Faina NakhlisDivision of Surgical OncologyDana Farber Cancer Institute

September 24, 2016

The Role of Surgery in Metastatic Breast Cancer (MBC)

Outline

•Palliative surgery for MBC• Symptomatic intact primary site• Local and/or regional recurrence

•Surgery in the asymptomatic patient with MBC

Incidence of De Novo Stage IV Breast Cancer in the US (SEER)

De Meglio et al, Breast Cancer Res Treatment, 2016

What is the Role of Palliative Surgery?

Complex Resections of Advanced Primary or Recurrent Disease

Feasible* but what are the endpoints?

*Veronesi et al, The Breast 2007

Goals of Palliative Surgery (Overview of Published Literature – 1990-1994)

Pain Control (12%)

Quality of Life (17%)

Morbidity and Mortality (61%)

Survival (64%)

“Prophylactic” Palliation (59%)

Cost Effectiveness (2%)

Physiologic Response (69%)

Miner et al, Am J Surg 1999

Surgical Palliation for Symptom Control or Quality of Life Improvement

Miner et al, Ann Surgery, 2004

Palliative procedures (N=823)

Improved symptoms (N=659, 80%)

Symptom free (N=303, 46%),

median 135 days

Additional symptoms (N=191, 29%)

median 58 days

Recurrent symptoms (N=165, 25%)

Median 52 days

No improvement (N=164, 20%)

How Symptomatic is Local Disease?

MSKCC Experience* - June 2001 – July 2003

Median follow-up after intervention – 75 months

Symptom relief:•30 days – 91%•100 days – 81 %

Stage IV breast cancer, N=91 (de novo – N=20, 22%)

Palliative procedures, N=109 (Mastectomies, N=3, 3%)

Additional procedures, N=60, 60%

*Morrough et al, Cancer 2010

Primary Local Therapy (PLT) for Stage IV LABC (SEER Medicare, N=5111, 2005-2010)

Fairweather et al, SABCS 2015

Total Cohort (N=5111)

Asymptomatic (N=4645, 91%)

PLT (N=1294, 28%)

Asymptomatic(N=998, 81%)

New symptoms(N=246, 19%)

No PLT (N=3351, 72%)

Asymptomatic(N=3003, 90%)

New symptoms (N=348, 10%)

Symptomatic(N=466, 9%)

PLT (N=118, 25%)

Asymptomatic(N=57, 48%)

New/recurrent symptoms(N=61, 52%)

No PLT (N=348, 75%)

Is Palliative Surgery Justified in the Setting of Stage IV Breast Cancer?

Pain Control - Yes

Quality of Life - Yes

Morbidity and Mortality - ?

Survival - ?

“Prophylactic” Palliation - ?

Cost Effectiveness - ?

Physiologic Response - ?

Patients with Stage IV Breast Cancer and Asymptomatic Intact Primary Site

Do Patients with Stage IV Breast Cancer Live Longer with Their Disease?

*Chia et al, Cancer 2007

Kaplan-Meier Overall Survival Curves• British Columbia Registry*

• N=2150 patients with stage IV breast cancer

• Diagnosis years – 1991-2001

Systemic Therapy Utilization

Chia et al, Cancer 2007

Cox Regression Analysis for Survival in Stage IV Breast Cancer

Chia et al, Cancer 2007

Improved Disease Specific SurvivalSEER, 1973-2010*

*Park et al, JCO 2015A <3 years from diagnosisB >5 years from diagnosis

Does Surgery in Stage IV Breast Cancer Improve Survival?

Meta-analysis of Retrospective Data*Overall Mortality – Surgery vs. No Surgery

*Headon et al, Molecular and Clinical Oncology, 2016

How can Surgery Impact Survival in Stage IV Breast Cancer:“Theories”

Control of seeding from primary tumor site1

Decrease in formation of tumor stem cells within the primary

tumor stroma2

Decrease in tumor-induced

immunosuppression by the intact primary site3,

4

1Norton, Massague, Nat Med 20062Kamoub et al, Nature 20073Campbell et al, Breast Cancer Res Treat 20054Danna et al, Cancer Res 2004

*King et al, ASCO 2016

A Prospective Analysis of Surgery and Survival in Stage IV Breast Cancer (TBCRC 013)*

Cohort A (N=112)Median Age 51 years (21-77)

Median Follow-up 54 months (34-78)

Median Tumor Size 3.2 cm (0.8-15 cm)

ER+/HER2- 71 (63%)

ER+/HER2+ 24 (21%)

ER-/HER2+ 9 (8%)

ER-/HER2- 8 (7%)

Responders 94 (85%)

3 year OS 70% (95% CI, 63-79%)

*King et al, ASCO 2016

A Prospective Analysis of Surgery and Survival in Stage IV Breast Cancer (TBCRC 013)*

Responders (N=94)

Surgery (N=39, 41%)

No Surgery (n=55, 59%) P

Median Tumor Size 3.8 cm 3.2 cm 0.01

Single Metastatic Site 77% 41% 0.001

1st Line Chemotherapy 39% 17% 0.002

*King et al, ASCO 2016

A Prospective Analysis of Surgery and Survival in Stage IV Breast Cancer (TBCRC 013)*

Responders Surgery N Median Survival, mos (95%CI) 3yr OS (95%CI) P

OverallN 51 71 (56-NR) 76 (66-89)

0.85Y 39 77 (52-NR) 77 (65-91)

ER positiveN 46 71 (56-NR) 78 (67-91)

0.47Y 34 77 (53-NR) 79 (67-94)

HER2 positiveN 12 NR (NR-NR) 83 (65-100)

0.39Y 15 77 (77-NR) 100 (100-100)

TBCRC 013Prognostic Impact of 21-Gene Recurrence Score in Patients

With Stage IV Breast Cancer*

*King et al, JCO 2016

• Prospective registry to evaluate approach to local therapy for stage IV breast cancer (N=127)

• Cohort A – Patients diagnosed with de novo metastatic disease (N=112)

• Cohort B – Patients found to have distant metastases within 3 months of breast cancer diagnosis (N=15)

• Median patient age - 52 years

• Median follow-up – 29 months

TBCRC 013Clinical Characteristics and the 21-Gene Recurrence Score in Patients With

Stage IV Breast Cancer*

*King et al, JCO 2016

TBCRC 01321-Gene RS vs. Time to First Progression and 2 Year Overall Survival*

*King et al, JCO 2016

TBCRC 013Median Time to Progression and 2 Year Overall Survival in Patients with De

Novo Stage IV Breast Cancer*

*King et al, JCO 2016

Prospective Randomized Trials

Country Accrual Period N Initial Therapy Radiotherapy Status

India 2005-2012 350 Chemotherapy If indicated Closed, mature follow-up

Japan 2011-2016 410 Systemic therapy Not addressed Enrolling

USA, Canada 2011-2015 368 Systemic therapy

As for stage I-III disease Closed, July 2015

Turkey 2008-2012 271 Surgery For breast conservation

Closed, mature follow-up

Netherlands 2011-2016 516 SurgeryFor positive margins and

palliationClosed due to lack of accrual

Austria 2010-2019 254 Surgery As for stage I-III disease

Closed, now allows pre-operative

systemic therapy

Locoregional Treatment versus No Treatment of the Primary Tumour in Metastatic Breast Cancer: an Open-Label Randomized Controlled Trial*

*Badwe et al, Lancet Oncology 2015

• 350 patients with de novo stage IV breast cancer (February 2005 – January 2013) who had an objective response to 6 cycles of anthracycline-based chemotherapy

• Randomization• Loco-regional treatment (LRT) (N=173)• No LRT (N=177)

• LRT – Surgery (breast conservation or mastectomy , plus ALND), followed by radiation therapy, “as per standard adjuvant guidelines”

• Stratification (balanced by all criteria)• ER Status• Number of metastatic lesions (<3 vs. >3)• Metastatic sites:

• Bone• Visceral• Both

• Median Follow-up – 17 months• Total deaths N=218 (LRT – N=111 (64%), no LRT – N=107 (60%))

Locoregional Treatment versus No Treatment of the Primary Tumour in Metastatic Breast Cancer: an Open-Label Randomized Controlled Trial*

*Badwe et al, Lancet Oncology 2015

LRT (N=173)

No LRT (N=177) Hazard Ratio P

Median OS (months) 18.8 20.5 1.07 (95% CI 0.82-1.4) 0.6

2 year OS 40.8% 43.3% 1.00 (95% CI 0.76-1.33) 0.98

Problem – lack of HER2 directed therapy

Locoregional Treatment versus No Treatment of the Primary Tumour in Metastatic Breast Cancer: an Open-Label Randomized Controlled Trial*

*Badwe et al, Lancet Oncology 2015

Locoregional Progression

Locoregional Treatment versus No Treatment of the Primary Tumour in Metastatic Breast Cancer: an Open-Label Randomized Controlled Trial*

*Badwe et al, Lancet Oncology 2015

Distant Progression

A Randomized Controlled Trial Evaluating Resection of the Primary Breast Tumor in Women Presenting with De Novo Stage IV Breast

Cancer: Turkish Study (Protocol MF07-01)*

*Soran et al, ASCO 2016

• 274 patients with de novo stage IV breast cancer• Randomization• Loco-regional surgery (LRS) group (N=138)• Systemic therapy (ST) only group (N=136)

• Balanced for age, BMI, HER2 status, tumor histology, tumor size, tumor grade, bone and visceral metastases

• Median follow-up – 40 months• Total deaths – N=187 (LRS – N=76 (55%), ST – N=101 (74%))• 36-month survival – no difference (60% for LRS, 51% for ST, p=0.5)• Median OS - 34 months longer with LRS than with ST

Median Overall SurvivalTurkish Study (Protocol MF07-01)*

*Soran et al, ASCO 2016

Hazard Ratio P

LRS vs. ST 0.66 (95% CI 0.49-0.88) 0.005

ER+/PR+ vs. not 0.64 (95% CI 0.46-0.91) 0.01

HER2 negative vs. not 0.64 (95% CI 0.45-0.91) 0.01

Age <55 years 0.57 (95% CI 0.38-0.86) 0.006

Solitary bone metastasis only 0.47 (95% CI 0.23-0.98) 0.04

Is Definitive Local Therapy Justified in the Asymptomatic Stage IV Breast Cancer Patient?

•Possibly for those with a dramatic and durable response to systemic therapy - more data are needed

•Systemic therapy and advances in the development of future targeted therapies remain a top priority for these patients