Metastatic breast cancer: Who benefits from surgery?

The role of locoregional surgery in de novo stage IV breast cancer: A meta-analysis of randomized controlled trials

BACKGROUND

We performed an updated meta-analysis to explore the value of locoregional surgery in de novo stage IV breast cancer patients.

METHODS

A literature search was conducted to identify randomized controlled trials comparing primary tumor resection with systemic therapy in de novo stage IV breast cancer. The hazard ratio (HR) of overall survival (OS), local relapse-free survival (LRFS), and distant relapse-free survival (DRFS) were estimated and pooled.

RESULTS

Six studies were eligible, including a total of 1368 patients. Both OS (HR = 0.86; 95 %CI: 0.77-0.96; p = 0.01; I2 = 45 %) and LRFS (HR = 0.35; 95 %CI: 0.20-0.62; p = 0.0003; I2 = 83 %) were significantly improved with locoregional surgery compared with systemic therapy alone. There was no significant difference in terms of DRFS (HR = 0.96; 95 %CI: 0.41-2.22; p = 0.92; I2 = 86 %). The OS benefit was more pronounced in hormone receptor-positive patients (HR = 0.79; p = 0.003) and HER2-negative patients (HR = 0.80; p = 0.003).

CONCLUSIONS

This study demonstrated that locoregional surgery conferred significant OS and LRFS benefits in de novo stage IV breast cancer patients and may serve as an alternative choice for selected patients.

Assessment of Treatment Sequence in Patients With Stage III Breast Cancer

INTRODUCTION

Stage III breast cancer is defined as locally advanced breast cancer and is treated with curative intent. Historically, overall survival (OS) did not differ based on treatment sequence (neoadjuvant chemotherapy [NAC] followed by surgery versus surgery followed by chemotherapy). Given recent advancements, we examined if treatment sequence may be associated with improved OS in a contemporary cohort of patients with stage III breast cancer.

METHODS

Patients aged 18-80 years with prognostic stage III breast cancer who received chemotherapy and surgery were selected from the Surveillance, Epidemiology, and End Results database. Patients were stratified by treatment sequence (NAC versus surgery first). Unadjusted OS and breast cancer-specific survival (BCSS) were estimated using the Kaplan-Meier method and compared with log-rank tests. Cox proportional hazards models were used to estimate the association of treatment sequence with OS and BCSS after adjustment for selected covariates.

RESULTS

The study included 26,573 patients; median follow-up was 62.0 months (95% confidence interval [CI] 61.0-63.0). Patients receiving NAC had a worse OS and BCSS compared to those who underwent surgery first (5-year OS rates 0.66 versus 0.73; 5-year BCSS rates 0.70 versus 0.77; both log-rank P < 0.001). After adjustment for tumor subtype, receipt of NAC (versus surgery first) remained associated with a worse OS (hazard ratio 1.27, 95% CI 1.2-1.34, P < 0.001) and BCSS (hazard ratio 1.35, 95% CI 1.27-1.43, P < 0.001).

CONCLUSIONS

Based on data from patients treated largely before 2020, undergoing surgery first may be associated with improved survival, even after adjustment for known covariates including tumor subtype. These findings may inform treatment when caring for patients with operable, locally advanced breast cancer.

New Frontiers in the Treatment of Patients with HER2+ Cancer and Brain Metastases: Is Radiotherapy Always Useful?

Brain metastases (BM) pose a significant challenge in the management of HER2+ breast cancer since almost 50% of patients with HER2+ breast cancer develop brain tumors. The complex process of brain metastases involves genetic mutations, adaptations and mechanisms to overcome the blood-brain barrier. While radiotherapy is still fundamental in local therapy, its use is associated with cognitive adverse effects and limited long-term control, necessitating the exploration of alternative treatments. Targeted therapies, including tyrosine kinase inhibitors, monoclonal antibodies, and antibody-drug conjugates, offer promising options for HER2+ breast cancer patients with BM. Clinical trials have demonstrated the efficacy of these agents in controlling tumor growth and improving patient outcomes, posing the question of whether radiotherapy is always the unique choice in treating this cancer. Ongoing research into novel anti-HER2 antibodies and innovative combination therapies holds promise for advancing treatment outcomes and enhancing patient care in this clinical scenario. This narrative review provides a comprehensive overview of traditional medical treatments, molecularly targeted therapy and investigational agents in the management of HER2+ breast cancer with BM, highlighting the evolving landscape and potential future directions in treatment strategies to improve patient survival and quality of life.

Survival among patients with untreated metastatic breast cancer: "What if I do nothing?"

PURPOSE

We sought to assess survival outcomes of patients with de novo metastatic breast cancer (dnMBC) who did not receive treatment irrespective of the reason.

METHODS

Adults with dnMBC were selected from the NCDB (2010-2016) and stratified based on receipt of treatment (treated = received at least one treatment and untreated = received no treatments). Overall survival (OS) was estimated using the Kaplan-Meier method, and groups were compared. Cox proportional hazards models were used to identify factors associated with OS.

RESULTS

Of the 53,240 patients with dnMBC, 92.1% received at least one treatment (treated), and 7.9% had no documented treatments, irrespective of the reason (untreated). Untreated patients were more likely to be older (median 68 y vs 61 y, p < 0.001), have higher comorbidity scores (p < 0.001), have triple-negative disease (17.8% vs 12.6%), and a higher disease burden (≥ 2 metastatic sites: 38.2% untreated vs 29.2% treated, p < 0.001). The median unadjusted OS in the untreated subgroup was 2.5 mo versus 36.4 mo in the treated subgroup (p < 0.001). After adjustment, variables associated with a worse OS in the untreated cohort included older age, higher comorbidity scores, higher tumor grade, and triple-negative (vs HR + /HER2-) subtype (all p < 0.05), while the number of metastatic sites was not associated with survival.

CONCLUSIONS

Patients with dnMBC who do not receive treatment are more likely to be older, present with comorbid conditions, and have clinically aggressive disease. Similar to those who do receive treatment, survival in an untreated population is associated with select patient and disease characteristics. However, the prognosis for untreated dnMBC is dismal.

Personalized surgical recommendations and quantitative therapeutic insights for patients with metastatic breast cancer: Insights from deep learning

Background

The role of surgery in metastatic breast cancer (MBC) is currently controversial. Several novel statistical and deep learning (DL) methods promise to infer the suitability of surgery at the individual level.

Objective

The objective of this study was to identify the most applicable DL model for determining patients with MBC who could benefit from surgery and the type of surgery required.

Methods

We introduced the deep survival regression with mixture effects (DSME), a semi-parametric DL model integrating three causal inference methods. Six models were trained to make individualized treatment recommendations. Patients who received treatments in line with the DL models' recommendations were compared with those who underwent treatments divergent from the recommendations. Inverse probability weighting (IPW) was used to minimize bias. The effects of various features on surgery selection were visualized and quantified using multivariate linear regression and causal inference.

Results

In total, 5269 female patients with MBC were included. DSME was an independent protective factor, outperforming other models in recommending surgery (IPW-adjusted hazard ratio [HR] = 0.39, 95% confidence interval [CI]: 0.19-0.78) and type of surgery (IPW-adjusted HR = 0.66, 95% CI: 0.48-0.93). DSME was superior to other models and traditional guidelines, suggesting a higher proportion of patients benefiting from surgery, especially breast-conserving surgery. The debiased effect of patient characteristics, including age, tumor size, metastatic sites, lymph node status, and breast cancer subtypes, on surgery decision was also quantified.

Conclusions

Our findings suggested that DSME could effectively identify patients with MBC likely to benefit from surgery and the specific type of surgery needed. This method can facilitate the development of efficient, reliable treatment recommendation systems and provide quantifiable evidence for decision-making.

Utilization and outcomes of the 21-gene recurrence score in de novo metastatic breast cancer

BACKGROUND

Limited data exist regarding the utility and validity of the 21-gene recurrence score (RS) in patients with de novo metastatic breast cancer (dnMBC). This study aimed to investigate the practice patterns as well as associated survival outcomes based on 21-gene RS in dnMBC.

RESEARCH DESIGN AND METHODS

The Surveillance, Epidemiology, and End Results Oncotype database was queried for women with hormone receptor-positive and Her2-negative dnMBC.

RESULTS

A total of 153 patients were identified, including 62.7% and 37.3% of patients who had RS < 26 and ≥ 26, respectively. Patients with RS ≥ 26 were more likely to receive chemotherapy compared to those with RS < 26 (61.4% vs. 28.1%, p < 0.001). Patients with RS ≥ 26 had an inferior breast cancer-specific survival (BCSS) (2-year BCSS: 84.3% vs. 89.5, p = 0.067) and overall survival (OS) compared to those with RS < 26 (2-year OS: 76.9% vs. 87.4%, p = 0.018). The multivariate Cox proportional hazard models showed that those with RS ≥ 26 had a significantly inferior BCSS (hazard ratio [HR] 2.251, 95% confidence interval [CI] 1.056-4.799, p = 0.036) and OS (HR 2.151, 95%CI 1.123-4.120, p = 0.021) compared to those with RS < 26.

CONCLUSIONS

The 21-gene RS assay is an important prognostic factor in patients with dnMBC.

Analysis of the distinct features of metastasis male breast cancer and its effect on overall survival based on the SEER database compared with female breast cancer

Background

Male breast cancer (MBC) is a rare disease and differs from female breast cancer (FBC) in clinicopathological and immune tissue types. Given the limited research on MBC due to its rarity, an understanding of the shared and distinct features of MBC and FBC is vital for formulating efficacious treatment strategies.

Methods

Data of patients diagnosed with metastatic breast cancer in the Surveillance, Epidemiology, and End Results (SEER) database from 2012 to 2017 were analysed. Chi-square test was used to compare clinicopathological characteristics between male and female patients. Kaplan-Meier analysis was utilized to compare differences in overall survival (OS).

Results

A total of 2,858 patients with MBC were studied, 134 of whom had distant metastasis. Compared with 8,698 patients with metastatic FBC, a higher proportion of metastatic MBC patients had tumors located in the center of the breast, received surgical treatment, and had bone + lung metastasis. Survival analysis revealed no difference in OS between metastatic MBC and FBC patients (P=0.27), but there was a significant difference in OS between metastatic and nonmetastatic MBC (P=0.004). Compared with metastatic FBC, MBC patients with bone metastasis alone, lung metastasis alone, liver metastasis alone, and bone + lung metastasis also had worse prognosis (P=0.021, 0.019, 0.024, 0.011, respectively).

Conclusions

Metastatic MBC has unique clinicopathological disease features and patterns of metastasis. No significant difference between the survival of metastatic MBC and FBC patients was observed. Distant metastasis was an independent risk factor impacting the prognosis of MBC patients.

Loco-Regional Treatment of the Primary Tumor in De Novo Metastatic Breast Cancer Patients Undergoing Front-Line Chemotherapy

BACKGROUND

Loco-regional therapy (LRT) in de novo metastatic breast cancer (MBC) has been investigated in several clinical trials, with heterogeneous and conflicting results.

METHODS

We conducted a retrospective study of de novo MBC patients treated with front-line chemotherapy (FLC) followed by LRT of the primary tumor. Our aims were to evaluate the characteristics, treatment, and oncological outcomes in terms of progression-free survival (PFS), distant progression-free survival (DPFS), and overall survival (OS) of de novo MBC. We also investigated possible subgroups of patients with better outcomes according to menopausal status, biological sub-type, location, number of metastases, and radiologic complete response after FLC.

RESULTS

We included 61 patients in the study. After a median follow-up of 55 months, disease progression occurred in 60.7% of patients and 49.2% died. There were no significant differences in PFS, DPFS, and OS between different subgroups of de novo MBC patients. A trend toward better PFS and DPFS was observed in triple-positive tumors, without a statistically significant difference in OS.

CONCLUSIONS

No specific subgroup of de novo MBC patients showed a statistically significant survival advantage after FLC followed by LRT of the primary tumor.