Changing indications for surgery in patients with stage IV breast cancer: a current perspective.

Background: Evolving concepts of cancer biology and emerging evidence of a potential survival benefit from local surgery have raised the question of an expanded role for surgery in select patients with metastatic breast cancer (MBC). To determine whether such developments have influenced clinical practice, the authors evaluated surgical practice patterns in the study institution over the last 15 years.

Methods: Two institutional databases were screened to identify patients with MBC who underwent breast surgery (1990-2005). Retrospective review was conducted to assess trends over time and to evaluate the role of surgery in the more modern era (1995-2005).

Results: The overall frequency of mastectomy remained stable over time (1.7%); however, between early (1990-1995) and late (2000-2005) periods the rate of 'symptom control' mastectomy decreased (41% to 25%), whereas the rate of 'local control' mastectomy increased (34% to 66%). Conversely, the overall frequency of wide-local excision (WLE) increased over time (1995-2001), from 1% to 9% (P< .001) with no differences noted between rates of symptom control or local control procedures. In the modern era (1995-2005), 256 of 12,529 patients (2%) with MBC underwent breast surgery (33% mastectomy, 52% WLE); most frequently to 'optimize local control' (50%) and primarily in the setting of limited/stable distant disease. Surgery was performed for palliation in only 19% of patients. At a median follow-up of 33.9 months (range, 0-198.7 months), 136 of 256 patients (53%) in this cohort remained alive; 88% were free of local disease.

Conclusions: Although surgery in MBC has historically been reserved for palliation, the authors observed a decreasing rate of traditional 'toilet mastectomy' and a broadened surgical approach to the asymptomatic patient. When viewed in parallel with evolving concepts in cancer biology, these data reflect a change in the traditional approach to patients with MBC and warrant further investigation.