THE VALUE OF SURGERY IN METASTATIC BREAST CANCER

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 PreviewPRO SURGERY STUDIESCONTRA SURGERY STUDIESMETASTATIC BREAST CANCERPRO SURGERY STUDIESPRO SURGERY STUDIESKhan 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 STUDIESEVIDENCEPRO SURGERY STUDIESDana 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 STUDIESEVIDENCEPRO SURGERY STUDIESFields 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 STUDIESEVIDENCEPRO SURGERY STUDIESBlanchard 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 STUDIESEVIDENCEPRO SURGERY STUDIESNeuman 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 STUDIESEVIDENCEPRO SURGERY STUDIESNguyen 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.

PRO SURGERY STUDIESEVIDENCEProblems for Those Pro Surgery Studies :All of those are retrospective studiesMost 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 STUDIESCONTRA SURGERY STUDIESFisher et al (1996) :experimental study : the presence of growth-stimulating 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 STUDIESEVIDENCECONTRA SURGERY STUDIESCady et al (2008) :No significant differences in survival with or without surgery when surgery and chemotherapy were done simultaneously.Cady et al and Dominici et al (2011) 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 resectionCONTRA SURGERY STUDIESCONTRA SURGERY STUDIESBafford 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 STUDIESEVIDENCEBafford 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 STUDIESEVIDENCE (Contd)CONTRA SURGERY STUDIESOngoing Prospective Randomized Controlled Trial: Preliminary ResultsCONTRA SURGERY STUDIESRandomized Controlled TrialCONTRA SURGERY STUDIESOngoing Prospective Randomized Controlled Trial: Preliminary Result 26Badwe et al (2013) :no statistically different in OS in LRT and in no LRT patientsdistant 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 STUDIESEVIDENCECONTRA SURGERY STUDIESOngoing Prospective Randomized Controlled TrialSoran 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 STUDIESEVIDENCECONTRA SURGERY STUDIES

currently waiting for the results from.ConclusionThe 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.

Lets look forward to final results of other prospective studies currently ongoingORLets do our own prospective studies with proper adjusment to our real condition that hopefully give us better reasons to make the best decision.

ConclusionThere is a tendency that results from prospective randomized controlled trials would probably show disagreement. THANK YOU