ASCO 2016

Surgery in stage 4 breast cancer increased survival

Prof Atilla Soran - University of Pittsburgh, Pennsylvania, USA

The presentation of my study called MF07-01, this study is evaluating surgery to primary breast in the patients who had stage 4 breast cancer at presentation compared to the control group which is daily giving systemic therapy only.

What were the results of the trial?

Actually, let me give you a little bit of background about the trial. Stage 4 breast cancer at presentation is around up to 10% of patients who have a breast cancer which means that patients, when you diagnose the primary breast cancer, already have cancer around other organs like bone and lung and liver. So so far the general belief is to just give systemic therapy on those patients and keep giving systemic therapy unless there is no bleeding or tumour progression on the primary breast. If it happens then do the surgery. Our hypothesis is if you take the primary breast out then you may deal with the metastatic site so the hypothesis was not proved before but there were a lot of retrospective studies showing that primary surgery in stage 4 breast cancer at presentation works. So this is the first time we showed that there is a benefit of surgery if you just take the primary breast tumour out and then you continue giving systemic therapy patients may get the benefit.

What sort of impacts were there to overall survival or median survival?

In the five year follow up the overall survival is around 44-45% in the surgery group and 25% on the systemic therapy group which means that around a 20% benefit, survival benefit, for the surgery group. The median follow up is around forty months and the median survival benefit is around nine months on the surgery group.

How do you see these results moving forwards into standard care?

Starting from tomorrow, most of the medical oncologists and also the surgeons are going to try to understand first which patients are eligible for this type of surgery. In our presentation we showed that subgroups such as the patients younger than 55 years old or ER/PR positive, HER2 negative or only they have solitary bone metastases they may get much benefit when compared to other types of metastasis. I think starting from tomorrow in the world people are going be supporting to do the surgery if this patient is in the subgroup of patients. So I think it’s going to impact a whole approach on stage 4 breast cancer presentation starting tomorrow.

To clarify, were the resections in combination with systemic therapy or individually?

Correct, systemic therapy is always after our surgery. The main goal is like the surgeon and medical oncologist should think about that, like the early stage breast cancer. So even if you diagnose a patient with bone mets or lung mets… not lung mets but most likely the bone mets or maybe resectable lung met, you may think about the primary tumour. If you take the primary tumour out it’s easy to go with the fight against the metastatic site. But the main thing is when you do the surgery to the breast, either breast conserving surgery or mastectomy, you have to have the clear margin and if the patient needs radiation therapy or an axillary dissection you have to do it. It’s not like there is a metastasis, don’t do the whole therapy. You have to do the main therapy if the disease extension is like sentinel lymph node biopsy as opposed to if you have to do axillary dissection. If the margin is positive you have to do a re-excision.

All the medical field, all the surgeons and medical oncologists, they should think about that there is a role for the surgery. Actually we are not saying after this study that all the stage 4 breast cancer at presentation should undergo primary surgery on the tumour but what we are saying is that if you have a patient that fits this criteria, if they are young, ER/PR positive, HER2 negative and just bone metastases or solitary bone metastases it will be better to think about that they may reach the five to ten year survival, they may have more survival with the surgery. Just consider it and discuss with the patient.