Initial Surgery and Survival in Stage IV Breast Cancer in the United States, 1988-2011

Abstract

IMPORTANCE Management of the primary tumor site in patients with metastatic breast cancer remains controversial. OBJECTIVE To evaluate the patterns of receipt of initial breast surgery for female patients with stage IV breast cancer in the United States, with particular attention to women who survived at least 10 years. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) program. Female patients diagnosed as having stage IV breast cancer between 1988 and 2011 and who did not receive radiation therapy as part of the first course of treatment were included (N = 21 372). Kaplan-Meier estimates of median survival and descriptive statistics were used to compare patient and tumor characteristics by receipt of breast surgery at diagnosis. A Royston-Parmar survival model and logistic regression analysis assessed demographic and clinical factors associated with survival and prolonged survival (of at least 10 years). MAIN OUTCOMES AND MEASURES Differences in survival, particularly survival of at least 10 years, by receipt of initial surgery to the primary tumor. RESULTS Among the 21 372 patients, the median survival increased from 20 months (1988–1991) to 26 months (2007–2011). During this time, the rate of surgery declined (odds ratio [OR], 0.16; 95% CI, 0.12–0.21). Even so, receipt of surgery was associated with improved survival in multivariate analysis, which controlled for patient and clinical characteristics, along with time period (hazard ratio, 0.60; 95% CI, 0.57–0.63). For women diagnosed as having cancer before 2002 (n = 7504), survival of at least 10 years was seen in 9.6%(n = 353) and 2.9% (n = 107) of those who did and did not receive surgery, respectively (OR, 3.61; 95% CI, 2.89–4.50). In multivariate analysis, survival of at least 10 years was associated with receipt of surgery (odds ratio, 2.80; 95% CI, 2.08–3.77), hormone receptor–positive disease (OR, 1.76; 95% CI, 1.25–2.48), older age (OR, 0.41; 95% CI, 0.32–0.54), larger tumor size (OR, 0.37; 95% CI, 0.27–0.51), marital status of being separated at the time of diagnosis (OR, 0.67; 95% CI, 0.51–0.88), and more recent year of diagnosis (OR, 1.43; 95% CI, 1.02–1.99). CONCLUSIONS AND RELEVANCE Survival in stage IV breast cancer has improved and is increasingly of prolonged duration, particularly for some women undergoing initial breast surgery. As systemic therapy advances provide better control of distant disease in stage IV breast cancer, and as women present with lower distant disease burdens, these findings on initial surgery to the primary tumor may be of importance.

Surgery and survival in patients with stage IV breast cancer

“…The most recent examination of the SEER database (1988‐2011) again proposed a benefit to surgical intervention in patients with Stage IV breast cancer. In an examination of a sample of 21 372 cases, an improved overall survival for the surgical group was noted when compared to the non‐surgical group (HR 0.60, 95% 0.57‐0.63) . These findings are confirmed in this analysis of the NCDB, providing consistent evidence based on observational data that well‐selected patients with de novo Stage IV breast cancer who undergo surgical resection of their primary tumor enjoy significantly improved survival, despite the clinical dogma suggesting otherwise.…”

Impact of Locoregional Treatment on Prognosis of de novo Stage IV Breast Cancer: A Retrospective Long-Term Study of Chinese Population

“…This retrospective single-institution study demonstrated superior DPFS and OS for patients with de novo stage IV breast cancer who underwent surgical resection of primary tumor and suggested a potential survival benefit for radiotherapy. In the present study, the 5-year OS and 5-year DPFS of stage IV breast cancer in the institution were 24.2 and 8.9%, respectively, which were similar to the survival rates reported in other studies [14][15][16]. Statistical analysis indicated that liver or brain metastasis behaved as a bad prognostic factor that significantly influenced the survival time.…”

3rd ESO–ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC 3)

“…Results of larger, prospective studies are awaited. Until then, the recommendation is to discuss surgery on a case-by-case basis and importantly, only consider surgery if it can be performed with a high quality procedure [21]. …”