Author Reply: Surgery in Stage IV Breast Cancer Patients: Continued Controversy
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KeywordsBreast Cancer Surgical Intervention Progesterone Receptor Systemic Therapy Epirubicin
We appreciate the opportunity to respond to Dr. Fitzal’s letter to this journal regarding our 2008 study evaluating the impact of timing on surgical intervention at the primary tumor site in Stage IV breast cancer.1 The limitations of any retrospective analysis are well known; currently, however, these are the data available to guide treatment decisions and future trials. In this light, there are multiple retrospective single-institution and database reviews that indicate a possible survival advantage.2, 3, 4, 5 Included in these are both our initial analysis comparing surgical intervention and systemic therapy versus systemic therapy alone,2 as well as the Fields’ et al. publication supporting our initial findings.4
To our knowledge, the surgical intervention timing study is the only one to carefully evaluate a cohort of patients treated at a single institution and identify factors that contributed to increased survival among the patients who received surgical intervention.1 Timing of surgical intervention did not contribute to survival on multivariate analysis, a point discussed extensively; however, there was an improvement in metastatic progression-free survival (P = .0008) on univarate analysis. Estrogen receptor and progesterone receptor status were evaluated and not found to be contributing factors to survival (P = .74, .339, respectively) or metastatic progression-free survival (P = .796, .952 respectively) and therefore not reported. The study from Fields et al. does evaluate why surgical intervention was performed—diagnosis, curative intent, or palliation; however, there is no specific evaluation of the timing of surgical intervention from the date of diagnosis and its correlation with survival.
In reference to the ongoing study of Dr. Badwe, the group at Tata Memorial is congratulated for being able to initiate a trial that has been discussed in the United States for years, but unfortunately not performed. Their preliminary analysis of 99 patients suggests an improvement in progression-free survival in patients with local resection.6 All patients were randomized only AFTER completing chemotherapy with cyclophosphamide, 5FU, and epirubicin; therefore, most likely placing them in the same group that had improved metastatic progression-free survival in our review—those patients who had surgery >3 months after their initial diagnosis of breast cancer. Patients in this initial dataset were not randomized prior to initiation of systemic therapy.
Improving systemic therapies have enabled increased survival in Stage IV patients, underlining the need for prospective data to optimize patient outcomes.7 We look forward to the results of Dr. Badwe’s trial, which plans to have an enrollment of 350 patients and should be adequately powered to answer this important question.
- 6.Badwe RA, Hawaldar RW, Khare A, Nadkarni M, Jalali R, Parmar V. Role of local-regional treatment in metastatic breast cancer at presentation: A randomized trial. San Francisco, CA: In ASCO Breast Cancer Symposium; 2008.Google Scholar