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All TopicsForum: Stage IV and Metastatic Breast Cancer ONLY → Topic: Removing the main tumor or not?

Topic: Removing the main tumor or not?

Forum: Stage IV and Metastatic Breast Cancer ONLY —

A place for those managing the ups & downs of a Stage IV/metastatic breast cancer diagnosis. Please respect that this forum is for Stage IV members only. There is a separate forum For Family and Caregivers of People with a STAGE IV Diagnosis.

Posted on: Aug 15, 2010 12:22PM

dinddind2003 wrote:

This is my first time visiting the forum and now there is a hard decision for my family. My mother-in-law was diagnosed with breast cancer that was bonemetastasis this March. The size of the main tumor is 5cm×3cm after 6 times radiation. We are concerned that whether now removing the main tumor is a better treatment for her or not, since we heard that there is a likelihood that removing the main tumor may accelerate the spread of breast cancer. Is there any person has similar experience and knowledge about this risk? I really appreciate any advice. Thank you all.

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Aug 15, 2010 12:56PM EnglishMajor wrote:

 Surgery is not standard of care for Stage IV, but in certain cases there is thought to be some benefit. Typically surgery would only be done if the disease in good control. If there was visceral involvement, surgery probably wouldn't be done. 

I don't think that tumor removal could accelerate the spread of the disease. But equally important, there is no guarantee that having the surgery will benefit your MIL. Ultimately it is your MIL's choice. 

I have a low volume of bone mets and had a mastectomy this past May. If you do a search on thi site you will find additional discussions. 

[from a previous thread]

AnnNYC AnnNYC wrote:

Hi Donna -- I hope you don't mind my posting the following literature links (this kind of literature search and review is part of what I do for a living). There are in fact recent (2006-2008)retrospective studies showing an overall survival benefit -- and even more of a progression-free survival benefit -- with removal of an intact primary tumor in women who are diagnosed at Stage IV, especially in women who are ER+ and have only bone mets.

These are probably some of the studies Becky shared with English Major -- and like English Major said, they are all retrospective "chart reviews" comparing the outcomes in women who had surgery to women who didn't. So the results may be biased -- the women who had surgery may have been chosen to have it because they were healthier, or the fact that they had surgery may just have been part of their having more "involved" care from their doctors -- so that's why the prospective trial English Major mentioned is so important.

But still, here is a summary of reports that found a benefit:

Babiera GV, et al. Effect of primary tumor extirpation in breast cancer patients who present with stage IV disease and an intact primary tumor. Annals of Surgical Oncology 2006;13:776-782.
M.D. Anderson, Houston, TX -- All (224) breast cancer patients treated at M.D. Anderson between 1997 and 2002 who presented with stage IV disease and an intact primary tumor. CONCLUSIONS: Removal of the intact primary tumor for breast cancer patients with synchronous stage IV disease is associated with improvement in metastatic progression-free survival. Prospective studies are needed to validate these findings.

Gnerlich J, et al. Surgical removal of the primary tumor increases overall survival in patients with metastatic breast cancer: analysis of the 1988-2003 SEER data. Annals of Surgical Oncology 2007;14:2187-2194.
A retrospective, population-based cohort study by using the 1988-2003 Surveillance, Epidemiology, and End Results (SEER) program data: 9734 SEER patients with stage IV breast cancer. CONCLUSIONS: Extirpation of the primary breast tumor in patients with stage IV disease was associated with a marked reduction in risk of dying after controlling for variables associated with survival.

www.ncbi.nlm.nih.gov/p ubmed/17687611
Fields RC, et al. Surgical resection of the primary tumor is associated with increased long-term survival in patients with stage IV breast cancer after controlling for site of metastasis. Annals of Surgical Oncology 2007;14:3345-3351.
Washington University School of Medicine, St. Louis, MO - 409 patients with stage IV breast cancer treated from 1996 to 2005. CONCLUSIONS: Surgical excision of the primary breast tumor was associated with significantly longer survival in this cohort of stage IV breast cancer patients, even after controlling for other factors associated with survival. Randomized clinical trials are needed to validate these findings.

Blanchard DK, et al. Association of surgery with improved survival in stage IV breast cancer patients. Annals of Surgery 2008;247:732-738.

Baylor College of Medicine, Houston, TX - 807 women with stage IV disease at presentation. CONCLUSION: Patients with stage IV breast cancer who had definitive surgical treatment of their primary tumors had more favorable disease characteristics. However, after adjustment for these characteristics, surgical treatment remained an independent factor associated with improved survival.

Rao R, et al. Timing of surgical intervention for the intact primary in stage IV breast cancer patients. Annals of Surgical Oncology 2008;15:1696-702.
University of Texas Southwestern Medical Center, Dallas - review of all breast cancer patients between 1997 and 2002 presenting with an intact tumor and synchronous metastatic disease. Patients who underwent surgery in the 3-8.9 month or later period had improved metastatic progression-free survival. CONCLUSIONS: Surgical extirpation of the primary tumor in patients with synchronous stage IV disease is associated with improved metastatic PFS when performed more than 3 months after diagnosis. Resection should be planned with the intent of obtaining negative margins.

HOWEVER, this paper from Brigham and Women's in Boston does NOT see any real benefit:
Bafford AC et al. Breast surgery in stage IV breast cancer: impact of staging and patient selection on overall survival. Breast Cancer Research and Treatment 2009;115:7-12
Brigham and Women's Hospital, Boston - Review of prospectively maintained database of 147 women who presented with stage IV breast cancer between 1998 and 2005. CONCLUSIONS: Breast surgery is associated with improved survival in stage IV breast cancer. However, in our experience, this benefit is only realized among patients operated on before diagnosis of metastatic disease and is likely a consequence of stage migration bias. While some women may warrant palliative surgery to the breast, it is unclear that such surgery otherwise improves clinical outcomes.

The possible biases in these retrospective studies are summed up well in this editorial (the link should take you to the whole article):
Khan SA. Primary Tumor Resection in Stage IV Breast Cancer: Consistent Benefit, or Consistent Bias? Annals of Surgical Oncolog 2007;14:3285-3287
...five retrospective studies... present us with consistent evidence that either surgical therapy of the primary tumor has a substantial survival benefit in women with metastatic breast cancer, or there is a strong and consistent selection bias driving the use of surgery in women who have more favorable profiles (i.e., younger age, smaller tumor burden, better access to care). It is also possible that surgery is a surrogate indicator of more aggressive therapy overall, including more aggressive systemic therapy, which translates into better survival. All authors acknowledge the problem of selection bias in the interpretation of these data, and all advocate for a randomized trial to settle this question.

Dx 7/6/2009, IDC, 3cm, Stage IV, Grade 3, mets, ER+/PR+, HER2-
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Aug 15, 2010 01:51PM katie11 wrote:

Hi there!

I did have surgery but only after I'd gone through five cycles of Taxotere and Xeloda that put my disease into remission.  There are different opinions on the benefits of surgery at Stage IV in the wonderful world of oncology, though.  My onc at the time felt it could be beneficial to me but he'd recently been to a conference where research from Switzerland suggested it could help longer term survival.  I'm still kicking cancer butt 4 years on, but don't know whether it's down to the mastectomy.  BTW I've never heard of surgery helping spread the disease!  Good luck with your decision. 

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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Aug 15, 2010 07:10PM Cafelovr wrote:

I was Stage IV from the get go! I had an 11 cm tumor, plus a single liver met. I have a very pro-active oncologist that said he was going to treat me as if I was Stage III. I had 4-DD ACs and 9/12 Taxol/Herceptin cocktails. I finished with chemo in March and had a BMX in April. My tumor at the time was 1.5 cm. My liver met went from 16 mm to 10, and at the beginning of rads in May, it was gone.

I am finally NED, and intend to stay that way. I intend to fight this head on with whatever artillary is available!

Good luck to your MIL!

Linda J Dx 10/19/2009, IDC, Left, 6cm+, Stage IV, metastasized to liver, Grade 3, 2/2 nodes, mets, ER+/PR-, HER2+ Chemotherapy 11/23/2009 AC + T (Taxol) Targeted Therapy 1/22/2010 Herceptin (trastuzumab) Surgery 4/4/2010 Lymph node removal: Left, Underarm/Axillary; Mastectomy: Left; Prophylactic mastectomy: Right Radiation Therapy 5/4/2010 Breast, Lymph nodes Hormonal Therapy 7/10/2010 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 12/28/2011 Reconstruction (left): Latissimus dorsi flap, Tissue expander placement; Reconstruction (right): Latissimus dorsi flap, Tissue expander placement Surgery 5/28/2013 Prophylactic ovary removal
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Aug 16, 2010 09:09AM Fitztwins wrote:

I agree, I feel that you need to remove the main tumor.

Enjoy Every Sandwich. Dx 12/12/2004, IDC, Left, 3cm, Stage IV, metastasized to bone/lungs, Grade 2, mets, ER+/PR+, HER2+ (FISH) Surgery 1/19/2005 Lymph node removal: Left, Underarm/Axillary; Mastectomy: Left; Reconstruction (left): Free TRAM flap Chemotherapy 2/1/2005 AC + T (Taxol) Radiation Therapy 5/1/2005 Breast, Lymph nodes Targeted Therapy 6/1/2005 Herceptin (trastuzumab) Hormonal Therapy 1/1/2006 Femara (letrozole) Hormonal Therapy 6/2/2008 Aromasin (exemestane) Targeted Therapy 7/1/2008 Herceptin (trastuzumab) Hormonal Therapy 6/15/2013 Arimidex (anastrozole) Targeted Therapy 9/5/2015 Perjeta (pertuzumab)

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