[European Cancer Organization]
Purpose: In the Netherlands approximately one out of nine women are diagnosed with breast cancer annually. 3-10 % of them have metastatic disease at initial presentation. Because metastatic breast cancer is considered to be an incurable disease, it is treated palliatively. Local treatment of the primary tumor is only recommended if the primary tumor is symptomatic. In order to analyse whether local surgery of the breast tumor affects the survival of patients with primary metastatic breast cancer, a retrospective study was conducted.
Methods: In the period 1975 till 2002 approximately 20.000 patients with breast cancer were diagnosed in the South of the Netherlands. Metastatic disease at initial presentation was detected in 5 %. The use of local surgery of the breast tumor was examined in the latter group. The primary goal was to analyze the effect on survival. Information collected included tumor characteristics, site(s) of metastases, type of treatment and type of surgical procedure and co-morbidity. Multivariate analyses were conducted to compare overall survival between operated and non-operated patients. Adjustments were made for age, TNM-classification, localisation and number of metastases and co-morbidity.
Results: Of the 728 patients identified, 288 underwent surgical excision of the primary tumor. Significant differences between the patients, who received operation or palliative procedures, are age, the number of metastatic sites, clinical T-classification, co-morbidity and systemic treatment. Median survival in patients who were treated with local surgery was 2,55 years, compared with 1,17 years in patients who did not receive surgical treatment (p<0,0001). Significant independent prognostic covariates for a better prognosis are surgery, age, number of metastatic sites and systemic therapy. After controlling for potential confounding, patients who are treated surgically, have a lower mortality risk with a hazard ratio (HR) of 0,69. Patients with multiple metastases and co-morbidity have a reduced effect of the surgical treatment, though the effect is still significant.
Conclusions: Local surgery of the tumor in patients with primary metastatic breast cancer is associated with a 40% reduction of the mortality risk. The association is independent of age and co-morbidity, but appears to be stronger in patients with an isolated metastatic site. Further research is necessary and therefore a randomized controlled trial should be designed in order to rule out unsuspected confounding.
1st dx ILC st 3, er+, pr+, her2-, T3, N1 1998. Bone mets 2004. Liver mets 2008. Leptomeningial mets 2009.
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