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THE VALUE OF SURGERY IN

METASTATIC BREAST
CANCER

dr. Farida Briani Sobri, Sp.B.Onk.


Divisi Bedah Onkologi, Departemen
Ilmu Bedah FKUI-RSCM, Jakarta

General Preview

PRO
SURGER
Y
STUDIE
S

METASTATIC
BREAST
CANCER

CONTRA
SURGERY
STUDIES

PRO SURGERY STUDIES


Khan et
al 2002

Barbiera
et al
2006

Blanchar
d et al
2008

Lang et
al 2013

Danna et
al 2004

Fields et
al 2007

Neuman
et al
2009

Schreiber
et al
2003

Gnerlich
et al
2007

Nguyen
et al
2011

Rapiti et
al 2006

Ruiterka
mp 2009

Harris et
al 2013

PRO SURGERY STUDIES


Khan et
al 2002

Barbiera
et al
2006

Blanchar
d et al
2008

Lang et
al 2013

Danna et
al 2004

Fields et
al 2007

Neuman
et al
2009

Schreiber
et al
2003

Gnerlich
et al
2007

Nguyen
et al
2011

Rapiti et
al 2006

Ruiterka
mp et al
2009

Harris et
al 2013

PRO SURGERY STUDIES


EVIDENCE

Khan et al (2002) :
Surgical resection promotes the more
significantly superior prognosis for
partial as well as total mastectomy.

Rapiti et al (2006) and Babiera et al


(2006) :
Improvement in survival only identified
in patients who had the entire primary
tumor removed with free surgical margin

PRO SURGERY STUDIES


Khan et
al 2002

Barbiera
et al
2006

Blanchar
d et al
2008

Lang et
al 2013

Danna et
al 2004

Fields et
al 2007

Neuman
et al
2009

Schreiber
et al
2003

Gnerlich
et al
2007

Nguyen
et al
2011

Rapiti et
al 2006

Ruiterka
mp et al
2009

Harris et
al 2013

PRO SURGERY STUDIES


EVIDENCE

Dana et al (2004) and Schreiber et al


(2003) :
Inverse relationship between
immunotherapy and tumor burden.
Therefore to induce improved prognosis,
there is a need to remove primary
tumor.

PRO SURGERY STUDIES


Khan et
al 2002

Barbiera
et al
2006

Blanchar
d et al
2008

Lang et
al 2013

Danna et
al 2004

Fields et
al 2007

Neuman
et al
2009

Schreiber
et al
2003

Gnerlich
et al
2007

Nguyen
et al
2011

Rapiti et
al 2006

Ruiterka
mp 2009

Harris et
al 2013

PRO SURGERY STUDIES


EVIDENCE

Fields et al (2007) and Gnerlich


(2007) :
Extension of survival in patients who
had surgical resection.

Ruiterkamp et al (2009) :
Decrease in mortality risk resulted from
the removal of primary tumor.

PRO SURGERY STUDIES


Khan et
al 2002

Barbiera
et al
2006

Blanchar
d et al
2008

Lang et
al 2013

Danna et
al 2004

Fields et
al 2007

Neuman
et al
2009

Schreiber
et al
2003

Gnerlich
et al
2007

Nguyen
et al
2011

Rapiti et
al 2006

Ruiterka
mp et al
2009

Harris et
al 2013

PRO SURGERY STUDIES


EVIDENCE

Blanchard et al (2009)
Little association between increased
morbidity and breast surgery in stage 4
breast cancer patients.
Surgery contributed to control bulk
disease, reduce symptoms, prevent
complication and does not minimize
survival.

PRO SURGERY STUDIES

PRO SURGERY STUDIES


EVIDENCE

Neuman et al (2009) :
Increase in the trend of overall survival
in surgery group of patients with ER/PR
positive and/or Hr2/neu amplified
disease.

Harris et al (2013) :
Favorable prognosis if surgery is done to
the appropriately selected candidates.

PRO SURGERY STUDIES

PRO SURGERY STUDIES


EVIDENCE

Nguyen et al (2013) :
Locoregional treatment of the primary
disease is associated with increased
survival.

Lang et al (2013) :
Favorable stage 4 patiens for surgery :
fewer T4 tumors and solitary metastasis.

Problems for Those Pro Surgery


Studies :
All of those are retrospective studies
Most studies admitted they were
affected by patients selection bias.
No studies have been analyzed by
randomized controlled trial in order to
specify the finding.

CONTRA SURGERY STUDIES

CONTRA SURGERY STUDIES

CONTRA SURGERY STUDIES


EVIDENCE

Fisher et al (1996) :
experimental study : the presence of growthstimulating factor after primary tumor resection
in mice.
The primary tumor resection among the C3H
mouse mammary specimen had an inclined in
the serum growth factor inclined metastatic
tumor growth.
Conclusion: increased in tumor growth following
the transfer of the serum to the tumor-bearing
mice.

CONTRA SURGERY STUDIES

CONTRA SURGERY STUDIES


Cady et al (2008) :
No significant differences in survival
with or without surgery when surgery
and chemotherapy were done
Cady et al and Dominici et al (2011)
simultaneously.
Favorable impact on other population
studies :

Case selection bias.


There is a need to conduct more trials
to define the appropriate candidates
of stage IV breast cancer patients that
potentially benefit from tumor
resection

CONTRA SURGERY STUDIES

CONTRA SURGERY STUDIES


EVIDENCE

Bafford et al (2009) :
The benefit of surgery was found to be
more likely to improve the survival
among the patients operated before the
diagnosis of metastatic disease and also
a consequence of stage migration bias.
ER and HER2NEU status were positive
predictors contributed to survival

CONTRA SURGERY STUDIES


EVIDENCE (Contd)

Bafford et al (2009) :
CNS (central neural system) and liver
metastases involvement were negative
predictors.
The group of patients that are noted to
had metastatic disease preoperatively
had an incomparable survival to the
patients that had not experienced
surgery.

CONTRA SURGERY STUDIES


Ongoing Prospective Randomized Controlled
Trial: Preliminary Results

CONTRA
SURGERY STUDIES
CONTRA
SURGERY
STUDIES
Ongoing Prospective Randomized Controlled Trial: Preliminary
RandomizedResult
Controlled Trial

CONTRA SURGERY STUDIES


EVIDENCE

Badwe et al (2013) :
no statistically different in OS in LRT and in
no LRT patients
distant progression-free survival was
increased in no LRT arm.
However, it is noted that there are
limitations among the study
99 of the patients were identified to had disease
representing HER2 overexpression
did not receive her2 targeted therapy
did not analyzed by stratification of HER2 status.

CONTRA SURGERY STUDIES


Ongoing Prospective Randomized Controlled Trial

CONTRA SURGERY STUDIES


EVIDENCE

Soran et al (2013) and :


Even though there is an increased in median
overall survival (OS) in the LRT group, the
difference in comparison to the no LRT group was
not statistically significant.
only one-half of the patients with solitary bone
metastatic had biopsy-proven metastatic disease
there are considerable number of patients in
the group that probably not experienced stage IV
disease.
the participants were administered with up-front
LRT is the result applicable to patients who first
received systemic therapy??

CONTRA SURGERY STUDIES


currently waiting for the results
from.

Conclusion
The role of surgery in patients with
MBC remains controversial.
Numerous retrospective studies
seemed to give permission for
clinicians to perform surgery in MBC
patients - particularly ones with
promising prognosis and good
respons to previous systemic therapy.

Conclusion
There is a tendency that results
from prospective randomized
controlled trials would probably
show disagreement.
Lets
look forward to final results of other
prospective studies currently ongoing
OR
Lets do our own prospective studies with proper
adjusment to our real condition that hopefully
give us better reasons to make the best decision.

THANK YOU