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Topic: Question on Stage 4

Forum: Stage IV/Metastatic Breast Cancer ONLY —

Please respect that this forum is for members with stage IV/metastatic breast cancer only. There is a separate forum for caregivers and friends: Caring for Someone with Stage 4 or Mets.

Metastatic breast cancer (MBC; also called stage IV) is breast cancer that has spread to other parts of the body, most commonly the bones, liver, brain, or lungs. Metastatic breast cancer can be treated but not cured. Metastatic disease is NOT hopeless. There are a wide variety of treatment options for metastatic breast cancer, and new medicines are being tested every day. More and more people are living life to the fullest while being treated for metastatic breast cancer.

Note: Please contact your doctor for any specific concerns about symptoms you are experiencing or your course of treatment.

Learn more about living with MBC.

Intro medically reviewed by: Brian Wojciechowski, M.D.
Last review date: November 22, 2020

Posted on: Jul 25, 2007 09:01AM

Malone wrote:

Hi I was diagnosed with BC which had also spread to my bones and liver in April 2007. I am taking Taxatere herceptin and zometa. My question is they did not remove my breast. Is this normal to leave the breast when it has already spread?

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Jul 25, 2007 11:15AM Maya1 wrote:

Hi Malone,
There are women here who've had a mastectomy after Stage 4 diagnosis and some who have not. My onc did not believe that removing the primary tumour was necessary and as it turned out the chemo shrank the tumour completely. (I also had liver mets at diagnosis.) There is only one small hard lump left that my CT scan reports have always referred to as scar tissue.
It's an individual decision - some people feel better knowing the primary tumour is gone.
Good luck with your treatments,
Pray to God but row for shore..... Russian proverb Dx 6/30/2004, IDC, 3cm, Stage IV, mets, ER+/PR+, HER2-
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Jul 25, 2007 11:55AM katie11 wrote:

Hi Malone,

Sorry to hear of your diagnosis. I was also diagnosed with bone and liver mets at presentation a year ago and had surgery in May to remove the original tumour. My onc would only go ahead with the surgery when the mets were stable which happened after 7 rounds of taxotere and xeloda. Maya is right - this is a very individual decision and there seem to be some oncs who believe it is worthwhile and others who don't. My onc did say that there had been some recent research in Switzerland to suggest that removing the original tumour may help, but I've never seen anything myself.

It might be worth discussing this with your onc - let me know if you have any other questions.


Katie xx
Hope for the best, prepare for the worst! Dx 7/15/2006, ILC, 2cm, Stage IV, Grade 2, mets, ER+/PR+, HER2-
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Jul 25, 2007 01:56PM Mary1968 wrote:

In my mom case it had to be done...Her left breast was too irritated. Now, she feels much better, however she lives with a lot of pelvis pain.

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Jul 25, 2007 04:43PM WendyV wrote:

Hey Malone - It's me Wendy!!!! I've been thinking about you often and hoping that you are doing OK. If you remember my situation was very similar to yours and yes I did have my breast removed after I finished 6 rounds of chemo. I won't go into all the details here. If you still have my email or phone number please feel free to use either one and we can chat. If you lost them, just send me a PM! I am so glad to see you posting again!!!!
Take Care!
Life isn't about waiting for the storm to pass, it's about learning to dance in the rain.( bone,liver,brain,lung mets) Dx 10/9/2006, IDC, 4cm, Stage IV, Grade 3, mets, ER+/PR+, HER2+
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Jul 26, 2007 08:04AM HappyTrisha wrote:

I would do some research on this because I remember reading somewhere that they now believe you have a better result if you have the tumor/breast removed. If I can find anything further for you I will post it here.

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Jul 26, 2007 08:13AM Shepgirl wrote:

Originally published as JCO Early Release 10.1200/JCO.2006.05.9824 on May 15 2006

Journal of Clinical Oncology, Vol 24, No 18 (June 20), 2006: pp. 2694-2696
© 2006 American Society of Clinical Oncology.
This Article

Articles by Morrow, M.
Articles by Goldstein, L.
Articles citing this Article

Articles by Morrow, M.
Articles by Goldstein, L.
Pubmed/NCBI databasesMedline Plus Health Information
Breast Cancer



Surgery of the Primary Tumor in Metastatic Breast Cancer: Closing the Barn Door After the Horse Has Bolted?
Monica Morrow, Lori Goldstein
Departments of Surgical Oncology and Medical Oncology, Fox Chase Cancer Center, Philadelphia, PA

Traditionally, metastatic breast cancer is considered to be incurable, and the goals of treatment are the prolongation of life and the palliation or prevention of symptoms. Within this context, it is not surprising that local therapy is not routinely recommended for patients presenting with stage IV disease and intact primary tumors. Surgery is reserved for patients who develop complications such as bleeding, ulceration, and infection at the primary tumor site, a type of surgery that historically has been described as "toilette" mastectomy. In this issue of the Journal of Clinical Oncology, Rapiti et al1 present the results of a retrospective, population-based study of the impact of surgical therapy of the primary tumor on survival outcomes in 300 women with metastatic disease at the time of the initial diagnosis of breast cancer. The authors observed that women having surgery of the primary tumor had a 50% reduction in breast cancer mortality compared with women who did not undergo surgery, the survival benefit was limited to women with tumor-free margins of resection, and a significant survival benefit for axillary surgery was not observed.

These results are strikingly similar to those reported by Khan et al2 in a retrospective study of 16,023 patients presenting with stage IV disease at initial breast cancer diagnosis. In the work of Khan, surgery of the primary tumor was associated with a 39% reduction in the risk of death, with a 3-year survival of 35% for patients excised to negative margins, 26% for those with positive margins, and 17.3% for those not having surgery (P < .0001). Again, axillary dissection was not found to contribute significantly to survival.

Both Rapiti et al1 and Khan et al2 adjusted for factors such as number of metastatic sites, location of metastases (visceral v bone and soft tissue), and type of systemic therapy that might have differed between patients who had surgical treatment and those who did not. However, both studies concluded that unrecognized selection bias may have accounted for the observed benefit of surgery, and only a large, prospective randomized trial could determine reliably whether surgery of the primary tumor prolongs survival in the patient presenting with metastatic breast cancer.

The merits of prospective, randomized trials are obvious, but in this era of limited research resources, study questions must be selected with care. In considering a trial of surgical management of the primary tumor in metastatic disease, it is reasonable to ask whether a survival benefit for surgery is biologically plausible and whether the conduct of such a trial is feasible. Several lines of evidence suggest that it is time to re-examine the approach to the patient diagnosed with distant metastases at the initial breast cancer presentation. First, improved imaging technology has resulted in the diagnosis of stage IV disease with considerably lower tumor burdens than were seen in the past. This has led to a stage shift, in which women who previously would have been classified as having stage II or III disease and treated aggressively with multimodality therapy are now being classified as stage IV and managed for palliation.

The natural history of this patient population is not well defined. However, limited experience with aggressive multimodal management of patients with limited metastatic disease, sometimes referred to as oligometastases, supports the validity of testing such an approach in patients with stage IV disease and intact primary tumors. M.D. Anderson Cancer Center (Houston, TX) has reported a 15-year disease-free survival rate of 24% in 134 patients with solitary locoregional recurrences or metastases treated with surgical resection, systemic therapy, and in selected cases, radiotherapy.3 Nieto et al4 reported the outcome of 60 patients with minimal metastatic disease treated with surgery and/or radiation therapy and high-dose chemotherapy. Included in this group were 17 patients with distant metastases at the time of breast cancer diagnosis. After a median follow-up of 62 months, 51.6% of the entire patient group (95% CI, 39% to 64%) remained alive and free of disease. In the patients with metastatic disease at presentation, 46% of those with distant metastases and three of four with supraclavicular metastases were alive and free of disease. Others have also reported prolonged survival after surgical resection of limited metastatic disease in breast cancer.5,6

Improvements in systemic therapies for women with breast cancer also raise the possibility of cure for a select group of patients with stage IV disease in the future. Giordano et al7 examined survival in patients with metastatic breast cancer who experienced relapse between 1974 and 2000. In multivariate analysis, each more recent year of recurrence was associated with a 1% per year reduction in the risk of death. Rapiti et al1 also observed improved survival in patients diagnosed as stage IV in more recent time periods. The hazard ratio for death was 0.6 (95% CI, 0.4 to 0.9; P < .01) for those diagnosed between 1992 and 1996 compared with those diagnosed between 1977 and 1981. Neither the data of Giordano et al7 nor Rapiti et al1 include the benefits obtained from newer therapies such as trastuzumab and bevacizumab. As chemotherapy, endocrine therapy, and biologic therapy improve, the potential for reseeding from the intact primary tumor becomes an issue worthy of consideration.

The suggestion that surgery in some patients with metastatic disease may improve survival is not as outlandish as it may initially seem. Prospective randomized trials of postmastectomy radiotherapy demonstrated that local therapy in the form of chest wall and node field irradiation prolonged survival in node-positive women receiving tamoxifen or chemotherapy.8-10 Although concerns were raised about the extent of surgery and the chemotherapy regimens used in these studies, these observations challenged the prevailing dogma that local therapy has little impact on survival in breast cancer that is likely to be systemic. Instead, the postmastectomy radiotherapy trial results suggest that uncontrolled local disease may act as a source of tumor reseeding, diminishing the effectiveness of systemic therapy. The observation that the increased local recurrence rate after lumpectomy without radiotherapy translates to a decrease in 15-year survival also supports this concept.11 The possible benefit of primary site surgery in metastatic disease is an extension of this line of reasoning.

In aggregate, there is a biologic rationale that supports a proper evaluation of the role of surgery on the primary tumor in stage IV disease. Is such a trial feasible? Data from the Surveillance, Epidemiology, and End Results program indicate that between 1998 and 2002, 6% of women newly diagnosed with breast cancer had stage IV disease.12 This amounts to 12,674 new cases in the United States in 2005. Somewhat surprisingly, a substantial minority of women in this group do not have locally advanced primary tumors. In the study of Rapiti et al,1 31% had T1 and T2 tumors, whereas this figure was 45.7% in the report by Khan et al.2 Primary tumors of this size are readily treated by breast-conserving approaches or mastectomy, whereas T3 tumors (12% and 16.9%, respectively) usually require mastectomy.

If removal of the primary tumor improves survival by reducing total body tumor burden then it is logical to assume that reduction of the tumor burden in the axillary nodes will also be beneficial. The failure of the work of Rapiti et al1 and Khan et al2 to show a benefit for axillary dissection is probably related to the small number of axillary dissections that were performed and their correlation with excision to negative margins. Thus, any trial examining the role of surgery would need to incorporate axillary staging and dissection of tumor-bearing nodes. The possibility of modified radical mastectomy in women with stage IV disease may raise concerns about unduly aggressive surgical therapy. It is useful to remember that the 30-day operative mortality of mastectomy as long ago as the 1970s was 0.35%13; major complications are infrequent and at present, hospitalizations of longer than 2 days after mastectomy are uncommon. These morbidity and mortality statistics compare favorably with the toxicity profiles of many systemic therapy agents used in the metastatic setting. If the survival benefit of surgery were confirmed in a randomized trial it would represent a safe, low-cost form of treatment, a major advantage in this era of escalating medical expenses.

It would be naïve to believe that surgery will benefit all women with metastatic breast cancer. However, from the limited data that exist, it is not clear whether it is the extent of metastatic disease, the sensitivity to systemic therapy of an individual's tumor, or some combination of these factors that identifies the woman most likely to benefit from surgical resection. The oncology community has come to recognize that trials of new agents targeted toward subsets of breast cancer patients, often defined by molecular characteristics, is the approach most likely to provide useful information for therapy in the future. Ultimately, the size of the stem-cell compartment may predict which patients with metastatic disease are likely to benefit from aggressive multimodal therapy. At present, a study design in which patients are selected for surgery based on an initial response to systemic therapy is a reasonable place to start. Philosophically, the approach to metastatic breast cancer has not changed during the last 20 years. If a new drug with low toxicity were observed in retrospective studies to reduce mortality by 39% to 50% in metastatic disease, it would be rushed into clinical trial.

Patients presenting with intact primary tumors and metastatic disease represent a small proportion of women with metastatic breast cancer. Does the work of Rapiti et al1 have any implications for the larger population of women with metastatic breast cancer? Hortobagyi14 has suggested that an aggressive, multimodal approach that includes surgery produces long-term, disease-free survival or cure in a subset of patients with limited metastatic breast cancer. Surgical resection of pulmonary metastases secondary to sarcoma and hepatic metastases from colorectal carcinoma is accepted as standard management, primarily because metastases are often limited to these organs.15 Oligometastatic breast cancer is uncommon, with autopsy studies documenting an approximately 5% incidence of isolated metastasis in lung, liver, or bone.16 Although the proportion of patients with limited metastatic disease is low, the absolute number of women who might benefit from combined-modality therapy is high, given that 40,970 breast cancer deaths are expected to occur in the United States in 2006.17 Just as we have begun to approach primary breast cancer not as a single entity, but as a group of diseases where optimal therapy is defined by molecular characteristics, it is time to recognize that palliation may not be an appropriate goal for all women with metastatic breast cancer. The evidence provided by Rapiti et al1 confirms that it is an appropriate time to asses the relative benefit of aggressive multimodality therapy for women with stage IV breast cancer and a low disease burden.
Dx 12/23/2004, IDC, 2cm, Stage IV, Grade 2, 2/22 nodes, mets, ER+/PR-, HER2-
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Jul 26, 2007 11:57AM mrsjck wrote:

In my case I had clear mammograms for 7 years since 1998 when I had one lymph node positive. Then after almost 8 years I was dx with bone mets. Decision was made with the input of 3 doctors and my the onc put it "why close the door when the horse is already out of the barn". I still have no visible lumps so I think for me I made the right decision to avoid any traumatic surgery. My treatments have been successful in lowering the tumor marker numbers which were rather high (1103 & 561). As others have said, it is an individual decision. All I would advise is that you get your unique facts together before making your decision.

This too shall pass
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Jul 26, 2007 12:12PM katie11 wrote:


Thanks so much for posting this - it's the first piece of research I've actually seen that suggests there may be some benefit in removing the primary tumour for those of us presenting with mets.

Katie xx
Hope for the best, prepare for the worst! Dx 7/15/2006, ILC, 2cm, Stage IV, Grade 2, mets, ER+/PR+, HER2-

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