Stage IV and Mastectomy

[alw]

Hello,

I'm wondering if anyone has any thoughts on having a mastectomy after being diagnosed at Stage IV.

My sister's initial BC diagnosis was earlier this year with bone mets (HER +++ and ER/PR -). She has had a complete response in both the primary and bone mets after a 4 month course of TCH plus Zometa. Currently on Herceptin and Zometa alone.

She is now struggling with the decision to have a mastectomy.

Thankful for any thoughts/comments/experience you may have to share.

Regards,

Amy

[aquinis2000]

although this is not the current protocol, these studies are interesting
hope this helps

Does aggressive local therapy improve survival in metastatic breast cancer?

CME


Surgery. 2002; 132(4):620-6; discussion 626-7 (http://www.medscape.com/medline/publicationbrowser/123?pmid=12407345) (ISSN: 0039-6060)




Khan SA; Stewart AK; Morrow M
Department of Surgery, Northwestern University Medical School, and the American College of Surgeons, Chicago, Ill 60611, USA.

BACKGROUND: Women with metastatic breast cancer and an intact primary tumor are currently treated with systemic therapy. Local therapy of the primary tumor is considered irrelevant to the outcome, and is recommended only for palliation of symptoms. METHODS: We have examined the use of local therapy, and its impact on survival in patients presenting with stage IV breast cancer at initial diagnosis, who were reported to the National Cancer Data Base (NCDB) between 1990 and 1993. RESULTS: A total of 16,023 patients with stage IV disease were identified in the NCDB during this period, of whom 6861 (42.8%) received either no operation or a variety of diagnostic or palliative procedures, and 9162 (57.2%) underwent partial (3513) or total (5649) mastectomy. The presence of free surgical margins was associated with an improvement in 3-year survival in partial or total mastectomy groups (26% vs 35%, respectively). A multivariate proportional hazards model identified the number of metastatic sites, the type of metastatic burden, and the extent of resection of the primary tumor as significant independent prognostic covariates. Women treated with surgical resection with free margins, when compared with those not surgically treated, had superior prognosis, with a hazard ratio of 0.61 (95% confidence interval 0.58,0.65). CONCLUSIONS: These data suggest that the role of local therapy in women with stage IV breast cancer needs to be re-evaluated, and local therapy plus systemic therapy should be compared with systemic therapy alone in a randomized trial.

Subject Headings ("]http://images.medscape.com/pi/homepages/splash/arrow-closed.gif[/url]Effect of primary tumor extirpation in breast cancer patients who present with stage IV disease and an intact primary tumor.[/b]

CME


Ann Surg Oncol. 2006; 13(6):776-82 (http://www.medscape.com/medline/publicationbrowser/123?pmid=16614878) (ISSN: 1068-9265)




Babiera GV; Rao R; Feng L; Meric-Bernstam F; Kuerer HM; Singletary SE; Hunt KK; Ross MI; Gwyn KM; Feig BW; Ames FC; Hortobagyi GN
Department of Surgical Oncology, Unit 444, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA. gvbabiera@mdanderson.org

BACKGROUND: Currently, therapy for breast cancer patients with stage IV disease and an intact primary tumor is metastasis directed; the primary tumor is treated only when it causes symptoms. A recent review suggested that surgery may improve long-term survival in such patients. We evaluated the effect of surgery in such patients on long-term survival and disease progression. METHODS: We reviewed the records of all breast cancer patients treated at our institution between 1997 and 2002 who presented with stage IV disease and an intact primary tumor. Information collected included demographics, tumor characteristics, site(s) of metastases, type/date of operation, use of radiotherapy, chemotherapy and hormonal therapy, disease progression (time to progression and location of progression) in the first year after diagnosis, and last follow-up. Overall and metastatic progression-free survival were compared between surgery and nonsurgery patients. RESULTS: Of 224 patients identified, 82 (37%) underwent surgical extirpation of the primary tumor (segmental mastectomy in 39 [48%] and mastectomy in 43 [52%]), and 142 (63%) were treated without surgery. The median follow-up time was 32.1 months. After adjustment for other covariates, surgery was associated with a trend toward improvement in overall survival (P=.12; relative risk, .50; 95% confidence interval, .21-1.19) and a significant improvement in metastatic progression-free survival (P=.0007; relative risk, .54; 95% confidence interval, .38-.77). CONCLUSIONS: Removal of the intact primary tumor for breast cancer patients with synchronous stage IV disease is associated with improvement in metastatic progression-free survival. Prospective studies are needed to validate these findings.

Subject Headings ("]http://images.medscape.com/pi/homepages/splash/arrow-closed.gif[url=")

[alw]

Thank you for the response. Very much appreciated.

I have seen these studies indicating surgery to remove the primary tumor in those with Stage IV cancer can be beneficial (particularly in those with bone only metastasis).

But what if the primary has been eliminated by chemotherapy? Should one still push for a mastectomy? I do a lot of research and have not been able to come across a similar situation.

Regards,

Amy

[dede10]

I was dx'd stage 4, and I have never had a Mastectomy. I just figured I was going thru enough without the added surgery. I think I did the right thing for myself. My primary tumor is completely gone, and was NED for 18 mos.

[al from Canada]

Dear Amy,

It's kind of closing the barn door after the horse is out but.........based on the attached published literature, it is food for thought. The problem with the studies however is that they never break-down who was HER2+ and who wasn't. HER2 is an aggressive disease where growth factors have gone wild; that said, some studies have shown that surgical trauma, thus the increase of growth factors, may stimulate the cancer.

Personally, I would opt for neo-adjuvant chemo, that is; shrink the tumor with chemo and then go for the lumpectomy (if any surgery is indicated). Most studies have shown that this approach has the same survival as mastectomy in stages 1-3. I would think you would achieve a similar result in stage 4. Mastectomy and resultant damage to the lymphatic system in stage 4 based on one or two studies doesn't make a lot of sense to me. Just my opinion.

Good luck, Al

[John21]

I would opt for the masectomy. I am not a woman and am just giving my opinion as a husband. My wife was diagnosed stage IV with mets to nodes and bones. Large breast mass. I would too shrink the primary site, but then do the masectomy and reconstruction at the same time. In the long run, I think it would be the best choice as I see many mets flare up again after treatments. It is still your choice and your Quality of Life.



Also, As a husband, I would rather have my wife around without a breast than not around at all.


Hope it helps and good luck

John

[Laura]

I am the sister that Amy has been talking about. I have a father/daughter oncologist team... one in Chicago, one in Milwaukee. They both say that current, standard treatment would be to not have the mastecomy. My primary tumor is gone, so there is nothing to shrink; my bone mets have healed. I/we have not found any studies that address this situation. Is it in my best interest to remove the breast? My gut says yes--but I need some research to back me up. I have 4 small children at home; I am 38 years old. er/pr-; her2+++; mets limited to bone. Had 4 cycles on TCH (3 weeks on 1 week off), now only Herceptin/Zometa. Any direction would be greatly appreciated.

Thanks,
Laura

[al from Canada]

Laura,

The research you are looking for is re-occurance of BC in breast after surgery with clean margins. The re-occurance probability should be the same as for the general population unless you have BRCA gene mutations. If you are stage 4 then chances are that it will appear in the liver or lungs before it appears in the same breast. I still maintain that the surgical trauma is worse than the possible advantages of profilactic mast.
It's a tough and personal decision only you can make. Good luck.
Al

[JerseyGirl]

Laura/Amy

I was diagnosed stage IV with a met to the liver. My masectomy is scheduled for Monday. I fought with the idea for months, but my onc is very adament about removing the primary site. I had a full response to chemo and now on Herceptin. My PET and CT were completely clear last week. I guess part of it might be psychological, but the one thing all of the doctors have agreed on is that it isn't a difficult surgery; it sounds worse than it is. Of course those are men....! Like Al said, it's a personal decision, but I'm going with getting rid of it, as I plan on being here for many years to come. And I can get new ones that won't cause me anymore trouble! :)
Julie

[Val Pfeiffer]

Laura--
Did you have a lumpectomy? Did you have radiation? How large was your primary tumor at diagnosis? If your oncologist is pushing for it, then a mastectomy is probably warrented, however you may want to get a second opinion. I was stage 3 and had neo-adjuvant chemo as well (you can read my story if you're bored) and could have shrunk the tumor until it was gone and not had surgery I suppose. But I didn't want to take any chances. I have very small breasts (well, now that would be "breast" :-) and started with a large tumor, so a lumpectomy was out of the question.

If you have had no surgery, then with the way Her2 cells behave, there could still be cancer cells in there, but I suspect that at the fast rate that these cells grow, that you would know if they were in there by now.

Sounds like you are geographically close to me--UW Madison
has a decent cancer center if you are looking for a second opinion.

Ultimately, you need to listen to your gut. My husband and my surgeon friend thought I should have a double mastectomy right away, but I am young and didn't want to make that decision at the time. Your oncologist is probably trying to be conservative, but there isn't anything wrong with that. A family I grew up with had four girls, one died of BC, the other is a survivor, and the other two had their breast removed and reconstructed so they wouldn't have to worry about it. It is such a personal decision, but I tend to agree with the comment about having you around with one breast vs. not having you around!

Good luck with your decision :-)
Val

[Laura]

I haven't had any surgery or radiation. I have no family history of breast cancer. The primary tumor was about 7cm at diagnosis. After one month, it was no longer palpable, CT scan at 4 months showed it was gone and my bone mets were healed. Both doctors say a mastectomy in not in my cards, "the barn door has been opened" and current, standard treatment is to not have the mastectomy. I have no problem with having one (or no) breasts, this is definitely not a body image problem I am having. I want to see my children grow into adults. I want to do what is best for my health and if pushing for a mastectomy is what it takes, I will do it. But... I also want to know if that will stir up cells that should not be stirred up. I continue to struggle with what to do.



Val... I live in West Bend, 20 miles north of Milwaukee.



Thanks for all of your comments and helpful advice.

Laura

[Val Pfeiffer]

Laura--I am in Neenah--we are so close :-) I have a close friend who is a top surgeon in this area -- his name is Ray Georgen -- he practices out of Theda Clark. You may want to make an appointment with him for a second opinion. He is the person who suggested to me that I do the neo-adjuvant chemo before I had surgery and I completely trust his judgement. I am farily sure he does second opinions--I wouldn't see why not. He is conservative, so he will tell you the most conservative approach, but he will tell you the "why" behind his opinion so you can be educated and then make a decision. If you are interested in doing that, let me know and I'd be happy to call him and tell him why I told you about him.

It just seems so strange that with a case of Her2 stage 4 that they didn't want to discuss surgery. But I am no expert :-)

Please let me know how I can help.

Val

[aquinis2000]

Since reading these post, I would recommend doing some research on the Internet about "recurrence after mastectomy". From what I have been reading
there is alot to consider. Local and distant recurrences had a pretty high rate in most of the literature I read.It seemed as though radiation combined with mastectomy, the precision of the surgeon, lymph involvement ,grade, stage all played a part. It seemed to be the roll of the dice. As micrometastisis, those hiding little bugers, no one, not even the most qualified surgeon, can see, are the culprit. Whether it be recurrence to original primary, or new recurrence
both were evident .There are alot of studies out there. Maybe this line of research will help make a decision. Good luck

[jessica]

Hi~
I'm in a similar situation-and this is a REALLY TOUGH DECISION.
I was dx'd StageIV-liver mets- at primary dx in May 2002. I've since had a lumpectomy,TONS of chemo, Herceptin only, even been NED for a year before a recurrence w/a single liver met. After more wrestling w/The Spot & on/off chemo for another year, I had a liver resection last December. Since then I've been NED, thank God (sort of, i'll explain...) and on Herceptin only, ever since.
Here's the complicated part...8 weeks after my resection, I discovered a "new"lump in my breast,in what seems to be the exact same location as the primary tumor in 2002, only this time surrounded by pervasive, high grade DCIS. I had an excisional biopsy to remove the "new" 1cm invasive disease, but now am vigilantly watching the DCIS w/frequent breast MRI's. If it starts to look "funny" then there's no other option but to have a mastectomy.In the meantime, we watch & wait,but I continue to wrestle with the question of pursuing the mastectomy, before things look "funny".
Al's post re:stimulating growth factors post surgery is really important to consider. I do believe that was a factor in this invasive spot in my breast popping up, combined with being off Herceptin before & after the liver resection. I think in my body's efforts to heal, all those growth factors FIRED UP, stimulating healing & re-growth everywhere. Good for my liver, BAD for HER2+ cells!Also, being off Herceptin left me unprotected & vulnerable. One GOOD THING, is I believe you can stay on schedule w/Herceptin & don't have take a break to accomodate a mastectomy...?
So many questions....If I'd had a mastec back in 2002, inspite of the "Barn-door-already-open" philosophy, I might not be dealing with this today...?Hindsight is 20/20...There is no "RIGHT" decision, only what feels right to you.

I haven't decided yet either-the last thing I want is for that DCIS to fire up, become invasive, break off a piece & invade my poor NEW liver, or anything else for that matter.

The bottom line is this disease, at this stage, must be viewed as a chronic one. We can only do the best we can, make the best decisions we can, with the information available to us, and what our instinct guides us towards.
In the meantime, those scientists just keep cranking away at a CURE, if not more manageable, chronic treatment!

Prayers, Faith & Courage~

[tousled1]

I am not Stage IV but am Stage III and I opted for a bilateral mastectomy and have absolutely no regrets. I had neoadjunct chemo to shrink the primary tumor and then had the surgery. I'm glad I did as I had a very large number of lymph nodes involved. But as everyone here as said, it is a personal decision and you and only you can make that decision. There are not right or wrong decisions. Best of luck to you.

[dede10]

Just food to add for thought....I have a friend who was dx'd stage 2 about 3 yrs ago. She is also her2+++. After Chemo, and clear scans, she had a double mastectomy w/reconstruction. That was done in nov 2004. Sept 2005, she was redx'd stage 4.

I, having been initially dx'd stage 4 her2+++, chose not to have surgery. My initial tumors, & all others shrunk completely and I was NED for 18 mos. My flare ups have never been in the same breast, nor in the other. I am getting scans every 3 mos.

I had initially planned on surgery, but could not come up with the right reason for doing it. I didn't see the benefit.

We all have to make our own decisions on this, and either way, its not easy. I will pray you make the right decision for you.

Blessings
-dede

[jessica]

For those of us who are on a regular, q12 week, Scan Schedule...Don't forget to keep up w/your mammo's too! I know, it may feel like one more test that you can forgo, especially since a PET scan will light up with anythng metabolic - atleast that's how I felt about it. And that is true but, remember, Scans are fallible picking up things under .5cm.
So, even though the PET is scanning everything for "Eyes to Thighs", it may miss other nuances in the breast tissue, especially DCIS-a mammo will pick that up, when a PET won't.
Just hoping to share some wisdom & others may learn from my oversight...

Prayers, Faith & Courage!

[kk1]

Hi;

I was dx at primary as stage IV with liver mets , had a complete resonse from chemo and continue to be ned going on 3 years now. I too struggled with the surgery issue. In the end I had the masectomy after the chemo and when they looked at the tissue there were micro mets that had not shown up on the ct and pet scans. Bottom line is I am really glad I had the surgery.

take care hope this helps
kk1

[Sher]

Amy,


I just had a complete mascetomy at Stage IV and I have no regrets. My tumor was extremely rapid growing. In less then 2 months time tumor grew to 80% in right breast. I also had to go through a second surgery because of major tissue damage (long time smoker) where they transplanted fat from my abdomen to my chest wall and then did skin grafts from my pubic area to my chest. Just arrived back home this past Saturday. The grafts were and still are are horribly painful and I hope I never have to have another one done........or if I do it damn sure won't come from the pubic area!!! I go back in three weeks to meet with the oncologist and surgeon for treatment/reconstruction plans. The surgeon I have is phenominal. You know the funny thing I learned about myself is it didn't bother me at all to lose a breast but I'm scared ****less about losing my hair!!!!

I was very confused and very angry at my first surgeon who did my biopsy. Because of that I sought a second opinion at CTCA......best decision I ever made. My only fear is I hope I don't regret not taking the left too later down the road.

((((Hugs)))) She'll know what she wants to do when the time is right for her and her gut tells her.....just as it did me.

[Lani]

perhaps you could get an MRI pre-op It can show false positives, but it also can show DCIS and recurrence that does not show up on mammograms and ultrasounds. Wouldn't it be nice to know more what might be lurking in that breast?

If you had multicentric disease perhaps that would influence their decision re mastectomy vs rads.

I am suffering from 9 time zones difference jetlag, so don't think any other opinion would be useful right now.

In the best of all possible worlds they would let you get a PET scan and other staging tests AND a bone marrow to help you in your decision.

Best of luck

[Lani]

ABSTRACT: Correlation of targeted ultrasound with magnetic resonance imaging abnormalities of the breast [American Journal of Surgery; Subscribe]
Background: Magnetic resonance imaging (MRI) of the breast is highly sensitive for cancer. However, MRI frequently detects additional lesions that mandate further evaluation. The intent of this study was to assess the ability of targeted ultrasound to identify additional lesions detected on MRI in patients undergoing evaluation for breast cancer.

Methods: Between January 1, 1999, and July 15, 2004, 270 women underwent breast MRI at Grant Medical Center. MRI was obtained in 191 women during evaluation for documented or suspected breast cancer. Fifty-two patients had additional suspicious lesions on MRI, prompting targeted ultrasound; these patients constituted our study population.

Results: Seventy-five additional suspicious lesions were detected on breast MRI in 52 women. Two women underwent mastectomy without targeted ultrasound. Targeted ultrasound identified 65 of the remaining 73 lesions (89%). Eight lesions (11%) were not visible on targeted ultrasound.

Conclusion: Targeted ultrasound can be a reliable method to correlate MRI abnormalities in breast cancer patients.


Hope this helps!