Primary Tumor Surgery for Patients with De Novo Stage IV Breast Cancer can Decrease Local Symptoms and Improve Quality of Life

Survival nomogram for patients with de novo metastatic breast cancer based on the SEER database and an external validation cohort

Background

On average, 5-10% of patients are diagnosed with metastatic breast cancer (MBC) at the initial diagnosis. This study aimed to develop a nomogram to predict the overall survival (OS) in these patients.

Methods

The nomogram was based on a retrospective study of 9435 patients with de novo MBC from the Surveillance, Epidemiology, and End Results (SEER) database. The predictive accuracy and discriminative ability of the nomogram were determined using the concordance index (C-index), area under the time-dependent receiver operating characteristic curve (AUC), and calibration curve. Decision curve analysis (DCA) was employed to evaluate the benefits and advantages of our new predicting model over the 8th edition of the American Joint Committee on Cancer (AJCC) Tumor Node Metastasis (TNM) staging system. The results were validated in a retrospective study of 103 patients with de novo MBC from January 2013 to June 2022 at an institution in northwest China.

Results

Multivariate analysis of the primary cohort revealed that independent factors for survival were age at diagnosis, pathological type, histological grade, T stage, N stage, molecular subtype, bone metastasis, brain metastasis, liver metastasis, lung metastasis, surgery, chemotherapy, and radiotherapy. The nomogram achieved a C-index of 0.688 (95% confidence interval [CI], 0.682-0.694) in the training cohort and 0.875 (95% CI, 0.816-0.934) in the validation cohort. The AUC of the nomograms indicated good specificity and sensitivity in the training and validation cohorts, respectively. Calibration curves showed favorable consistency between the predicted and actual survival probabilities. Additionally, the DCA curve produced higher net gains than by the AJCC-TNM staging system. Finally, risk stratification can accurately identify groups of patients with de novo MBC at different risk levels.

Conclusions

The nomogram showed favorable predictive and discriminative abilities for OS in patients with de novo MBC. Other populations from different countries or prospective studies are needed to further validate the nomogram.

Nomogram Predicts the Role of Primary Tumor Surgery on De Novo Stage-IV Breast Cancer Patients: A SEER-Based Competing Risk Analysis Model

Objective

The efficacy of primary tumor surgery on survival in female patients with de novo stage IV breast cancer (BC) remains unclear. Our study endeavored to develop comprehensive competing risk nomograms to predict clinical outcomes and guide precision treatment in these patients.

Participants and Methods

A total of 12281 patients who had distant metastasis at initial BC diagnosis between 2010 and 2017 in the Surveillance Epidemiology and End Results (SEER) database, were enrolled in this study. First, we assessed the impacts of primary tumor surgery on overall survival (OS) and breast cancer-specific survival (BCSS) using the Kaplan-Meier curves. Then subgroup analyses stratified by different metastatic patterns were performed using Cox and competing risk models (CRM). Based on the filtered independent prognostic parameters by CRM, we established two nomograms to predict the probability of breast cancer-specific death (BCSD) at 1-,2- and 3-year intervals. Furthermore, calibration curves and area under the curves (AUC) were conducted for validation.

Results

Kaplan-Meier analysis revealed that surgery was associated with better OS and BCSS (P<0.001). Subgroup analyses demonstrated that in bone-only metastases pattern, relative to breast-conserving surgery (BCS), patients receiving mastectomy had worse prognosis and the poorest survival belonged to non-surgery individuals (BCSS: mastectomy: HR=1.35; 95%CI=1.15-1.60; non-surgery: 2.42; 2.08-2.82; OS: mastectomy: 1.44; 1.23-1.68; non-surgery: 2.40; 2.08-2.78). Additionally, no survival difference was observed between BCS and reconstruction recipients (BCSS: HR=1.10; 95%CI=0.85-1.43; OS: 1.11; 0.86-1.44). Furthermore, patients undergoing BCS possessed similar BCSS with mastectomy recipients as well as reconstruction recipients in viscera metastases pattern, whereas non-surgery individuals had a worse survival (mastectomy: HR=1.04; 95%CI=0.92-1.18; reconstruction: 0.86; 0.69-1.06; non-surgery: 1.83; 1.63-2.05). Two competing risk nomograms of distinct metastatic patterns were established to comprehensively predict the survival of patients. Calibration curves indicated the terrific consistency of the models. Moreover, the AUC values in the training and validation sets were in the range of 0.70–0.80, exhibiting good specificity and sensitivity.

Conclusion

The surgery implementation was associated with a lower probability of BCSD in de novo stage-IV BC patients. Our nomograms could offer a relatively accurate and individualized prediction of the cumulative incidence rate of BCSD after primary tumor resection.

Pure drug nano-assemblies: A facile carrier-free nanoplatform for efficient cancer therapy

Nanoparticulate drug delivery systems (Nano-DDSs) have emerged as possible solution to the obstacles of anticancer drug delivery. However, the clinical outcomes and translation are restricted by several drawbacks, such as low drug loading, premature drug leakage and carrier-related toxicity. Recently, pure drug nano-assemblies (PDNAs), fabricated by the self-assembly or co-assembly of pure drug molecules, have attracted considerable attention. Their facile and reproducible preparation technique helps to remove the bottleneck of nanomedicines including quality control, scale-up production and clinical translation. Acting as both carriers and cargos, the carrier-free PDNAs have an ultra-high or even 100% drug loading. In addition, combination therapies based on PDNAs could possibly address the most intractable problems in cancer treatment, such as tumor metastasis and drug resistance. In the present review, the latest development of PDNAs for cancer treatment is overviewed. First, PDNAs are classified according to the composition of drug molecules, and the assembly mechanisms are discussed. Furthermore, the co-delivery of PDNAs for combination therapies is summarized, with special focus on the improvement of therapeutic outcomes. Finally, future prospects and challenges of PDNAs for efficient cancer therapy are spotlighted.

Locoregional Therapy in De novo Metastatic Breast Cancer: A Retrospective Cohort Study

Objective: Whether locoregional therapy (LRT) should be performed in patients with de novo metastatic breast cancer (dnMBC) has been debated. Here we report the survival outcomes of LRT in patients with dnMBC, focusing on the association of surgical timings and surgical margins with survival in this patient population. Methods: The retrospective study included patients with dnMBC in our hospital, between March 1, 2007 and December 31, 2017. Overall survival (OS) was evaluated by means of a stratified log-rank test and summarized with the use of Kaplan–Meier methods. Results: A total of 153 patients were included, of whom 87 underwent LRT and 66 systemic therapy alone (STA). LRT showed a significant OS benefit over STA (HR, 0.62; 95% CI, 0.39 to 0.99; P  =  .043). The OS of LRT group and STA group were 39 months (95% CI, 33.6 to 44.4 months) and 24.6 months (95% CI, 20.6 to 28.6 months), respectively. The benefit was consistent across most subgroups. The OS of patients undergoing surgery was better than that of patients without surgery (HR, 0.58; 95% CI, 0.35 to 0.94; P  =  .0001), and there was difference in survival improvement at different surgical timings (surgery before chemotherapy, during chemotherapy, and after chemotherapy) (P  =  .0001). The survival benefit of surgery after chemotherapy was significantly greater than that of the other 2 options (HR, 0.77; 95% CI, 0.63 to 0.94). Moreover, compared with patients with positive margins, the OS of patients with negative margins was significantly improved (HR, 0.22; 95% CI, 0.13 to 0.37; P < .001). Conclusions: Our results suggest that LRT is associated with improved OS in women with dnMBC, and patients who had surgery after systemic chemotherapy with negative surgical margins, are expected to benefit more.

Low neighborhood socioeconomic status is associated with higher mortality and increased surgery utilization among metastatic breast cancer patients

PURPOSE

Low socioeconomic status (SES) is associated with advanced stage, lower-quality care, and higher mortality among breast cancer patients. The purpose of this study is to examine the association between neighborhood SES (nSES), surgical management, and disease-specific mortality in de novo metastatic breast cancer (MBC) patients in the Surveillance, Epidemiology, and End Results (SEER) Program.

METHODS

MBC patients ages 18 to 85+ years diagnosed from 2010 through 2016 were identified in SEER. The cohort was divided into low, middle, and high nSES based on the NCI census tract-level index. Univariable and multivariable analyses were used to examine the relationship between nSES, surgery, and disease specific mortality in MBC patients.

RESULTS

There were 24,532 de novo MBC patients who met study criteria, with 28.7 % undergoing surgery. Over the study period, surgery utilization decreased across all nSES groups. However, lower nSES was associated with a higher odds of undergoing surgery (low OR 1.25 [1.15-1.36] p < 0.001; middle OR 1.09 [1.01-1.18] p = 0.022; ref high). Living in an area with lower SES was associated with a worse disease specific mortality (low HR 1.24 [1.25, 1.44; ], middle 1.20 [1.1-1.29]: ref high). Specifically, there was a 9.26 month mean survival differences between the lowest (41.02 ± 0.47 months) and highest (50.28 ± 0.47 months) nSES groups.

CONCLUSION

These results suggest area of residence may contribute to differences in surgical management and clinical outcomes among de novo MBC patients. Future studies should examine the contributions of patient characteristics and preferences within the context of surgeon recommendations.

Predicting the survival benefit of local surgery in patients aged 70 years or older with stage IV breast cancer: A population-based analysis

PURPOSE

The aim of this study was to establish individualized nomograms to predict survival outcomes in older female patients with stage IV breast cancer who did or did not undergo local surgery, and to determine which patients could benefit from surgery.

METHODS

A total of 3,129 female patients with stage IV breast cancer aged ≥70 years between 2010 and 2015 were included in the Surveillance, Epidemiology, and End Results program. Multivariate Cox regression analysis was used to identify risk factors for overall survival (OS) and breast cancer-specific survival (BCSS). Survival analysis was performed using the Kaplan-Meier plot and log-rank test. Nomograms and risk stratification models were constructed.

RESULTS

Patients who underwent surgery had better OS (HR = 0.751, 95% CI [0.668-0.843], P < 0.001) and BCSS (HR = 0.713, 95% CI [0.627-0.810], P < 0.001) than patients who did not undergo surgery. Patients with human epidermal growth factor receptor 2-positive, lung or liver metastases may not benefit from surgery. In the stratification model, low-risk patients benefited from surgery (OS, HR = 0.688, 95% CI [0.568-0.833], P < 0.001; BCSS, HR = 0.632, 95% CI [0.509-0.784], P < 0.001), while patients in the high-risk group had similar outcomes (OS, HR = 0.920, 95% CI [0.709-1.193], P = 0.509; BCSS, HR = 0.953, 95% CI [0.713-1.275], P = 0.737).

CONCLUSION

Older female patients with stage IV breast cancer who underwent surgery had better OS and BCSS than those who did not in each specific subgroup. Patients in low- or intermediate-risk group benefit from surgery while those in the high-risk group do not.

Primary Surgery with Systemic Therapy in Patients with de Novo Stage IV Breast Cancer: 10-year Follow-up; Protocol MF07-01 Randomized Clinical Trial

BACKGROUND

The aim of this randomized clinical trial was to evaluate the overall survival (OS) data of patients diagnosed with de novo stage IV breast cancer (BC) who received locoregional treatment (LRT) over a 10-year follow-up.

STUDY DESIGN

The MF07-01 is a 1:1 multicenter, randomized clinical trial comparing the LRT with systemic therapy (ST), where ST was given to all patients either immediately after randomization or after surgical resection of the intact primary tumor.

RESULTS

A total of 278 patients were randomized and 265 patients were in the final analysis. At 10-year follow-up, survivals were 19% (95% CI 13%-28%) and 5% (95% CI 2%-12%) in the LRT group and ST group, respectively. Median survival was 46 months for the LRT group and 35 months for the ST group, and hazard of death was 29% lower in the LRT group compared with the ST group (hazard ratio [HR] 0.71; 95% CI 0.59-0.86; p = 0.0003).

CONCLUSIONS

Patients with a diagnosis of de novo stage IV BC who underwent LRT followed by ST had a 14% higher chance of OS by the end of the 10-year follow-up compared with the patients who received only ST. The longer study follow-up revealed that LRT should be presented to patients when discussing treatment options.

The Effect of Primary Surgery in Patients with De Novo Stage IV Breast Cancer with Bone Metastasis Only (Protocol BOMET MF 14-01): A Multi-Center, Prospective Registry Study

BACKGROUND

More evidence shows that primary surgery for de novo metastatic breast cancer (BC) prolongs overall survival (OS) in selected cases. The aim of this study was to evaluate the role of locoregional treatment (LRT) in BC patients with de novo stage IV bone only metastasis (BOM).

METHODS

The prospective, multicenter registry study BOMET MF14-01 was initiated in May 2014. Patients with de novo stage IV BOM BC were divided into two groups: those receiving systemic treatment (ST group) and those receiving LRT (LRT group). Patients who received LRT were further divided into two groups: ST after LRT (LRT + ST group) and ST before LRT (ST + LRT group).

RESULTS

We included 505 patients in this study; 240 (47.5%) patients in the ST group and 265 (52.5%) in the LRT group. One hundred and thirteen patients (26.3%) died in the 34-month median follow-up, 85 (35.4%) in the ST group and 28 (10.5%) in LRT group. Local progression was observed in 39 (16.2%) of the patients in the ST group and 18 (6.7%) in the LRT group (p = 0.001). Hazard of death was 60% lower in the LRT group compared with the ST group (HR 0.40, 95% CI 0.30-0.54, p < 0.0001).

CONCLUSION

In this prospectively maintained registry study, we found that LRT prolonged survival and decreased locoregional recurrence in the median 3-year follow-up. Timing of primary breast surgery either at diagnosis or after ST provided a survival benefit similar to ST alone in de novo stage IV BOM BC patients.