Should Newly Diagnosed Stage 4 Breast Cancer Patients Undergo Surgery?

To determine cancer extent after breast cancer diagnosis, imaging includes PET-CT, ultrasound, MRI and CT. If cancer has spread to another organ, this is called stage 4 or metastatic breast cancer . Patients previously diagnosed with early-stage breast cancer and treated may also recur soon afterward or years later. Recurrence may be local in the operated breast and/or axilla or metastases in one or several organs, including bone, liver, lung and brain.

Should the Breast and Axilla Be Operated on in Newly Diagnosed Metastatic Breast Cancer?

This question has been debated for years. At the 2016 United States ASCO Cancer Congress, Pittsburgh Magy Woman Hospital's breast cancer department chair, Prof. Atilla Soran, addressed it through a study conducted in Türkiye. Among 274 metastatic patients, one group received breast surgery before chemotherapy or chemotherapy-targeted drug combinations, while the other received drugs alone. Median survival was 46 months with surgery before drugs versus 37 months with drugs alone. At 5 years, survival was % 41 versus %24. Detailed analysis found marked benefit particularly in women with limited metastatic burden and bone metastases. Because Soran's study was the best designed to date, surgery in selected patients is considered appropriate despite conflicting other studies.

Based on available evidence and Atilla Soran's study, for patients metastatic at initial diagnosis, we favor breast surgery after 3-6 months of chemotherapy, targeted drugs and hormone therapy when needed if response is very good.

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Suitable candidates may have limited burden, for example no more than 1-3 bone metastatic sites, a single lung or liver metastasis or one surgically removed brain metastasis, and response to drug treatment. Avoiding breast surgery in stage-four patients is also an option. Discuss benefits, harms and team expertise comprehensively with the patient.

Should Liver, Lung or Bone Metastases Be Operated on at Initial Diagnosis?

Surgery outside the breast and axilla is generally not preferred. Selected patients with limited burden and one metastasis in one organ, responding very well to chemotherapy, targeted drugs or hormones, may receive breast/axillary surgery and local treatment of one or two shrunken metastases elsewhere. Options include SBRT, cryoablation through freezing, RFA and microwave treatment.

Comprehensive studies of these methods' benefits in metastatic patients are lacking. Consider individually, accounting for team experience and ensuring patients and families understand treatment and expected success.

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The Most Important Breast Cancer Decision: Remove the Entire Breast or Perform Breast-Conserving Surgery?