Today I talked about the problem of surgery in patients that present to us with already metastatic breast cancer, what we call stage 4 at presentation. Usually now we have patients that present with early breast cancer due to better screening, better diagnostic exams, but some patients, usually around 5%, present with cancer that has already metastasised to other organs. In those cases the idea is if surgery of the primary tumour will have an impact or not in survival.

What we thought until now, based on retrospective studies, is it appeared to have some impact on overall survival. So the meaning is if we remove the tumour survival was better. But now with the results of all the prospective trials we have coming out it seems that the results we have were due to bias introduced in the studies. What we observe in prospective trials is not at all that, it’s doing surgery to the primary tumour doesn’t impact on survival in the majority of cases. So in those patients what makes the difference is the quality of systemic treatment. Some patients can have surgery but this must be decided case by case in multidisciplinary meetings and usually are patients that are very young, very fit and have only one or two, usually bone, metastases. Otherwise it doesn’t have any impact on overall survival.

If a patient has just bone metastasis, could taking out the primary tumour prevent other types of metastasis?

We think yes because when we analyse the results of the trials we see that in those particular cases there is really a benefit on the prospective trials in survival. So what we think is if we take out the theory of the seeding cells, if we take and we treat all the disease with an intention to cure, we remove the possibility of having more seeding. So we have a more prolonged time until the next recurrence. We have doubts because we have not enough time until now if we could have a cure in those cases. But what we do is we tend to lower down the most possible we can the burden of disease to try to avoid self-seeding after the rest of disease.

What is the psychological impact on the patient?

It’s curious because we have now the results of three prospective trials. They are very small because it’s very difficult to recruit on these trials but what we observe in two of those trials is they had a sub-analysis of quality of life. For us it was like quality of life would be better if the patients have the primary tumour removed but it’s not. It’s curious because the sub-analysis of quality of life doesn’t show any impact on quality of life whatsoever.

So what we think is because you have a very good relation with your patient, you explain that the impact of removing the primary will not affect survival. They understand that and they don’t want surgery. But if not, if they are expecting to be cured by the removal of the primary possibly that would impact on survival. This is the benefit of having prospective trials is that you can analyse in a very serious manner the effect that you want and regarding quality of life it doesn’t affect at all.

Any final thoughts?

To finalise is to understand that like in any other aspects of breast cancer, or any other cancer, having a multidisciplinary decision is fundamental because in those cases jumping into situations that are very difficult and very difficult to control like, for instance, going for surgery that will have some morbidities, will not have the result that we think it will have and the patient will delay systemic treatments, will possibly have a worse impact on survival, that discussing this with all the team and, of course, with the patient.