Benefits of Surgical Treatment of Stage IV Breast Cancer for Patients With Known Hormone Receptor and HER2 Status

Primary site surgery of de novo stage IV HER2-positive breast cancer in the era of new drug treatments

Objective

The surgical treatment of the primary site has been a subject of controversy in patients with de novo metastatic breast cancer. In recent years, studies using large databases and retrospective analyses have provided evidence of the survival benefits of localized surgery for these patients. However, due to the improved prognosis associated with novel antitumor agents and the widespread use of anti-HER2 therapy, it is important to investigate the role of primary site surgery in the context of new drug treatments for stage IV HER2-positive breast cancer.

Methods

This retrospective analysis included patients with metastatic breast cancer at diagnosis who were consulted at the First Hospital of Jilin University between 2016 and 2022. We compared the patients' clinical and pathological characteristics, treatment regimens, and prognosis between the surgery and non-surgery groups.

Results

A total of 96 patients with stage IV HER2-positive breast cancer were included in the study, with 24 patients (25%) undergoing surgery for the primary lesion. Patients with lower Eastern Cooperative Oncology Group (ECOG) scores, earlier T-stage, metastases confined to one organ/site, and fewer metastases were more likely to undergo surgery. Patients in the surgical group had longer progression-free survival (median 25.7 vs. 15.9 months, p=0.073) and overall survival (median 79.1 vs. 48 months, p=0.073) compared to patients in the non-surgical group, however, there was no statistical difference. Univariate and multivariate Cox regression analysis suggested that the choice of first-line targeted therapy regimens rather than surgical treatment influenced the patients' prognoses. In the subgroup of patients receiving first-line targeted therapy with trastuzumab plus pertuzumab, the decision to undergo surgery on the primary site did not have a statistically significant effect on prognosis.

Conclusion

Primary site surgery does not improve the prognosis of de novo stage IV HER2-positive breast cancer. In the era of anti-HER2 therapy, primary surgery is not recommended, except in exceptional circumstances.

Outcomes of the patients with metastatic male breast cancer

BACKGROUND

The goal of this research is to investigate the clinical characteristics and prognosis of men with metastatic breast cancer (mMBC).

METHODS

A retrospective analysis of the data of 28 patients was conducted. Kaplan-Meier and Cox regression analyses were used to assess overall survival (OS) and prognostic variables.

RESULTS

At the time of diagnosis, the median age was 57 years (range 26-86). The most prevalent pathological subtype was invasive ductal carcinoma (92.6%). HER2 positivity was 21.6% in patients, with estrogen and progesterone receptor positivity at 96.4% and 71.4%, respectively. Bone-75%, lung-39.3%, brain-21.4%, and adrenal gland-10.7% were the most prevalent metastatic sites. Trastuzumab-based chemotherapy was given to six patients. During the study period, 14 patients (or half) died. All patients had a median OS of 42.6 months (range: 21.6-63.7). The OS rates after 1, 3, and 5 years were 95.7%, 54.2%, and 36.6%, respectively. The number of metastatic locations (P = 0.045), brain metastasis (P = 0.033), and a history of regular alcohol intake (P = 0.008) were all shown to be statistically significant factors affecting OS in univariate analysis. However, multivariate analysis did not support the findings. In addition, we discovered that trastuzumab-based therapy and de-novo metastatic disease had no effect on OS for mMBC.

CONCLUSIONS

The data on mMBC is restricted because of its rarity. The prognosis of mMBC was shown to be poor in this investigation. Despite the small number of patients, we discovered that in univariate analysis, having brain metastases, the number of metastatic locations, and a history of alcohol intake may be prognostic factors.

De Novo Oligometastatic Breast Cancer

De novo oligometastatic breast cancer, a unique disease needing new treatment paradigms.

HR+/HER2- de novo metastatic breast cancer: a true peculiar entity?

De novo metastatic breast cancer (dnMBC) accounts for ~6-10% of all breast cancers and for ~30% of MBC with increasing incidence over time. Hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR⁺/HER2^-) tumours are the most frequent subtype with a similar incidence to that observed amongst recurrent MBC (rMBC). Higher frequency of PI3KCA and ARID2 mutations and a lower frequency of ESR1 mutations and of genes involved in DNA damage, as compared with rMBC, have been reported in HR⁺/HER2^- dnMBC; however, these are not correlating with prognosis, whilst tumour mutational burden is inversely correlated with outcome. Bone represents the most frequent metastatic site, being the single site in up to 60% of patients with dnMBC. HR⁺/HER2^- dnMBC has been generally reported to have better outcomes than rMBC, with a median overall survival ranging from 26 months to nearly 5 years in patients with favourable features such as age <40 years and bone-only disease, but not when compared with patients with late recurring disease (≥2-5 years). Analyses of the de novo cohorts within randomized clinical trials and large real-world series report a better outcome after treatment with CDK4/6 inhibitors and endocrine agents as compared to rMBC. Despite the limitations of retrospective studies and controversial results of the randomized trials, locoregional treatment of the primary tumour after response to systemic therapy appears to confer a survival benefit, particularly in patients with favourable prognostic factors. Altogether genomic, biological and clinical findings highlight HR⁺/HER2^- dnMBC as a peculiar entity as compared with rMBC and deserve a dedicated treatment algorithm. This article is part of the Tackling clinical complexity in breast cancer Special Issue: https://www.drugsincontext.com/special_issues/tackling-clinical-complexity-in-breast-cancer/.

Radiotherapy of the Primary Disease for Synchronous Metastatic Cancer: A Systematic Review

In the case of synchronous metastatic disease, the local treatment of primary tumors by radiotherapy has long been reserved for palliative indications. The emergence of the concept of oligometastatic and oligopersistent diseases, the advent of new systemic therapies enabling longer overall survival with an enhanced quality of life, a better understanding of the biologic history of metastatic spread, and technical advances in radiation therapy are revolutionizing the management of patients with de novo metastatic cancer. The prognosis of these patients has been markedly improved and many studies have investigated the survival benefits from the local treatment of various primary tumors in cases of advanced disease at the time of diagnosis or in the case of oligopersistence. This article provides an update on the place of irradiation of the primary tumor in cancer with synchronous metastases, and discusses its interest through published or ongoing trials.

Primary Breast Neuroendocrine Tumors: An Analysis of the National Cancer Database

BACKGROUND

Primary breast neuroendocrine tumors (BNETs) represent < 1% of breast cancers. Diagnosing BNETs can be challenging, and a limited amount of cohort data currently exists in literature. We aimed to describe primary BNET characteristics, treatment modalities, and survival outcomes through the National Cancer Database (NCDB).

METHODS

A retrospective cohort analysis was performed using the NCDB from 2004 to 2017. BNET cases were compared with patients with invasive ductal carcinoma (IDC). A matched IDC cohort was created by matching patient age, race, and disease stage. Kaplan-Meier analysis was performed, and hazard ratios (HR) were calculated through the bootstrap sampling method.

RESULTS

A total of 1389 BNET and 1,967,401 IDC cases were identified. When compared with IDC patients, BNET patients were older, had more comorbidities, and were more often male (p < 0.01). BNETs were larger, higher grade, and more frequently hormone receptor negative (p < 0.01). While BNET patients were treated with surgery and radiotherapy (p < 0.01) less often compared with IDC patients, they presented at later disease stage (p < 0.001) and received systemic treatment more frequently (53.5% vs. 40%, p < 0.01). Patients with BNET had increased mortality compared with the matched IDC cohort: stage 1 HR 1.8, stage 2 HR 2.0, stage 3 HR 1.8, and stage 4 HR 1.5 (p < 0.001 for all).

CONCLUSION

Patients with BNET tend to present at higher clinical stages, are more frequently hormone receptor negative, and have inferior overall survival compared with patients with IDC. Further treatment strategies and studies are needed to elucidate optimal therapies to maximize patient outcomes.

Are there differences in outcomes by race among women with metastatic triple-negative breast cancer?

PURPOSE

Black women have higher breast cancer mortality rates than other groups, with Triple-negative breast cancer (TNBC) being more common among AAs with a worse prognosis. Our study seeks to explore differences among Non-Hispanic Black (NHB) vs. White (NHW) women, with Stage IV TNBC, focusing on survival and treatment patterns.

METHODS

SEER database was queried for TNBC patients diagnosed with metastatic disease from 2012 to 2016. Neighborhood socioeconomic status (nSES) was defined using the Yost index based on income, education, housing, and employment. Univariate and multivariate analyses were performed to evaluate receipt of surgery, radiation, and chemotherapy. Overall survival was evaluated using Kaplan-Meier curve and Cox proportional hazards model analysis.

RESULTS

25,761 TNBC cases were identified with 1420 being metastatic (5.5%). Bone was the most common site for metastasis, with patients' age being 63.7 years for NHW vs. 59.5 years for NHB. NHB women had the highest percentage of low nSES (62.3% vs 29.3%; p value = 0.001). On univariate analysis, fewer NHBs received radiation compared to NHWs (27.1 vs. 32.6%; p value = 0.040). On multivariate analysis, all women were less likely to undergo treatment if unmarried (p value < 0.01). NHB women had lower median survival compared to NHW women (13 vs. 15 months; p value < 0.01). Receipt of surgery and chemotherapy reduced the risk of mortality (p value < 0.01).

CONCLUSION

NHB women had lower median survival with metastatic TNBC. Race was associated with different treatment utilization. With a mortality differential between NHW and NHB women with metastatic TNBC, more investigation is needed to inform strategies to reduce this disparity.

Development and validation of a nomogram to predict survival for advanced male breast cancer

Male breast cancer is a rare disease. Many experiences of male breast cancer were derived of female breast cancer. However, there are huge differences between two groups. We conducted this study to find a reliable prognostic model for advanced male breast cancer. The cohort was selected from the Surveillance, Epidemiology, and End Results database. The enrolled patients were randomly divided into training and validation group. The univariate and multivariate analyses were used for prognostic assessment and a nomogram was built. Calibration curves and concordance index were compiled to determine predictive and discriminatory capacity. The time-dependent receiver operating curves and the decision curve analysis was used to verify the model's ability. Two hundred and eighty individuals were enrolled. The cumulative rates of 1-, 3- and 5-year overall survival (OS) rates were 98.6%, 72% and 57.9%. The C-indexes for OS were 0.835 (95%CI, 0.777-0.893) in the training group and 0.765 (95%CI, 0.668-0.862) in the validation group. The calibration curves confirmed the consistency of the nomogram both in the training and validation group. The time-dependent receiver operating curves and decision curve analysis demonstrated that the nomogram had better prediction capacity than TNM stage system for advanced male breast cancer. The nomogram we built was a reliable and solid predictive model.

Locoregional tumor burden and risk of mortality in metastatic breast cancer

The role of lymph node involvement and tumor size in metastatic disease including breast cancer is unclear. Here, nodal metastasis and T stage on the risk of mortality were investigated in de novo metastatic breast cancer population (35812 patients) in the Surveillance, Epidemiology, and End Results (SEER) Program database in the United States. We found an association between all-cause mortality and regional node involvement (adjusted hazard ratio [HR] = 1.45, 95% confidence interval [CI] 1.36–1.55, p < 0.0001) or T stage (HR = 1.20, 95% CI 1.14–1.25, p < 0.0001), independent of known clinicopathologic measurements. Number of positive nodes, and size and chest wall involvement of the breast tumors exhibited similar significance for breast cancer-specific mortality in the population (p < 0.0001 each), and all-cause mortality in hormone receptor (HR)-positive/HER2-negative (HR⁺/HER2^–), HR⁺/HER2⁺, HR^–/HER2⁺ and triple-negative metastatic breast cancer subtypes. Thus, nodal involvement and T stage are independent risk factors for mortality in the population of de novo metastatic breast cancer.

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.

Benefits of Trimodality Therapy Compared with Systemic Therapy Alone in Male Patients with Stage IV Breast Cancer

BACKGROUND

Male breast cancer (MBC) represents <1% of all breast cancer (BC) diagnoses. Recent publications in female stage IV BC have shown that surgical intervention has a survival benefit. This study aims to determine the impact of surgical intervention in men with stage IV BC and known estrogen (ER) and progesterone receptor (PR) status.

METHODS

The National Cancer Database was used to identify 539 stage IV MBC patients with known ER/PR status from 2004 to 2017. Chi-square tests examined subgroup differences between the treatment modalities received. Overall survival (OS) was assessed using the Kaplan-Meier method. Multivariate Cox proportional hazard models examined factors associated with survival.

RESULTS

The Kaplan-Meier estimation showed that ER-positive (ER+) and PR-positive (PR+) patients who received surgery, systemic therapy, and radiation (Trimodality) or systemic therapy and surgery (ST+Surg) had improved survival compared with systemic therapy alone (ST) [ER+, p < 0.003; PR+, p < 0.033]. For ER+ patients, the 5-year OS rates by treatment were: Trimodality, 40%; ST+Surg, 27%; and ST, 20%. For PR+ patients, the 5-year OS rates were: Trimodality, 39%; ST+Surg, 24%; and ST, 20%. The Cox proportional hazard model revealed a survival advantage in patients who received Trimodality compared with ST (hazard ratio 0.622; p < 0.002). The timing of systemic therapy in relation to surgery was not found to be significant.

CONCLUSIONS

Trimodality therapy has a survival benefit in stage IV MBC patients with known ER+ status than in male patients who receive systemic therapy alone.