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Meta-Analysis to Determine if Surgical Resection of the Primary Tumour in the Setting of Stage IV Breast Cancer Impacts on Survival

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Introduction

The role of primary tumor excision in patients with stage IV breast cancer is unclear. Therefore, a meta-analysis of relevant studies was performed to determine whether surgical excision of the primary tumor enhances oncological outcome in the setting of stage IV breast cancer.

Methods

A comprehensive search for relevant published trials that evaluated outcomes following excision of the primary tumor in stage IV breast cancer was performed using MEDLINE and available data were cross-referenced. Data were extracted following review of appropriate studies by authors. The primary outcome was overall survival following surgical removal of the primary tumor.

Results

Data from ten studies included 28,693 patients with stage IV disease of whom 52.8 % underwent excision of the primary carcinoma. Surgical excision of the primary tumor in the setting of stage IV breast cancer was associated with a superior survival at 3 years (40 % (surgery) versus 22 % (no surgery) (odds ratio 2.32, 95 % confidence interval 2.08–2.6, p < 0.01). Subgroup analyses for selection of patients for surgery or not, favored smaller primary tumors, less competing medical comorbidities and lower metastatic burden (p < 0.01). There was no statistical difference between the two groups regarding location of metastatic disease, grade of tumor, or receptor status.

Conclusions

Patients with stage IV disease undergoing surgical excision of the primary tumor achieve a superior survival rate then their nonsurgical counterparts. In the absence of robust evidence, this meta-analysis provides evidence base for primary resection in the setting of stage IV breast cancer for appropriately selected patients.

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References

  1. Office for national statistics, cancer statistics registrations: registrations of cancer diagnosed in 2008, England. (PDF 544 KB) Series MB1 no.39. London: National Statistics, 2010.

  2. Howlader N, Noone AM, Krapcho M, et al., editors. SEER cancer statistics review. Bethesda: National Cancer Institute,1975–2008. http://seer.cancer.gov/csr/1975_2008/.

  3. Giordano SH, Buzdar AU, Smith TL, et al. Is breast cancer survival improving? Cancer. 2004;100(1):44–52.

    Article  PubMed  Google Scholar 

  4. Andre F, Slimane K, Bachelot T, et al. Breast cancer with synchronous metastases: trends in survival during a 14-year period. J Clin Oncol. 2004;22(16):3302–8.

    Article  PubMed  Google Scholar 

  5. Feinstein AR, Sosin DM, Wells CK. The Will Rogers phenomenon. Stage migration and new diagnostic techniques as a source of misleading statistics for survival in cancer. N Engl J Med. 1985;312(25):1604–8.

    Article  PubMed  CAS  Google Scholar 

  6. Essner R, Lee JH, Wanek LA, et al. Contemporary surgical treatment of advanced-stage melanoma. Arch Surg. 2004;139(9):961–6.

    Article  PubMed  Google Scholar 

  7. Flanigan RC, Salmon SE, Blumenstein BA, et al. Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med. 2001;345(23):1655–9.

    Article  PubMed  CAS  Google Scholar 

  8. Rosen SA, Buell JF, Yoshida A, et al. Initial presentation with stage IV colorectal cancer: how aggressive should we be? Arch Surg. 2000;135(5):530–4.

    Article  PubMed  CAS  Google Scholar 

  9. Hallissey MT, Allum WH, Roginski C, et al. Palliative surgery for gastric cancer. Cancer. 1988;62(2):440–4.

    Article  PubMed  CAS  Google Scholar 

  10. Danna EA, Sinha P, Gilbert M, et al. Surgical removal of primary tumor reverses tumor-induced immunosuppression despite the presence of metastatic disease. Cancer Res. 2004;64(6):2205–11.

    Article  PubMed  CAS  Google Scholar 

  11. Norton L, Massague J, et al. Is cancer a disease of self-seeding? Nat Med. 2006;12(8):875–8.

    Article  PubMed  CAS  Google Scholar 

  12. Khan SA. Primary tumor resection in stage IV breast cancer: consistent benefit, or consistent bias? Ann Surg Oncol. 2007;14(12):3285–7.

    Article  PubMed  Google Scholar 

  13. Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in systematic reviews. Ann Intern Med. 1997;127(9):820–6.

    Article  PubMed  CAS  Google Scholar 

  14. Babiera GV, Rao R, Feng L, et al. Effect of primary tumor extirpation in breast cancer patients who present with stage IV disease and an intact primary tumor. Ann Surg Oncol. 2006;13(6):776–82.

    Article  PubMed  Google Scholar 

  15. Bafford AC, Burstein HJ, Barkley CR, et al. Breast surgery in stage IV breast cancer: impact of staging and patient selection on overall survival. Breast Cancer Res Treat. 2009;115(1):7–12.

    Article  PubMed  Google Scholar 

  16. Fields RC, Jeffe DB, Trinkaus K, 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. Ann Surg Oncol. 2007;14(12):3345–51.

    Article  PubMed  Google Scholar 

  17. Gnerlich J, Jeffe DB, Deshpande AD, et al. Surgical removal of the primary tumor increases overall survival in patients with metastatic breast cancer: analysis of the 1988-2003 SEER data. Ann Surg Oncol. 2007;14(8):2187–94.

    Article  PubMed  Google Scholar 

  18. Hazard HW, Gorla SR, Scholtens D, et al. Surgical resection of the primary tumor, chest wall control, and survival in women with metastatic breast cancer. Cancer. 2008;113(8):2011–9.

    Article  PubMed  Google Scholar 

  19. Khan, SA, Stewart AK, Morrow M. Does aggressive local therapy improve survival in metastatic breast cancer? Surgery. 2002;132(4):620–7.

    Article  PubMed  Google Scholar 

  20. Ruiterkamp J, Ernst MF, van de Poll-Franse LV, et al. Surgical resection of the primary tumour is associated with improved survival in patients with distant metastatic breast cancer at diagnosis. Eur J Surg Oncol. 2009;35(11):1146–51.

    Article  PubMed  CAS  Google Scholar 

  21. Rapiti E, Verkooijen HM, Vlastos G, et al. Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol. 2006;24(18):2743–9.

    Article  PubMed  Google Scholar 

  22. Blanchard DK, Shetty PB, Hilsenbeck SG, et al. Association of surgery with improved survival in stage IV breast cancer patients. Ann Surg. 2008;247(5):732–8.

    Article  PubMed  Google Scholar 

  23. Cady B, Nathan NR, Michaelson JS, et al. Matched pair analyses of stage IV breast cancer with or without resection of primary breast site. Ann Surg Oncol. 2008;15(12):3384–95.

    Article  PubMed  CAS  Google Scholar 

  24. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med. 1997;337(14):949–55.

    Article  PubMed  CAS  Google Scholar 

  25. Overgaard M, Jensen MB, Overgaard J, et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet. 1999;353(9165):1641–8.

    Article  PubMed  CAS  Google Scholar 

  26. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med. 1997;337(14):956–62.

    Article  PubMed  CAS  Google Scholar 

  27. Cristofanilli M, Budd GT, Ellis MJ, et al. Circulating tumor cells, disease progression, and survival in metastatic breast cancer. N Engl J Med. 2004;351(8):781–91.

    Article  PubMed  CAS  Google Scholar 

  28. Arriagada R, Rutqvist LE, Mattsson A, et al. Adequate locoregional treatment for early breast cancer may prevent secondary dissemination. J Clin Oncol. 1995;13(12):2869–78.

    PubMed  CAS  Google Scholar 

  29. Goldie JH, Coldman AJ. A mathematic model for relating the drug sensitivity of tumors to their spontaneous mutation rate. Cancer Treat Rep. 1979;63(11–12):1727–33.

    PubMed  CAS  Google Scholar 

  30. Dauplat J, Le Bouedec G, Pomel C, et al. Cytoreductive surgery for advanced stages of ovarian cancer. Semin Surg Oncol. 2000;19(1):42–8.

    Article  PubMed  CAS  Google Scholar 

  31. Nieto Y, Nawaz S, Jones RB, et al. Prognostic model for relapse after high-dose chemotherapy with autologous stem-cell transplantation for stage IV oligometastatic breast cancer. J Clin Oncol. 2002;20(3):707–18.

    Article  PubMed  CAS  Google Scholar 

  32. Baum M, Demicheli R, Hrushesky W, et al. Does surgery unfavourably perturb the “natural history” of early breast cancer by accelerating the appearance of distant metastases? Eur J Cancer. 2005;41(4):508–15.

    Article  PubMed  Google Scholar 

  33. Coffey JC, Wang JH, Smith MJ, et al. Excisional surgery for cancer cure: therapy at a cost. Lancet Oncol. 2003;4(12):760–8.

    Article  PubMed  CAS  Google Scholar 

  34. Demicheli R, Valagussa P, Bonadonna G. Does surgery modify growth kinetics of breast cancer micrometastases? Br J Cancer. 2001;85(4):490–2.

    Article  PubMed  CAS  Google Scholar 

  35. Fisher B, Gunduz N, Coyle J, et al. Presence of a growth-stimulating factor in serum following primary tumor removal in mice. Cancer Res. 1989;49(8):1996–2001.

    PubMed  CAS  Google Scholar 

  36. O’Reilly MS, Holmgren L, Shing Y, et al. Angiostatin: a novel angiogenesis inhibitor that mediates the suppression of metastases by a Lewis lung carcinoma. Cell. 1994;79(2):315–28.

    Article  PubMed  Google Scholar 

  37. Gunduz N, Fisher B, Saffer EA. Effect of surgical removal on the growth and kinetics of residual tumor. Cancer Res. 1979;39(10):3861–5.

    PubMed  CAS  Google Scholar 

  38. Hormbrey E, Han C, Roberts A, et al. The relationship of human wound vascular endothelial growth factor (VEGF) after breast cancer surgery to circulating VEGF and angiogenesis. Clin Cancer Res. 2003;9(12):4332–9.

    PubMed  CAS  Google Scholar 

  39. Salo M. Effects of anaesthesia and surgery on the immune response. Acta Anaesthesiol Scand. 1992;36(3):201–20.

    Article  PubMed  CAS  Google Scholar 

  40. Retsky M, Bonadonna G, Demicheli R, et al. Hypothesis: Induced angiogenesis after surgery in premenopausal node-positive breast cancer patients is a major underlying reason why adjuvant chemotherapy works particularly well for those patients. Breast Cancer Res. 2004;6(4):372–4.

    Article  Google Scholar 

  41. Mauri D, Pavlidis N, Ioannidis JP. Neo-adjuvant versus adjuvant systemic treatment in breast cancer: a meta-analysis. J Natl Cancer Inst. 2005;97:188–94.

    Article  PubMed  Google Scholar 

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Conflict of interest

None of the authors have a conflict of interest to declare.

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Authors and Affiliations

  1. Department of Breast Surgery, BreastCheck, Mater Misericordiae University Hospital, Dublin, Ireland

    Elly Harris, Mitchel Barry & Malcolm R. Kell

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  1. Elly Harris
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  2. Mitchel Barry
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  3. Malcolm R. Kell
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Correspondence to Mitchel Barry.

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Harris, E., Barry, M. & Kell, M.R. Meta-Analysis to Determine if Surgical Resection of the Primary Tumour in the Setting of Stage IV Breast Cancer Impacts on Survival. Ann Surg Oncol 20, 2828–2834 (2013). https://doi.org/10.1245/s10434-013-2998-2

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  • DOI: https://doi.org/10.1245/s10434-013-2998-2

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