Surgery in Stage IV Breast Cancer

The role of locoregional treatment in the setting of de novo metastatic breast cancer:
- Is controversial
Typically, surgery has been reserved for:
- Palliation
A 2012 meta-analysis of 15 retrospective studies:
- Showed resection of the primary tumor was associated with:
  - Increased overall survival:
    - OS; HR 0.69, 95% CI 0.63 to 0.77, P<0.00001
Unfortunately, recent prospective studies have shown conflicting results:
- A Turkish study showed improved survival at a median of 40 months follow-up:
  - Especially in more indolent forms of breast cancer
- In contrast, a U.S. study did not show improvement in survival associated with surgery
Determinants of improved survival:
- Were related to response to therapy
An Italian study showed:
- Improvement in survival:
  - In patients with HER2 positive disease after first-line trastuzumab-based therapy
In addition, an Indian study by Badwe et al:
- Did not show a survival advantage with resection of the primary cancer:
  - At a median follow-up of 23 months:
    - The overall survival was 41.9% in the locoregional surgical arm vs. 43.0% in the non-locoregional treatment arm
Each of these studies has potential bias flaws:
- But show potential benefit of resection:
  - In select patients with:
    - High functional status and good response to optimal systemic therapy
While awaiting the results of ECOG E2108 clinical trial:
- Surgery in stage IV breast cancer:
  - Patients should be discussed in a multidisciplinary setting, taking into account:
    - Comorbidities, response to therapy, and tumor burden
References
- Poggio F, Lambertini M, de Azambuja E. Controversies in oncology: Surgery of the primary tumour in patients presenting with de novo metastatic breast cancer: to do or not to do? ESMO Open 2018;3:e000324.
- Wu SG, Zhang WW, Sun JY, et al. The survival benefits of local surgery in stage IV breast cancer are not affected by breast cancer subtypes: a population-based analysis. Oncotarget. 2017;8(40):67851-67860. Published 2017 Jun 29.
- Soran A, Ozmen V, Ozbas S, et al. randomized trial comparing resection of primary tumor with no surgery in Stage IV breast cancer at presentation: Protocol MF07-01. Ann Surg Oncol. 2018;25(11): 3141-3149.
- R Badwe, R Hawaldar, N Nair, 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(13):1380-1388.