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Surgery receipt linked to improvements in stage IV breast cancer over time
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Survival rates have increased among women with stage IV breast cancer, particularly among those who underwent initial breast surgery, according to results of a retrospective cohort study.
However, the researchers acknowledged surgery may not benefit the majority of women with stage IV breast cancer in the era of effective and targeted agents.
Between 5% and 10% of women diagnosed with breast cancer in the U.S. present with stage IV disease and have an intact primary breast tumor, according to study background. Appropriate management of the primary tumor site in this population is debated because the disease at this stage is considered incurable.
“Systemic therapies cannot yet manage all macroscopic disease fully,” Mary C. Schroeder, PhD, assistant professor of health services research at University of Iowa, and colleagues wrote. “Hopefully, this time will come. Until then, local therapy with surgery to the primary tumor may offer critical disease control for select patients and could be an essential component of prolonged survival.”
The researchers used the SEER database to evaluate 21,372 women (median age, 63 years) who were diagnosed with stage IV breast cancer between 1988 and 2011 and who did not receive radiation therapy in their first course of treatment. Researchers used median survival estimates to compare patient and tumor characteristics by receipt of breast surgery at diagnosis.
Overall, median survival increased from 20 months between 1988 and 1991 (HR = 0.63; 95% CI, 0.56-0.71) to 26 months between 2007 and 2011 (HR = 0.61; 95% CI, 0.57-0.66).
The rate of surgery declined from 67.8% in 1988 to 25.1% in 2011 (OR = 0.16; 95% CI, 0.12-0.21).
However, receipt of surgery appeared associated with improved survival.
From 1988 to 2001, the median survival was 13 months among those who did not undergo surgery and 24 months among those who did (HR = 0.63; 95% CI, 0.56-0.71). From 2007 to 2011, the median survival further improved from 22 months among patients who did not undergo surgery to 35 months among those who did (HR = 0.61; 95% CI, 0.57-0.66).
Among women who were diagnosed prior to 2002, rates of prolonged survival — defined as survival of at least 10 years — were 9.6% among women who underwent surgery vs. 2.9% among those who did not (OR = 3.61; 95% CI, 2.89-4.5).
Results of a multivariate analysis showed women were more likely to survive at least 10 years if they underwent surgery (OR = 2.8; 95% CI, 2.08-3.77), had hormone receptor-positive disease (OR = 1.76; 95% CI, 1.25-2.48) and had a more recent year of diagnosis (OR = 1.43; 95% CI, 1.02-1.99).
However, women who were older (OR = 0.41; 95% CI, 0.32-0.54), had a larger tumor size (OR = 0.37; 95% CI, 0.27-0.51) and whose marital status was separated at time of diagnosis (OR = 0.67; 95% CI, 0.51-0.88) appeared less likely to achieve prolonged survival.
“This work will add to the body of evidence on these important concepts in the care of women with advanced breast cancer,” Schroeder and colleagues wrote. “Randomized clinical trials and prospectively enrolled registries will be essential to understanding the underlying casual relationship between our observed association of receipt of surgery and improved survival.”
In an accompanying editorial, Lisa A. Newman, MD, MPH, formerly of University of Michigan, added that information from this study could also provide important information regarding disparities associated with ethnicity.
“[The researchers] found a disproportionately high prevalence of African-American women among their stage IV study population and African-American women were also 30% less likely to undergo surgery,” Newman wrote. “This treatment imbalance raises questions regarding selection of patients that are triaged toward more aggressive care.” – by Anthony SanFilippo
Disclosure: The researchers and Newman reported no relevant financial disclosures.
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