Historically, women who present with stage IV metastatic breast cancer (MBC), even those with an intact primary tumor, are not offered surgical treatment. Instead, the recommended primary treatment approach is systemic therapy. However, improved breast cancer screening and imaging technology have presented a different dilemma: patients with MBC may have oligometastatic or stable metastatic disease with an operable intact primary tumor, suggesting that surgery may be effective. Furthermore, over the past 25 years, multimodality treatments for new and advanced breast cancers have resulted in improved median survival times for patients with MBC.1 Therefore, for patients with MBC, it is time to reevaluate the role of resection of the intact primary tumor and the role of metastasectomy in patients without an intact primary tumor.
It is generally accepted that mastectomy does not confer a survival advantage after metastases have developed.2 Surgical treatment of intact primary tumors in patients with MBC has generally been reserved for palliation, such as treatment of bleeding, tumor ulceration, infection, or hygienic conditions. A salvage, or "toilet," mastectomy is generally performed as a last resort, with no intent for cure. However, multiple national databases and single-institution studies in the past 8 years have reexamined the role of resection of intact primary tumors for patients with MBC to clarify its role in the care of breast cancer patients (Table 72-1).3-8
Table 72-1 Retrospective Studies on Resection of the Intact Primary Tumor in Patients with Metastatic Breast Cancer |Favorite Table|Download (.pdf)
Table 72-1 Retrospective Studies on Resection of the Intact Primary Tumor in Patients with Metastatic Breast Cancer
|Investigator||Study Period||Type of Study||Number of Patients Who Underwent Resection||Number of Patients Who Did Not Undergo Resection||Primary End Point||Results|
|Khan et al3||2002||NCDB||6861||9162||Time to death|
- No surgery: NA Surgery with negative margins: HR = 0.61, p < .0137
- Surgery with positive margins: HR = 0.75, p < .1035
|Rapiti et al4||2006||Geneva Cancer Registry||127||173||5-year breast cancer–specific survival|
- No surgery: NA Surgery with negative margins: HR = 0.6, p = .5
- Surgery with positive margins: HR = 1.3.
|Babiera et al5||2006||Single institution||82||142|
- 1. Overall survival
- 2. Metastatic PFS
|No surgery: NA Surgery: PFS, HR = 0.54, p < .007 OS: HR = 0.5, p < .12|
|Fields et al6||2007||Single institution||187||222||Overall survival|
- No surgery: NA Surgery: HR = 0.53, p < .0001
- Median survival = surgery 31.9 months vs no surgery 15.4 months
|Gnerlich et al7||2007||SEER program data||4578||5156||Overall survival||Median survival = surgery 36 months vs no surgery 21 months, p < .001|
|Blanchard et al8||2008||Single institution||242||153||Overall survival||Median survival = surgery 27.1 months vs no surgery 16.8 months, p < .0001|
Retrospective studies addressing ...