Should I push a Mastectomy surgery or not?

Hi Awheeler - I was stage 1 (no node involvement) in 2008 and stage 4 in 2019. I did not have a mastectomy but wanted to post because I had a lumpectomy/radiation and chemo and had a "low risk of recurrence" statistically after treatment. I took femara for 7 years after treatment. My stage 4 did not come back in my breast tissue - so a mastectomy would not have helped me way back in 2008.

I am telling you this because current thinking is that if it's in your blood stream, it's out. I would hate for any complication from the surgery to interrupt your treatment. Also, I wonder if it's helpful to monitor your breast tumor to see how the chemo is working? 5 years after I was dx my best friend was dx and she had chemo first, then a mastectomy (stage 2). The chemo she had first didn't really shrink the breast tumor so they switched chemos. Really helpful to know what was and wasn't working. Just my 2 cents!

I’m Stage IV, and when I asked my doc about it, he said the reason for mastectomy is so it won’t spread. Since I had already spread, it really wouldn’t have helped. I was grateful not to have to go through with a surgery after finding out I was de novo.

Awheeler- Of greatest importance is whether you have under five mets and only in one location (eg. bone), which would mean that you are oligometastatic, and that you have potentially a great outcome especially if they are aggressive now in the chemo plus radiating those individual mets. In about a quarter of those cases, that treatment is either curative or the cancer does not come back for many years. In that case, treatment would presumably also include removing the primary tumor.

However, this issue was addressed in a recent clinical trial, which showed no benefit to removing the primary tumor, in terms of overall survival. That should resolve it, however these kinds of trials are always looking backwards, whereas we may have such excellent meds coming out that people live such a long time to where you do see a benefit of having had it removed, it could be possible that looking in the rear view mirror, you might decide that getting it out it was a good call.

Another issue is mastectomy has risks with lymphedema and can really hurt quality of life. If the primary is not large can it be removed by lumpectomy?

A final issue about keeping it, and I really have no opinion one way or another about this question as its so complicated, is that there are pre-clinical data showing that having the primary tumor present can make immunotherapy work better, by giving a bigger source of cancer cells for the immune system to prime off of, and know what to go hunt for. Incredible to consider that leaving the tumor in there could be helpful for some future treatment. All in all, there are many considerations, so a second opinion could be helpful to make sure you are comfortable with your decision. The existing trial data clearly say there is no benefit to surgery, but they are not looking specifically at the oligometastatic population that have very few mets.