Metastatic Disease and Local Treatment of the Cancer in the Breast

Occasionally women will have a newly diagnosed breast cancer that has already spread elsewhere in their body - making them Stage IV.  Controversy surrounds the best treatment (if any at all) of the cancer in the breast itself.  Data from several large cancer centers and national databases have suggested that removing the cancer from their breast actually improves their survival (in addition to chemotherapy or hormonal therapy that circulates through their entire body).  However, other studies have found no improvement.  There may actually be some patients who benefit and some who don't but the problem is sorting them out.  Some have suggested that trying chemotherapy first and if they respond, they would be good candidates.  However, we know responders do better than non-responders so they will do well with or without mastectomy.  Others have suggested subgroups based on favorable clinicopathologic characteristics, specifically young age, good performance status, estrogen-positive disease, bone-only involvement and limited metastatic burden. These patients may derive greater benefit in locoregional control and potentially survival. But this seems absurd since of course they will do better than patients who are older, with poor performance status,  estrogen-negative disease, and those with extensive visceral metastases.  Clearly what is needed is a study - which hopefully will happen in the near future with the new research organization - Alliance (a merging of ACOSOG, CALGB, and NCCTG) which is set to open a prospective, randomized study of mastectomy vs observation for patients who present with metastatic disease at the time of their diagnosis.