GOOD MORNING EVERYONE!: oligometastatic breast cancer-- possibility of cure

[Lani]

unfortunately the full article is not up online that I can find to peruse and her2
breast cancer does not seem to be separated out from other bc, but here it is.
Only a few years ago oncologists were telling their patients that the average Stage IV patient survived an AVERAGE of two years no matter what their treatment and many were nihilisitic in their attitude. Oligometastatic disease has such a better prognosis, would this not imply it is important to be aggressive in trying to find and equally aggressive in trying to treat the first metastases if they are rare.

The rationale behind not testing periodically after completion of treatment and waiting for a fracture to occur , seizure or change in vision to occur etc has been that most patients don't, it is expensive to check, and there is not much benefit in finding the metastases earlier rather than later. That is obviously not so for oligometastatic disease.

Is oligometastatic disease a characteristic of the type of breast cancer or the fact it was found early?

All these things need to be looked at and as usual, I think looking at the bone marrow before and after treatment and periodically thereafter might be a way to start until CTC testing or Iron nanoparticles-fused-to herceptin MRI imaging become ready for primetime ways to detect minimal residual disease.

Breast Cancer. 2012 Apr 25. [Epub ahead of print]
Possible clinical cure of metastatic breast cancer: lessons from our 30-year experience with oligometastatic breast cancer patients and literature review.
Kobayashi T, Ichiba T, Sakuyama T, Arakawa Y, Nagasaki E, Aiba K, Nogi H, Kawase K, Takeyama H, Toriumi Y, Uchida K, Kobayashi M, Kanehira C, Suzuki M, Ando N, Natori K, Kuraishi Y.
Source
Department of Clinical Oncology and Hematology, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan, tadkob-1@kk.iij4u.or.jp.
Abstract
BACKGROUND:
Metastatic breast cancer (MBC) is generally incurable. However, 10-20-year relapse-free survival of MBC is approximately 2%, implying that at least a small subset of MBC patients achieve prolonged survival. We therefore analyzed long-term outcome in a particular subset, i.e., oligometastatic breast cancer (OMBC).
METHODS:
Data of OMBC subjects (N = 75) treated in our institution from April 1980 to March 2010 were retrospectively analyzed. OMBC was identified as: one or 2 organs involved with metastatic lesions (excluding the primary lesion resectable by surgery), fewer than 5 lesions per metastasized organ, and lesion diameter less than 5 cm. Patients were generally treated with systemic chemotherapy first, and those who achieved complete response (CR) or partial response (PR) were further treated, if applicable, with local therapy (surgical or radiation therapy) to maintain CR or to induce no evidence of clinical disease (NED), with additional systemic therapy.
RESULTS:
Median follow-up duration was 103 (6-329) months. Single or 2 organs were involved in, respectively, 44 (59%) and 31 (41%) cases with metastatic lesions, 48% of which were visceral. In cases where effects of systemic therapy, possibly in combination with other treatments, were evaluated (N = 68), CR or PR was achieved in 33 (48.5%) or 32 (47.1%), respectively, with overall response rate (ORR: CR + PR) of 95.6% (N = 65). In cases receiving multidisciplinary treatment (N = 75), CR or NED (CR/NED), or PR was induced in 48 (64.0%) or 23 (30.7%) cases, respectively, with ORR (CR/NED + PR) of 94.7% (N = 71). CR rates (60.5%) with systemic therapy and CR/NED rates (79.5%) with multidisciplinary treatment were significantly better in subjects with a single involved organ than in those with two involved organs (P = 0.047 and 0.002, systemic only or multidisciplinary treatments, respectively). Medians estimated by Kaplan-Meier method were: overall survival (OS) of 185.0 months and relapse-free interval (RFI) of 48.0 months. Estimated outcomes were: OS rates (OSR) of 59.2% at 10 years and 34.1% at 20 years, and relapse-free rates (RFR) of 27.4% at 10 years and 20 years. No disease progression was observed after 101.0 months as RFR. Cases with single organ involvement (N = 44) showed significantly better outcomes (OSR of 73% at 10 years and 52% at 20 years, RFR of 42% at 10 years and 20 years). Those who received local therapies (N = 35) also showed better prognosis: OSR of 82% at 10 years and 53% at 20 years, RFR of 38% at 10 years and 20 years. Three cases (4%) survived for their lifetime without relapse after achieving CR or NED, our definition of clinical cure. Multivariate analysis revealed factors favoring better prognosis as: none for OS, and single organ involvement with metastasis, administration of local treatment, and shorter disease-free interval (DFI) (P = 0.030, 0.039, and 0.042, respectively) for RFR. Outcomes in OMBC in literature were OSR of 35-73% at 10 years and 26-52% at 20 years, and RFR of 27-42% at 10 years and 26-42% at 20 years.
CONCLUSIONS:
The present analyses clearly indicate that OMBC is a distinct subgroup with long-term prognosis superior to MBC, with reasonable provability for clinical cure. Further prospective studies to better characterize OMBC are warranted to improve prognosis in MBC.
PMID: 22532161

[Bunty]

Thanks Lani! I would be interested to read more of this report, particularly as I'm going to see an Interventional Radiologist in two weeks' time to continue learning if it's worth doing RFA (or maybe something else) on my single liver and few lung tumours. My oncologist has been doing more research for me and has found a lot of reports on RFA for me to read. I think I've mentioned before, that it's not common in Australia to consider this type of intervention.
Cheers Marie

[KristinSchwick]

Loved this article- it is the first time I've actually seen statistics on long term survivors. Gives us gals hope. Thanks Lani!

[CoolBreeze]

I've been treated as an oligometastatic patient. Had only three tumors in the liver, all in the 3 cm range. Had a liver resection that removed 2 of them and an ablation that removed one.

The ablated area is in question now, but my last PET showed no cancer anywhere else, possibly in the ablated area and possibly not. I am on Abraxane.

It is exciting to think I have a 73% chance of being alive in ten years and more exciting to hear that three cases survived for their lifetime.

[Mtngrl]

Thanks. I've been wondering about whether it's useful to catch Stage IV "early." Sounds like it might be.

If so, I'm "lucky" to have presented at Stage IV. It was diagnosed via a routine staging workup. I had no symptoms. Of course, under the new guidelines, they would not have done the staging workup, because it looked like Stage II based on tumor size and lymph node involvement.

[CoolBreeze]

Mine wasn't caught early. I was Stage II and had tx for that. It wasn't until 4 months after my last herceptin that mets to my liver were found. They may have been there at the beginning but we'll never know.

Anyway, so far it is only in my liver and I've been treated as an oligo. I had a liver resection to cut half my liver out. As of my last scan, we saw nothing anywhere else, and my original dx was almost 3 years ago. Length of time from dx is important in determining oligio status.

My next scan will tell more. Next month, I think.

[Juls]

Just reading this again. Thought worth bumping up!
Think I fit in this!

[CoolBreeze]

Wow, I got a message about this thread. Haven't been here in a while.

Well, I guess I have bad news. Cancer has spread all though my abdomen and in my lungs. I started my 8th chemo (tdm-1). I got a good two years in remission though, can't complain. Hi all.

[jaykay]

So sorry to hear about the progression, Ann. Hope TDM-1 gets you back to NED

Janis

[michka]

Hi Ann. I only see your post now, down in this old thread. I am so sorry you have to try another treatment because of progression. I was hoping Pertuzumab would work for ever. I am hoping now that TDM1 will work as well for you as it worked for me.
Please post how you are. I 'll be thinking of you.

[Joan M]

Thanks for posting this.

I eagerly await the results of Steven Chmura's clinical trial of using radiation on MBC survivors with a limited number of mets. Preliminary results are due out next year.

I used a lung wedge resection in 2007, which at the time was considered blasphemy for metastatic cancer, and many MBC survivors felt likewise. As some of you old-timers on this board might remember. I was diagnosed stage II in 2003. Took H off-label, like in the adjuvant clinical trial at that time, or for 52 weeks.

In 2008, the tumor came back in the same area, and I did RFA. It hasn't been in the lung since. A brain tumor in that year was treated by standard of care, and it hasn't come back. So, thus far, I've been ok, as we all know there are no guarantees.

I first learned of oliogometastatic disease when I read in 2007 about clinical trial results in Japan -- I wonder whether the current authors are the same people. I also wonder whether sequencing is an issue: I have never done chemo with MBC, I did the local procedures from the get-go.

Often times, I think our docs throw everything except the kitchen sink at the cancer systemically, and when nothing works anymore they then decide to use local procedures as a last-ditch effort.

My heart goes out to women who have reached a near pCR and then the tumor just sits there until it inevitably starts to grow again. This happened to a sister of one of my girlfriends. One lung tumor. Stable for two years on H. She didn't want to remove it via surgery or RFA (being treated at Sloan Kettering, and they weren't going to suggest that to her, unless of course in a last-ditch effort). Now she's on TDM1.

To paraphrase Eric Winer quoting Lisa Carey: I took the path of least regret. That is, I never wanted to look back and ask myself what would have happened if I had used local procedures early on, EVEN if the cancer had come back.

[Mtngrl]

A few months ago I mentioned local treatment to try to eliminate my lung mets, and the (new) Nurse Practitioner said, "Oh, that isn't done with Stage IV." I knew that isn't always the case--some doctors, some centers, some patients do use it.

Right now I'm getting Abraxane, Herceptin & Perjeta. I started on it last July. The first scan, a month ago, was very encouraging. I had been on Taxol, and then Abraxane, in my first round of treatment. I never had progression while on it, so it was still an option. I thought maybe my cancer had changed in the 4 years since the first course of treatment, but I also thought it was worth a try. I'm glad, even though I am almost completely hairless, which makes me look weird.

One of the greatest things about a group like this is learning what has worked for others. That gives us reason to hope, and to expect (and insist on) something closer to "curative intent" from our caregivers.

[Juls]

Hi All
I bumped this up a few days ago because I thought interesting & think I might fall into this.
When 1st diagnosed outlook good but mistakes cost time & day before start of chemo they realised no scans done. So sent for CT. It showed tiny growth in liver thought benign. So next sent for MRI - from that they decided it was malignant as it had blood vessel! Months later Onc decides to contact liver specialist (to discuss removal) who also doesn't reply for months. When he finally does I am finished chemo and tumour not seen on CT. Once again they apologise for delays! I say " good it is no longer seen" Her reply " No it could still be there with 100's of cells" Fortunately I am ok to date but have to say a little disappointed with Specialist who couldn't be bothered to reply!
Apparently here it has only recently been a consideration to remove liver tumours in secondary cancers.
Think this mean that previously we were not treated with curative intent!!
If only I knew then what I know now - mostly thanks to this site!!

[Joan M]

Amy, I'm not surprised about their response, and it's great to know that you knew better.

I'm sorry for all the delay, Juls. Very frustrating.

Often, oncologists will use local procedures for only palliative reasons, or in other words to stop pain, by irradiating the chest wall or hip for example. But that's not what we're speaking about here. We're speaking about the so-called curative intent. But I never assume that I'm cured. That's a general phrase used when treating cancer with local procedures.

I just wish that oncs would view treatment of survivors with oliogometastatic disease differently than treating those with more widespread mets. We all don't fit into the same mold, and local procedures are clearly an option. But of course, that doesn't mean that they work well all the time.

And I always use a few rules of thumb:
Oncs want to do chemo
Radiation oncologists want to irradiate
And surgeons want to cut

And it's up to us to try to determine the best way for our own situation.

xo

[Juls]

I just wish they would treat us with some positivity.
When first diagnosed - Literally within minutes I was told treatable but not curable. No other tests had been done other than mammogram & biopsy at this point. In my ignorance at that time thought would be treated with curable intent. Or were they just covering themselves?

[Bunty]

Hi everyone,
Ann, good to hear from you again, but I'm sorry that you have some progression. I hope TDM-1 agrees with you.

Amy, as you may have read on one of my recent posts, I've just finished SBRT 4-D targeted radiation on a lung tumour. It will be a couple of months before we know how successful it has been. I found the process very easy, and very impressive. A few years ago, I certainly had the same responses from my medical team - that local intervention wasn't done for Stage IV breast cancer. However, certainly in my team, that thinking has changed somewhat. I like to think that because I 'banged' on about it so much, my oncologist became more open minded to the possibilities. (I was inspired by what I was reading here on the boards).

Last year I hoped to have my liver tumour treated with SBRT, but that didn't happen as it was too close to my bowel. But then I went on to have successful liver surgery, and that surgeon is very supportive of local intervention for breast cancer in the liver, and now lectures oncology teams.

Of course, each case is different, but, Amy, if you only have active lung tumours, then I would keep 'banging' on about it.

And even though my oncologist is now fully on board with me having local intervention, he claims that I'm not oligometastatic! (He has a different definition to me).

All the best to you all,
Marie