therapy. However, data supporting such an approach are lacking, and the decision to proceed with local management in a similar situation should take into account the expertise and experience of the treating institution as well as patient preferences. If lumpectomy is pursued for local management of the primary, radiation therapy (RT) is not indicated, as it would be for primary curative treatment for non-metastatic disease. Similarly, if mastectomy is used, reconstruction should not be offered (unless necessary to close a large wound).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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