Removal of Primary Tumor Improves Survival for Stage IV MBC
A recent study concluded that, for patients who are newly diagnosed with Stage IV breast cancer (i.e. patients who did not previously have early stage bc) surgery to remove the primary tumor improves survival.
A Phase III randomized, controlled trial of 274 women newly diagnosed with stage IV breast cancer was conducted to determine whether surgery to remove the primary tumor affected survival. Half the women received standard therapy, which avoids surgery and consists of a combination of chemotherapy, hormonal therapy and targeted therapy, while the other half first had surgery to remove their primary breast tumor, followed by the standard therapy.
At about 40 months after diagnosis, the women who received the surgery plus standard therapy lived an average of nine months longer than their counterparts who received standard therapy alone. Nearly 42 percent of the women who received surgery lived to five years after diagnosis, compared with less than 25 percent of the women who did not receive surgery.
"Our findings will change the standard of care for women newly diagnosed with stage IV breast cancer," said principal investigator Atilla Soran, M.D., M.P.H., clinical professor of surgery, University of Pittsburgh School of Medicine. "We've shown that surgery to remove the primary tumor--either through lumpectomy or mastectomy--followed by standard therapy, is beneficial over no surgery."
From: http://www.eurekalert.org/pub_releases/2016-06/uops-itc060116.php
Comments
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Wow, Bestbird, This is big news to me. About 6 months ago I talked to my MO about a clinical trial to study just this issue. He thought that the results would show that there was no difference between those who had surgery and those who did not. I think that particular trial was not limited to stage IV de novo. My breast surgeon, on the other hand, was convinced that removing the primary tumor would have a positive impact. She still brings up the subject when I see her, but I had so much happening in my life during the winter (DH was hospitalized for long period), that I need very a seriously considered it. I think I will bring up this study when I see her next week to see if surgery after a year of treatment would still be likely to be beneficial
Thank you for keeping us informed. I do appreciate it.
Lynne
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I have suspected this to be true. Glad to see some proof.
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This rather upsets me as when I was dx Stage IV right out of the box my Onc said absolutely not. Now I wonder if i am still eligible? That is a pretty large difference in Cancer World....thanks Bestbird
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My first PET scan was scheduled after my mastectomy. So I was diagnosed as stage IV shortly after the surgery.
Interestingly, I think there was some discussion about treating before surgery but the team decided to go the other way. It sounds like my medical team made a good decision.
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Thank you, dear Bestbird!
This has been a contentious issue in the breast cancer treatment community for years.
I hope that our treatment teams continue to define and refine proper procedures to ensure our well-being and longevity!
Healing wishes and hugs, Stephanie
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I was diagnosed Stage IV right from the start. One week after a mastectomy I had a PET/CT scan which showed cancer in my spine.
I had no choice regarding the mastectomy as the tumor had broken through my skin. If nothing else the mastectomy was done to "clean me up". I agreed wholeheartedly.
I'm small breasted, didn't choose reconstruction and wear a little fiber-filled prosthesis in regular bras.
I've lived with Stage IV for 10+ years and while I've had progression over the years I've often thought removal of the primary cancer has been to my advantage. The surgery removed the "mother ship" so to speak and reduced my tumor burden immediately.
Kessala
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I'm so happy to hear this news as I've second guessed myself. Not knowing my BC had already spread, I had BMX within 2 weeks of dx. Then found out it spread and heard that most likely insurance would not have paid for BMX knowing it had spread.
The results of the study makes sense as I firmly believe removing the tumor load just HAS to be beneficial. Thank you for finding this information and sharing Bestbird. As always you keep us in the light.
Amy
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I have long wondered about this since my situation was a bit unique. It was thought that I was lower stage sohad a bmx with some excellent recon, prior to proposed chemo. Through a series of unlikely and unfortunate events, a bone met was found a few short weeks after surgery. I will never know for sure if the bmx has helped me or not, but I like to think it contributed to almost five progression free years. If nothing else, it is emotionally comforting to know the darn thing is out of my body.
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Thanks, Bestbird and also to the Turkish Federation of Societies for Breast Diseases, the funder of the study.
In 2006, a retrospective Swiss study showed a strikingly similar result (40% of women survived 5 years) for surgery resulting in negative margins only.
http://jco.ascopubs.org/content/24/18/2743.full
I was diagnosed in 2007, but had chemo first before surgery in 2008, even after scans showed NED in both primary and mets. So it is possible to do the surgery later as well.
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Like a couple of you, it was discovered that I was really stage IV by a pt scan done after my mastectomy (which had labeled me as stage 1). I have also always felt like the reduction of the tumor burden had to have been beneficial as my extreme fatigue ended as soon as the surgery was done. I've been NED now for over 3 years with it being 4 years since initial diagnosis.
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This is VERY interesting! I have harbored some deep down anger and resentment for 7 years. It seemed that many were able to keep their breasts, and mine were gone. I missed them, honestly. I had oncologists who were surprised that I had the bilateral radical mastectomy. I had reconstruction (DIEP), and really have not been happy with my "new" body. It was unbelieveably painful, physically and emotionally.
This study has actually given me some peace. I was discussing this with my husband last night, and I think he was surprised that I had been so angry.
THANK YOU! for posting this.
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I am Stage 4 de novo, but had a mastectomy before the mets were found in follow up scans. Initially I was told my nodes were clear, but during surgery, the surgeon found 22/24 nodes infected and leaking cancer cells, so the follow-up scans were really to confirm how far it had already spread.
I can't imagine how it would have gone if they hadn't removed my large and painful tumor, and all those nodes.
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I had 6 sessions of TCH neoadjuvant chemo before a lumpectomy. radiation took place after surgery. I am a strong believer in surgery to get rid of the mothership tumor but think studies have shown that is best after neoadj. chemo rather than before. Anyway that was the standard protocol where I was and am being treated - Cedars-Sinai in Los Angeles. I'm strongly ER +, weak PR + and HER2+++ Tho diagnosed initially at stage IV in November-December 2007, I'm still here, on Herceptin, arimidex generic, xgeva and NED since the fall of 2008. My concern - which may not be rational - is that surgery before chemo may contribute to additional mets.
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I want to add to my comment above my complaint about the general under use of PET scans when warranted as part of the testing to inform treatment staging. I am disturbed by the number of reports that stage IV status was only identified after surgery or after adjuvant treatment started. I am disturbed because I think the better approach for stage IV is neoadjuvant chemo before surgery. I would like to see PET scans offered at least whenever there are reports of pain or the preliminary diagnosis is stage III.
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I had the breast tumor removed after being diagnosed from the start with stage iv bc.
My story: I found a lump which, after ilc malignancy was determined, a scan measured it to be 6.9 x 4.3 x 1.8 cm. (I recently got out my ruler and measured what this was in inches and thought, that was one big sucker). The onc and breast surgeon discussed neoadjuvant chemo with me to see if the tumor could be shrunk so I could have a lumpectomy rather than mastectomy. I really did not want to lose my breast(s) unless necessary. In the midst of these appointments, I had the pet scan that determined bone mets. I was still given the option of neoadjuvant chemo, so I had six rounds of taxotere and cytoxan and there was a noticeable, although not complete, reduction in the tumor. So I had a lumpectomy followed by 33 rounds of radiation. After that, I began arimidex in November 2011, and am currently still taking it. My scans over this time have read as either stable, regression or even ned and I reached the five year mark at the end of last year/beginning of this year.
Perhaps the only thing that surprises me in the study is that it had not been conducted sooner; apparently it started in 2007 begun by an oncologist inPittsburgh, Pa
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I wonder if doctors ever purposely save the scans for after breast surgery because they believe that breast surgery would be helpful in a particular case, and suspect that insurance would deny the surgery if stage iv was diagnosed.
I know this study is about de novo stage iv, but it does cause me to consider asking for a lumpectomy if a breast tumor re-appears. I had a lumpectomy for stage i in 2011. Then in 2014, a breast tumor was found, same breast but different quadrant. I thought I was going to need a mastectomy, but then the liver mets were diagnosed in the same week, so I went right to taxol instead. My onc believes the breast tumor was also metastatic disease, though it could also have been a new primary or an undiagnosed second primary from 2011. In any case, it disappeared with taxol. If it comes back, I will ask about surgery, based on articles like this one. (And I would ask for the right kind of anesthesia to avoid possibly promoting mets.)
Congratulations on five years, MrsM!
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Shetland, I was wondering the same thing. Doctors must realize that a shift has occurred as a result of better imaging where cancers are being diagnosed as stage IV which would previously have been stage II or III. If chemo is not appropriate with all its toxicities and with each case being different, surgery of the primary tumor is generally a safe and efficient treatment. Hopefully with the right kind of anesthesia, as you mentioned, and clean margins.
Divine, I think after some studies in 2002 and the study I linked above in 2006 people started thinking that palliation may not be an appropriate goal for all women with MBC. So what if the horse is out of the barn? But researchers acknowledged that unrecognized selection bias may have accounted for the observed benefit of surgery and a prospective randomized trial was needed. I'm glad Prof. Soran managed to get some funding for his study!
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Heidi, I guess timing of studies is affected by funding. (Gee, Komen, remember us stage iv-ers?) I read through the article from your link, and although parts of it were above my comprehension due to medical jargon, I found this about bone mets which is what I deal with: "Interestingly, the results of our study show that the patients with bone metastases benefit the most from surgical removal of the primary breast tumor."
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Hi all Im not stage 4 but often wonder why PET scans were not done at the time of my diagnosis to see if I was. How do they know without scans? Now you guys are saying you had a PET scan after a mastectomy? Whats the point of that? Wouldn't they want to know all the facts before any treatment decisions are made? Just don't get it......
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dtad,
I had a PET after my bmx for reasons unrelated to bc, so finding my bone met was quite accidental. PET scans are very expensive and the reality is that only a small percentage of women have mets at original dx. I think the cost, therefore, becomes a huge factor. PET scans expose one to radiation and that needs to be taken into consideration as well. When it became clear that I was doing well, my mo really cut back on the frequency of my scans for that very reason
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dtad, for some reason, as I was getting scheduled for chemo, my onc sent me to get a bone scan. At the time, she said it was to get a baseline of my bones prior to the chemo. The bone scan revealed some suspicious activity, so a PET was ordered. I go to a cancer center at a large hospital in Pittsburgh. Maybe it was the onc's experience that it is beneficial to have a baseline bone scan in case there is progression in the future. Maybe, since the tumor in my breast was a good size, she wanted to rule out progression from the start. I have occasionally wondered if, had I doctored at a local cancer center that doesn't have the expertise of the larger one, would I have been sent for a scan at diagnosis? Because I had no node involvement.
After a few years of twice yearly PET scans, my insurance no longer covered them. So now I get bone/ct scans. I have to say, where I go,the two scans together cost almost as much as the PET.
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I don't know how to feel about this. I am one who was told, "no surgery, that's off the plate, now you've been diagnosed with mets. Your treatment will be palliative."
Well, a year and a half later, after success with my first hormonal treatment, the only dark spots on my PET scan last month were from my primary tumor and one lymph node on that side. In other words, if I had had a mastectomy, I could be NED.
I just don't know how to feel.
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Thank you Bestbird, for bringing this to our attention. I'm trying to learn as much as possible about breast cancer for myself and my family.
I am amazed to learn that surgery isn't considered standard practice on Stage IV de novo. If we're trying to slow down progression, reduce current mets and prevent new mets, why not remove the primary source and lower the tumor burden immediately? Are the doctors and/or insurance companies just giving up on patients? I would think that removing the primary tumor would result in longer life, and lower costs per months/years of life saved.
Shetland, could you clarify about the anesthesia reducing possible mets? Are you referring to the Torodol/Ketorolac studies? I ask because I understand that it is the anti-inflammatory action of Torodol/Ketorolac that possibly prevents recurrence. Is there also anesthesia medications correlated with reducing possible mets?
sas-schatzi has started a thread with that information: https://community.breastcancer.org/forum/73/topics/833612
If you don't have much time, I'd recommend starting with this video:
https://www.youtube.com/watch?v=H8zVrYEW8vE&feature=youtu.be
A Simple, One-Time, Inexpensive and Non-Toxic Intervention to Improve Cancer SurvivalCongratulations MrsM. on 5 years. Here's to many, many more!
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The medical experts have been debating this for some time. It's worth looking into some medical history to better understand their perspectives and recommendations. Excerpts from two articles below. Click links to get to free full text articles.
I'll try to get to the debate around PET scans for those newly diagnosed with breast cancer at earlier stages.
healing regards, Stephanie
xxx
A 2006 article on the topic:
Surgery of the Primary Tumor in Metastatic Breast Cancer: Closing the Barn Door After the Horse Has Bolted?
Monica Morrow and Lori Goldstein
2006 by American Society of Clinical Oncology
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.
Continued at
http://jco.ascopubs.org/content/24/18/2694.full
xxx
And a 2014 article has a very good history of the topic:
Does Removal of the Primary Tumor in Metastatic Breast Cancer Improve Survival?
Omar M. Rashid, MD, JD and Kazuaki Takabe, MD, PhD, FACS
Journal of Women's Health
J Womens Health (Larchmt). 2014 Feb 1; 23(2): 184–188.
doi: 10.1089/jwh.2013.4517
PMCID: PMC3922396
Conclusion
Further improvement in the overall survival of breast cancer relies upon making greater advances in the treatment of patients with metastatic disease. Historically, the role of removal of the primary tumor in these patients has been limited to palliation alone. However, the theories underlying this approach have been based on animal studies, without translational clinical endpoints to determine to what degree they affect survival. In fact, multiple retrospective studies, as well as recent animal studies, call these theories into question. As several clinical trials across the world accrue patients, there is promise to discover which patients with metastatic breast cancer may benefit from removal of the primary tumor to improve survival.
Full article at:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3922396/
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fyi - http://www.choosingwisely.org/clinician-lists/amer...
American Society of Clinical Oncology
Released April 4, 2012
Don't perform PET, CT, and radionuclide bone scans in the staging of early breast cancer at low risk for metastasis.
- Imaging with PET, CT, or radionuclide bone scans can be useful in the staging of specific cancer types. However, these tests are often used in the staging evaluation of low-risk cancers, despite a lack of evidence suggesting they improve detection of metastatic disease or survival.
- In breast cancer, for example, there is a lack of evidence demonstrating a benefit for the use of PET, CT, or radionuclide bone scans in asymptomatic individuals with newly identified ductal carcinoma in situ (DCIS), or clinical stage I or II disease.
- Unnecessary imaging can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.
xxx
Also http://www.choosingwisely.org/clinician-lists/amer...
American Society of Clinical Oncology
Released April 4, 2012
Don't perform surveillance testing (biomarkers) or imaging (PET, CT, and radionuclide bone scans) for asymptomatic individuals who have been treated for breast cancer with curative intent.
- Surveillance testing with serum tumor markers or imaging has been shown to have clinical value for certain cancers (e.g., colorectal). However for breast cancer that has been treated with curative intent, several studies have shown there is no benefit from routine imaging or serial measurement of serum tumor markers in asymptomatic patients.
- False-positive tests can lead to harm through unnecessary invasive procedures, over-treatment, unnecessary radiation exposure, and misdiagnosis.
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I understand what they are saying in those articles about not doing the scans, but I had no symptoms, no nodes, and was only stage 1 in the breast. Like MrsM, thank goodness, I had a doctor who always did a scan before starting chemo so that there would be a baseline if ever needed. That is where my 7-10 liver tumors (with largest being 5.6cm when neither of the ones in my breast were over 2cm) were found. My liver numbers were even okay at the time (they actually are worse now than they were then). I understand that the focus in stage 4 is palliative, but the numbers on this thread alone show that NED is possible. I just hope they'll start looking at some of these things more.
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Yes, Mominator, I was thinking of the Toradol/Ketorolac studies. I thought I also remembered something about local vs. general anesthesia, but I can't find it right now.
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I was Dx in October and had a bilateral the following April. The surgeon didn't want to take the healthy breast, but with my oncologist's help, he acquiesced. I have no reservations or regrets. Mostly peace of mind. I would have had liver ablation too, had it not been for Herceptin getting rid of the tumor.
Just to follow up, I knew right off the bat that I was Stage IV. I had PET and CT scans right after my breast biopsy came back positive. That's when my liver lit up. That directed my plan of action with neoadjuvant chemo. My onc said it would make the surgeon's job easier to get all of the breast tumor. That sucker was a hot mess! I think I've had 8 cancer-related surgeries in all. Insurance paid all but 20%.
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nancy, My Onc did a baseline PET too because it was found in 3 nodes. They then ruled out surgery and I went straight to AI's. That is awesome that you remain NED! Lynne, I will be curious to see what your Onc says about surgery now, and I plan to ask my own as well. Heidihill says YES! Miracle, that is what I was wondering too, whether having a lumpectomy now would cause further mets? Which makes me more curious about the anesthesia comments above about it reducing the chance of promoting mets? Shetland I find it interesting that on your second Dx that started Taxol right away and that you achieved NEAD. If you don't mind my inquisition here how long before you had to change? Is Taxol an oral chemo? Mominator, it only makes sense to me too and sometimes I do feel like they just aren't that invested in keeping me alive as long as they can. Thanks for the link! You too Stephanie, as usual full of valuable info! Cafe, your Tx right off the bat compared to mine, and you being 6 1/2 years out now, just makes me wonder if I need to get more aggressive in my treatment plan....Best wishes all
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I was dx stage ll and after I finished treatment my onc did the ca 27-29 for 8 years until mets were found. I never had symptoms and still don't have any pain even when the mets are active. I thank God he did that test against recommendations. Who knows how far it would have had to progress for me to have symptoms? I would probably have needed some kind of spinal surgery. Sometimes these guidelines really piss me off, and yes, it seems like they think we will die anyway so why spend the $. I think removing the primary tumor should be an option given to every patient with de novo, even if they're not certain it will help. people know their bodies and they will usually make the right decision for themselves, given ALL of the information.
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