Oligometastatic Prognosis
On another forum, somebody posted this abstract, and I want to share it with you all - with comments. Since I am being treated as a true oligometastatic patient, this topic interests me. I think it is becoming more and more accepted as a real possibility, that a very small subset of women with mets can live long lives.
It is incredibly hopeful, especially that three people with mets lived out their full, natural lifespan, almost 70% with single organ mets made it 10 years, and 50% made it to 20 years. Too many doctors are still unaware of this possibility and may not treat patients appropriately. I am very pleased that my onc recognized the possibility and I got aggressive treatment. Of course, we are still waiting to find out if it is working or not.
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Only a few years ago oncologists were telling their patients that the average Stage IV patient survived an AVERAGE of two years no matter what their treatment and many were nihilisitic in their attitude. Oligometastatic disease has such a better prognosis, would this not imply it is important to be aggressive in trying to find and equally aggressive in trying to treat the first metastases if they are rare.
The rationale behind not testing periodically after completion of treatment and waiting for a fracture to occur , seizure or change in vision to occur etc has been that most patients don't, it is expensive to check, and there is not much benefit in finding the metastases earlier rather than later. That is obviously not so for oligometastatic disease.
Is oligometastatic disease a characteristic of the type of breast cancer or the fact it was found early?
Breast Cancer. 2012 Apr 25. [Epub ahead of print]
Possible clinical cure of metastatic breast cancer: lessons from our 30-year experience with oligometastatic breast cancer patients and literature review.
Kobayashi T, Ichiba T, Sakuyama T, Arakawa Y, Nagasaki E, Aiba K, Nogi H, Kawase K, Takeyama H, Toriumi Y, Uchida K, Kobayashi M, Kanehira C, Suzuki M, Ando N, Natori K, Kuraishi Y.
Source
Department of Clinical Oncology and Hematology, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan, tadkob-1@kk.iij4u.or.jp.
Abstract
BACKGROUND:
Metastatic breast cancer (MBC) is generally incurable. However, 10-20-year relapse-free survival of MBC is approximately 2%, implying that at least a small subset of MBC patients achieve prolonged survival. We therefore analyzed long-term outcome in a particular subset, i.e., oligometastatic breast cancer (OMBC).
METHODS:
Data of OMBC subjects (N = 75) treated in our institution from April 1980 to March 2010 were retrospectively analyzed. OMBC was identified as: one or 2 organs involved with metastatic lesions (excluding the primary lesion resectable by surgery), fewer than 5 lesions per metastasized organ, and lesion diameter less than 5 cm. Patients were generally treated with systemic chemotherapy first, and those who achieved complete response (CR) or partial response (PR) were further treated, if applicable, with local therapy (surgical or radiation therapy) to maintain CR or to induce no evidence of clinical disease (NED), with additional systemic therapy.
RESULTS:
Median follow-up duration was 103 (6-329) months. Single or 2 organs were involved in, respectively, 44 (59%) and 31 (41%) cases with metastatic lesions, 48% of which were visceral. In cases where effects of systemic therapy, possibly in combination with other treatments, were evaluated (N = 68), CR or PR was achieved in 33 (48.5%) or 32 (47.1%), respectively, with overall response rate (ORR: CR + PR) of 95.6% (N = 65). In cases receiving multidisciplinary treatment (N = 75), CR or NED (CR/NED), or PR was induced in 48 (64.0%) or 23 (30.7%) cases, respectively, with ORR (CR/NED + PR) of 94.7% (N = 71). CR rates (60.5%) with systemic therapy and CR/NED rates (79.5%) with multidisciplinary treatment were significantly better in subjects with a single involved organ than in those with two involved organs (P = 0.047 and 0.002, systemic only or multidisciplinary treatments, respectively). Medians estimated by Kaplan-Meier method were: overall survival (OS) of 185.0 months and relapse-free interval (RFI) of 48.0 months. Estimated outcomes were: OS rates (OSR) of 59.2% at 10 years and 34.1% at 20 years, and relapse-free rates (RFR) of 27.4% at 10 years and 20 years. No disease progression was observed after 101.0 months as RFR. Cases with single organ involvement (N = 44) showed significantly better outcomes (OSR of 73% at 10 years and 52% at 20 years, RFR of 42% at 10 years and 20 years). Those who received local therapies (N = 35) also showed better prognosis: OSR of 82% at 10 years and 53% at 20 years, RFR of 38% at 10 years and 20 years. Three cases (4%) survived for their lifetime without relapse after achieving CR or NED, our definition of clinical cure. Multivariate analysis revealed factors favoring better prognosis as: none for OS, and single organ involvement with metastasis, administration of local treatment, and shorter disease-free interval (DFI) (P = 0.030, 0.039, and 0.042, respectively) for RFR. Outcomes in OMBC in literature were OSR of 35-73% at 10 years and 26-52% at 20 years, and RFR of 27-42% at 10 years and 26-42% at 20 years.
CONCLUSIONS:
The present analyses clearly indicate that OMBC is a distinct subgroup with long-term prognosis superior to MBC, with reasonable provability for clinical cure. Further prospective studies to better characterize OMBC are warranted to improve prognosis in MBC.
PMID: 22532161
Comments
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Ann. since My sister has that MBC I have read more about that and the odds are amazingly better than even 10 years ago.. My sister has been in remission for over 4 yrs now and still working full time and is 73 now. She never had chemo or rads, but gets a shot and takes 1 pill a day. We had different Oncs, so I never understood the reasoning behind no chemo, but she's done well for what has happened,
BTW u r (as others) so unbelievably knowledeable of all of these topics--I'm always in awe how u can explain and so many of u do understand everything. U guys have really taken control of this orrible disease the best way u can and with such energy and niceness.
I remember talking with my onc. at the time about er treatment and she agreed that was what they do for her type of mets. Anyway I think there is a much larger survival with BC or MBC then ever before which is wonderful and as time goes by it can only be better.
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I raised this with my oncologist in 2009 after what I considered was aggressive chemo which was intended, I thought, to be palliative resulted in regression of my liver mets. And is since then gone. She thinks that I live in La La Land. I think she is wrong, wrong, wrong. My reading indicates that there are some of us who are incredibly lucky, who have a brush with death...but the cancer is gone, gone, gone. Thanks for posting this. It makes me very happy.
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Coolbreeze.. you are one cool lady.. thanks for sharing this.. I get more hopeful day by day - thanks to the likes of you and many of our sisters.. I really admire your gusto.
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Any shred of hope on liver mets fills my heart with joy. so, thank you Cool Breeze!
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What is this word anyway? I'm going to google this word, hope its me.
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Ann...
I'm very excited at the prospect of this, although I dare not mention the word. My oncologist has never mentioned the word either, and although I've been aware of the possibility I've never asked her about it. Don't want to jinx myself! But her aggressive actions with me suggest that we're going for it... NED since Jan. '11... much too soon to get comfortable but WOW I'm fortunate to be here and doing well. GO BIG OR STAY HOME! You're certainly no stranger to this with your liver resection, and I hope, hope, hope that we can live to tell the tale and that many others will follow!
I like the new approach to MBC and I hope that more oncologists start thinking this way!
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My onc hasn't said the word either. But, he did refer me to a surgeon who has written papers about the word, so he must think it's a possibility. I definitely got lucky when I got my onc. Wish you all the big O.
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Thanks for sharing the article. I found it very informative (after I look up the word 'Oligometastatic') and encouraging!
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Thank for pointing out that abstract, Ann.
I have shared my wife's story in the past. She had surgery for apparent stage I breast cancer early in 2002. Then in 2010, a single 2cm lung lesion and a small (~5mm) lesion on the posterior of her lower spine were found. She had consecutive surgeries a month apart to remove the two lesions in April/May 2010, and pathology of the lung tumor showed it was her breast cancer, still triple-positive. Oddly, the spine tumor was almost completely dead, and pathology was inconclusive, but it seems highly likely it was the breast cancer. The surgeries brought her to NED, but she still did a brief course of radiation to the spine and then chemo, similar to what early stage patients might do after surgery. She hadn't done any hormonal or chemo treatment after her primary surgery in 2002 (against onc's recommendations), but she has no regrets (in 2008, she gave birth to our son at age 45, and who knows how her ability to do that could have been impacted had she undergone intense adjuvant treatment earlier).
Now she is about 2 years out from those lung and spine surgeries, and results have been very good. Her overall health has been typical for her age (if not above average), and despite continuing on Tamoxifen and Herceptin for an indefinite period of time, has had no notable issues with those. We think she is NED, though recent scans show a small irregular lung nodule with mild activity on a PET that the doctors think is likely scarring or fibrosis caused by the surgery and/or subsequent re-shaping of her right lung, but it will have to be watched in future scans. But even if that eventually shows signs of being cancer and needs treatment, it is an isolated spot and could be treated in the future with additional surgery, ablation, or SBRT, if all other areas continue to be clear.
All our doctors referred to her case as oligometatatic, and her treatment was deemed curative from the start. That said, one never really knows what to expect from this disease. We hope her cancer remains limited and sluggish, as it seems to have been for the last 10 years.
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I've looked up the term but (having a stupid day) can't see the difference from ordinary metastatic cancer - can someone give me a simple explanation of the difference (I've got spine and brain mets - would this be oligo or not?)
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The original post defines oligometastatic cancer as fewer than five lesions to one or two organs, with lesions smaller than 5cm.
Thank you for sharing your wife's story, jhammel. It's very encouraging!
When I was diagnosed with a recurrence (mets to 2-3 lymph nodes just outside the supraclavicular chain and nowhere else) my original oncologist said I was a goner and wouldn't go with aggressive treatment. My NEW onc, God bless him, was very aggressive and started chemo the day after I saw him. I've been NED for 2.5 years since.
I'm so glad there's a curable component of stage IV disease. We just have to keep pushing until all of us are curable, and cured!
Scoot
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oligometastatic was not even in my online dictionary.
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Princess Margaret hospital in Ontario, Canada actually has an Oligometastatic Group that specializes in treating those lesions. Outstanding! Do we have a group like that in the US? Anyone know?
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I googled it, it means less than 5 lesions in any distant site. I'm not that word! But I don't get how that would really make a difference. I was that word at one time, most of us were. I mean most women start out with less than 5 lesions, don't they?
So, I'm taking it to say hope
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very generally speaking, oligometastates means metastases that are few in number,but it's a little difficult to pin down a single specific definition from the literature. The definitions of the word I have seen generally fall into 2 ctegories:
1) a definition based on location, the number of lesions, size of lesions, and the number of involved organs. This type of definition is necessary for determining who to include in a research study or analysis, but even these vary. Perhaps there is sound clinical reasoning behind some cutoffs selected for these definitions, but they may be partly influenced by the numbers of patients needed to include in analyses to reach meaningful conclusions,so I don't know. In general, I'd say the fewer and smaller the more likely the better anyhow.
2) another type of definition that I think is more direct to the true point is that oligometastasis is defined as a state of limited metastatic capacity of the cancer. Someone in such a condition may only develop a small number of metastatic lesions over a long period of time, whether aided by systemic therapies or not. If all those lesion are treatable, then such patients might be kept well for a long time. The problem with this definition is that limited metastatic capicity isn't necessarily true just because there is little visible spread currently, so nobody would know for sure if thay fit this definition or not.
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I was termed oligo last summer after an almost complete response to chemo. Tennis ball sized liver tumor completley gone and all scans showed lung lesions melting away..I had been sent to both lung and liver surgeons thruout my chemo to plot out removing the mets, Turned out I didn;t seem to need either of them. My Onc has called me a freak of nature-I have never been sick or looked sick except for the bald thing. Graet appetite no SEs ect. Felt I was a very rare case.
Did BMX and Rads and was finishing up Herceptin---then Jan scans showed a runaway train. I was expecting to be told I was NED instead the existing mets quadrupled in size (still very tiny) and some new places showed up. April; scan showed a mixed bag with some shrinking and some growing and 2 more new spot (still very tiny).
Feeling like I am sliding down that slippery slope of never getting better. Mets are scattered so far apart and are considered too small to be removed. Pinning my hopes on the Pertuzumaub to fix me up.
Oligometastatic is not brought up in my visits anymore-by either of us. It was a brief hopeful fling. My Onc is way more optimistic than me. I am in fabulous health other than some hand/foot crap from the Xeloda. Maybe I will be in that 2% group again 1 day. I wish it for all of us. Heck the first Onc I went to when I was fisrt DXed wanted to put me in Hospice and Pallitive Care after he saw my scans. he told me the time and resources to treat me wouldn;t be worth what was surely to be a bad outcome. Even thought I told him I had never missed a day of work, palying tennis 4 times a week, taking care of my parents...so I am still in a rare group-just not feeling curable these days.
Thanks Breeze for bringing this up again. When I posted about this last summer I saved my thread and return to it every once in a while to get me back to a positive place.
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One of my close friends was treated for lung mets something like 13 years ago. She will be on hormonal therapy (currently Arimidex) for the rest of her life, but otherwise is thriving.
I do believe that "cure" applies in her case. It was amazing. Her original onc did not give her hormonal therapy, and the mets were found in a routine chest x-ray for foot surgery. So she ended up having lung surgery but they were unable to get everything. Tamoxifen did the rest, and she has been NED for at least 10 years. She has moved on to AIs.
She also changed oncs and her new person monitors her very closely.
So I do believe that some Stage IV is curable. I also know that things are getting better and better in that arena.
And certainly the recent advances in genetic testing (discovering that BC really is 10 different diseases) will make this a very different game going forward, and I suspect with much higher cure rates. - Claire
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When I presented with bone mets 6 years ago, my onc used the term Ogliometastic to describe the 2 lesions in my illium. They were treated with radiation and chemo. I stayed with 2 healing lesions for a long time. Unfortunately though, things have changed and I've had progression
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CoolBreeze, thanks for posting this. It is encouraging but a very small study. But I do think they need to think more about the standard of care for oligometastatic mets.
When I received my Stage 4 dx in 2009 I had a single met to my C-spine. Rads zapped it into oblivion and I have been on AIs since then. I tried to persuade my onc to give me chemo but he refused saying the outcome would be the same.
I didnt get his logic. When I was treated for stage 2 disease in 2000, I got chemo, then rads to kill whatever local cells the chemo might have missed, and then finally, with no detectable disease anywhere, they put me on tamoxifen as a preventive thing...so why, when I had an inoperable tumor did they settle for *HOPING* the rads would kill it?
Apparently the rads did their job, for the time being at least. I have been NED since rads, 2 1/5 years ago. Knock on wood.
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I don't think there is an exact definition because many doctors still don't believe it exists. It has more to do with how breast cancer tumors spread and grow than anything else. The theory has been that once a woman has mets, that she has cancer cells circulating everywhere just waiting to grow. Now they are thinking that may not be true in a small subset of people. Those with oligiometastatic disease may not have cancer cells everywhere and if the site of initial spread is contained, then maybe the cancer can still be contained because it isn't anywhere else to seed out.
The only way they have to tell right now, of course, is where cancer grows. If you have smaller tumors in only one area that doesn't grow or spread rapidly, than you may have oligometastatic disease. This is where the new circulating tumor test could be interesting, if they can make it accurate and widely available, neither of which it is right now.
But for now, all they have to go on is tumor size, growth and location. They think if you only have it in one area after a certain period of time, there is a small possibility it isn't everywhere.
My multidisiplinary team is treating me as oligo. My surgeon believes I can live a long time. I had three tumors in my liver only, under 3 cm each. They were found four months past completion of treatment for Stage II (TCH with herceptin for a year). They resected half the liver to remove two of the tumors and ablated one spot they couldn't get to surgically. Two and a half years after initial dx, it was nowhere else in my body. Right now, It might be back in the liver or it might not, there was a conflict on what they see in the area of ablation, so we will find that out next month. But, so far <knocking wood furiously> it is nowhere else in my body.
In order to treat me, my surgeon was looking not only for a person in good general health (aside from cancer) but also time from initial diagnosis to metastasis, small number of mets in only one organ, response to previous treatment, all of which I had. And, they are continuing to do chemo with me, whether they see anything there or not. They only reason I had to stop was the colon infection, but I will be on chemo forever whether it grows back or doesn't.
If I'm super lucky and really am an oligo and I do get years, there might come a point in the future where I will get to be off treatment. But, so far the trade-off is a fair one and I'll take it.
Of course, next month's scan might show something different and then my hopes will be dashed again, like Lilylady's was. I feel for you, Lily, because we were in the same place at the same time. I hope that your new treatment works and you get to NED again.
Oligometastatic status is something they believe is very rare, those who even believe in it, only 2% of people with mets are considered possibilities. Maybe Kathy Rich had oligo metastatic disease - she got 19 years living with mets, and something like 25 years with cancer total. I don't know what treatment she was on at the end but I do think she was always on something. And, she had a bone marrow transplant in the beginning that they don't do now, so she was treated very aggressively. There are probably a few others here who have it too.
I wish it was all of us, and selfishly, I hope it is me.
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Thanks for the explanations - feel clearer now but sadly am not in that group...
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While I don't fit the definition that was used here for oglio , I consider myself to be as I had just 2 liver mets, but one was bigger than 5 cm. I also went 5 years from my original diagnosis to mets. I was also treated agggressively with chemo, than rfa.
I wish they would have broken it down into subsets. How many were er+ or Her2+? I am wondering if that plays a role in these survival numbers.
I think it would also be interesting for those who consider themselves to be oglio, and especially if you have been NED for an extended period of time, and have tumor markers that are reliable, what your numbers are.
I had the ca 27/29 done since I was diagnosed in 2005, it ranged between 9 and 11, until I was diagnosed with mets in 2010, when it jumped to 50. It quickly came back down to normal range after a few rounds of chemo, and has been back in the range of 9 to 11 for the last 17 months, 14 of those months I have been NED.
I am hoping that this could help support this theory that maybe all stage 4 don't have cancer cells all throughout their body waiting to grow.
This article gave me so much hope, My little girl turned 10 yesterday, and I never believed I would be here to see her grow up. I am hoping I could be one of the lucky ones to get 10 years or more.
Laurie
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I updated the book notes for red devil by Kathy Rich:
http://killerboob.blogspot.com/2012/04/kathy-richs-red-devil-book.html
Oligometastatic is a term that is initially limited but will be expanded in future. As more and more metsters live longer and achieve NED/stable, there will be more surgical options available for these patients. So even if you had innumerable mets, chemo/hormone/biologicals/radiation turned you into NED or stable, you may qualify for surgery.
Liver can regenerate itself. We need to fund more clinical trials that can work on stem cells to regenerate liver or help liver regenerate.
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My onc sent out 5 samples for the circulating tumor cell and all results came back the same-zero. Not a reliable outcome because at least 2 of the people he sent out were in active progression. In his group they have said they will wait til it is a better test before they do it again. 3 docs in the practice sent out 5 tests- each to a different place but pretty much the same results. of course I had hoped mine really was a zero.
As far as the tumor markers mine haven't ever really moved from when I was full if cancer to now when I have little pinpoint tumors thruout my lungs.
Whatever defines oligo I am thrilled for the ladies who experience it and pray that the rest of us will get there one day. For now-I am healthy and living pretty close to normal so I am grateful for that.
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I am oligometastatic but since it's bone (one met in my sacrum) "aggressive" won't necessarily do anything. There is no surgical option, only rads, and the onc feels that the Femara/Aredia is doing enough of a good job to keep on with it. I agree with his logic. If I have rads and it knocks the tumor out (and no guarantee that it would) I would still continue with the same tx. Not only that, if things change and the tumor grows/returns to that area and causes either severe pain or problems with function (sacral tumors can press on nerves to the sphiincter muscles, causing bad incontinence problems) then rads wouldn't be an option at that point.
I've had regression and now I'm stable with the tx I'm on - it's almost 2 years with this combo. Is the good response because it's oligo? Maybe, but I'm not surprised the AI is working so well for me - my tumor was 100% ER+.
If at any point in the future those nasty cells decide to take up residence in an organ, though, we're gonna go after them like gangbusters.
Leah
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Stem cells to help the liver regenerate? I don't know what that is supposed to mean. The liver does regenerate, all by itself. It's the only organ that does so. Supposedly happens pretty fast too, within a few weeks.
I never felt a thing!
That article I posted was ahead of publication - perhaps there will be more when it comes out. Whether we have access to it or not, I don't know but if so, I'll post it.
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Liver regenerates naturally. People can surgically remove 1/2 of liver and still be ok. However, Breast cancer has the nasty habit of dispersing itself like dandalions across liver. Some people who has big liver or total liver involvement will face high mortality risks if you cut more than 2/3 of liver. And cancer patients are not eligible for liver transplant anyway.
Enter stem cell technology to allow entire organs to regenerate. It's preclinical. But it will be coming:
Even if that is not an option, one can potentially inject stem cells into liver to speed up the regeneration process and reduce mortality risk and hence expand the usage of hepatic resection for metastatic breast cancer patients.
These technologies are improving from all over the world. China/Germany/Japan are places to watch. But be careful to sign up with any clinic who claims they already know how to do it. Whatever they know and can do, should be reproducable by other labs/hospitals across the world.
Nobody knows for sure, that's why we need clinical trials, we need international effort for data sharing and trustworthy data. Patients need to demand newer techniques and fund basic/translational research. Check out my blog
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I had this conversation with my oncologist and I am considered ogliometastatic. I had one stupid 1.5 inch met on my liver. My dr was very agressive with his treatment. However, he never told me I will be off chemo. I will take Herp & Zometa (to protect my bones) for life. I made a comment that I wanted to see my daughter graduate from HS. He said I will watch my grandkids graduate from HS. I've had a complete pathological response to my chemos and the like.
I went to a cancer seminar last year where my onc was the guest speaker. He looked right at me and told the crowd that one day he forsees a "cure" for Stace IV cancer. I'll take that!!
I hope I didn't just jinx myself...LOL
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Up to 70%, sometimes 80%, of the liver can be removed without consequence. Our livers are vital but you only need a small area to do the work. And, they regenerate, as I said, without stem cells, and it happens within weeks. It's a remarkable organ. The whole point of this thread is that it doesn't "reproduce like dandilions" for everybody, that is why we are considered oligo. You seem to be pushing a stem cell agenda without reading the information.
You are wrong in that many cancer patients are eligible for transplants. BREAST cancer patients are not because of what I said in above posts - so far, everybody believes that once breast cancer has spread, it is seeded everywhere and so a transplant will be useless, but that belief is starting to change. However, other cancers do get transplants.
So far, I have no interest in your blog because you are posting misinformation that isn't well-written.
I have a blog too as do many of us. If you put yours in your signature, people will find it if they are interested. If you keep posting it in every thread, it looks like you are doing a commerical.
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Breast cancer typically spread like dandalion seeds that's why oligometastatic is considered rare (2-5%). Also, that's why liver transplants are rarely given to breast cancer patients. They'd rather give them to colorectal cancer patients whose cancer often do NOT spread like dandalion seed.
I learned a lot from you so I thank you for it. But my information is not wrong, just because you think you know everything.
I typically post in clinical trials forum, but this thread is very informational, I think people might need this information. However, i'm ok if people delete my messages from this forum.
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