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Surgery and Metastatic Breast Cancer

7 June 2020

An abstract presented at last week’s virtual meeting of the American Society of Clinical Oncology focused on whether or not there is a benefit to surgery for the primary breast tumor in patients with metastatic, or Stage IV, breast cancer.

Metastatic breast cancer (Met-BC) is when the breast cancer spreads beyond the breast and underarm lymph nodes. Common sites of metastases include the lungs, liver, bones, and brain. Anyone diagnosed with breast cancer has the potential to develop metastatic disease, but approximately 5-10% of patients are found to have Met-BC at the time of initial diagnosis, known as de-novo Stage IV. For these patients, it has been controversial whether or not to recommend some form of breast surgery (lumpectomy or mastectomy) to remove the primary tumor. Some studies have shown a survival benefit when the primary tumor is removed, but widespread adoption of the results of these studies has been limited because in many of these studies, patients who underwent surgery were younger, healthier, and had a lower volume of metastatic disease compared with the general population of patients with Met-BC.

Dr. Seema Khan presented the results of the ECOG-ACRIN Research Group E2108 study. In this study, patients who had stable Met-BC (after 4-8 months of treatment) were randomized to either surgery or no surgery for the primary tumor. The two study groups were well-matched for age, race, and breast cancer subtype. With a median follow up of 59 months, there was no improvement in overall survival or in progression-free survival. Local progression (cancer continuing to grow in the breast) was more common in patients who did not undergo surgery (25.6 versus 10.2% at 3 years). At 18-month assessment, health-related quality of life was significantly worse in those who underwent surgery, but no differences were observed at the 6-month or 30-month assessment intervals.

During her presentation, Dr. Khan acknowledged that there may be situations where surgery for the primary tumor is a reasonable option in the setting of Met-BC. She noted that there is room for individualization, but stressed that as there is no survival benefit and no improvement in quality of life, surgery for the primary tumor in the setting of Met-BC should not routinely be performed. 

It is important to note that any medical meeting abstract, whether an oral presentation or poster, has been evaluated by the meeting program committee but has not been subject to rigorous peer review as would occur with a formal manuscript submission. Abstracts often do not include the full set of results, and additional findings may be included in the eventual publication, some of which may be different than those presented in the abstract. We look forward to the peer-reviewed publication when it is available. 

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Stage 4 Breast Cancer

4 December 2020

The actress Shannen Doherty revealed today that she has Stage 4 breast cancer. From media reports, it appears that she was initially diagnosed and treated in 2015 and developed a recurrence within the past year.

“Recurrence” simply means that the cancer has come back. Breast cancer can recur in the breast or chest area, which is called a local recurrence. This is usually treated with surgery to remove the recurrent tumor, most commonly mastectomy if lumpectomy was the original operation. Radiation therapy, chemotherapy, or hormonal therapy may also be recommended. The risk of local recurrence after lumpectomy is generally less than 10% and less than 5% after mastectomy.

Breast cancer cells can travel from the breast to the lymph nodes or through the blood stream and then deposit in other organs. This is termed systemic recurrence, metastatic breast cancer, or stage 4 breast cancer. The lungs, liver, bones and brain are the most common sites for metastatic breast cancer. Metastatic breast cancer is not curable, and patients who develop metastatic disease will require lifelong treatment.

Anyone who has been treated for breast cancer can develop metastatic disease. It is estimated that as many as 30% of patients will eventually develop metastatic disease but it difficult to get exact numbers because recurrences are not tracked like initial diagnoses are. The likelihood of developing metastatic disease is higher in patients who are diagnosed at more advanced stages and in those with more aggressive tumor biology / behavior, but even the less aggressive or slower growing tumors have the potential to spread. 

Since the most common sites of spread are the lungs, liver, bones and brain, attention should be paid to changes such as persistent cough or shortness of breath, abdominal pain, increased abdomen size, jaundice (yellowing of the eyes), persistent bone pain, fractures with no history of trauma, severe headaches, and new onset seizure. However, patients may have metastatic disease without any symptoms. While there is no true prevention, endocrine therapy (for those with estrogen receptor positive breast cancer) can reduce risk. A healthy diet, regular exercise, and weight control can also reduce risk. It is of course possible to do “everything right” and still develop metastatic cancer.

As mentioned, treatment for stage 4 breast cancer is lifelong. There have been many advances in the treatment of metastatic breast cancer – chemotherapy is not always required and newer targeted therapies have been developed. This is an area of active research. However, approximately 40,000 women and 500 men will die each year in the US due to metastatic breast cancer. More work is needed to better understand why some patients develop metastatic breast cancer, how to prevent breast cancer from spreading, and how best to treat it once it does spread.

Metastatic breast cancer information from cancer.net
Metastatic Breast Cancer Network
Metastatic Breast Cancer Alliance
Metavivor
MetUp

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Metastatic Breast Cancer

13 October 2016

The 13th of October is designated for metastatic breast cancer awareness. Metastatic, or Stage IV breast cancer, is when the cancer has spread outside of the breast or underarm lymph nodes. The most common sites of spread are the bones, liver, lung and brain.  Later stage of disease at the time of diagnosis is a risk factor, as is aggressive tumor biology. However, anyone who has been treated for breast cancer has the potential to develop metastatic disease. Metastatic disease can develop at any point after treatment – even many (15-20) years later. Approximately 6% of newly diagnosed breast cancer patients have metastatic disease at the time of diagnosis, known as “de novo” metastatic disease.

The overwhelming majority of the roughly 40,000 women and 500 men who die from breast cancer every year in the United States die from metastatic breast cancer. Patients who develop metastatic disease are on some form of treatment (chemotherapy, hormonal therapy, targeted agents, or a combination of medications) for life. Radiation therapy and surgery may also be used as part of treatment. In patients with metastatic disease, the focus shifts from potential cure of cancer to controlling areas of cancer growth and managing side effects related to treatment and disease progression. Treatments have improved considerably and many women and men with metastatic breast cancer are living longer than ever, but there is no cure.

During Breast Cancer Awareness Month, and all year, it is important to remember that early detection does not prevent spread. More aggressive surgery does not prevent spread. Metastatic cancer cells may be present before the tumor in the breast is even detected. Take a few minutes to become educated about the breast cancer that kills, and consider supporting research that is trying to find answers.

For more information:

10/13/2019 NPR Interview
Metastatic breast cancer information from cancer.net
Metastatic Breast Cancer Network
Metastatic Breast Cancer Alliance
Metavivor
MetUp

Updated 13 October 2019

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