De Novo Metastatic Breast Cancer: Does Local Therapy Help
Hester Hill Schnipper, LICSW, OSW-CProgram Manager Emeritus, Oncology, Social Work
De novo metastatic breast cancer is breast cancer that is already metastatic or Stage IV at the time of diagnosis. Unfortunately, over the years, I have known a number of patients for whom this was true. Some had been ignoring symptoms or obvious signs of trouble. I have known a few women who, at the time they first came for medical attention, had a large tumor that was distorting the breast.
As simplistic as it sounds, cancer that remains in the breast is not lethal the danger is in breast cancer cells that have invaded vital organs.
Usually, a de novo metastatic breast cancer diagnosis is made because of persistent pain, neurological concerns, or a long period of malaise that could not be explained. More often, this diagnosis is made during the staging and work up of a new patient who is initially thought to have earlier stage breast cancer. If there are particular concerns about the possible extent of someone’s cancer, the patient will likely undergo scans or MRIs prior to surgery. Occasionally, these tests find that the cancer has already spread beyond the breast, and the cancer is Stage IV rather than an earlier stage that was expected.
The results were that having the local therapy did not result in women living longer or having a better quality of life. The overall survival and progression-free survival were the same for both groups.
Early Local Therapy Ineffective For De Novo Metastatic Breast Cancer
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Early local therapy did not extend survival in women with de novo metastatic breast cancer and intact primary tumors, according to results from a randomized phase 3 study presented at ASCO20 Virtual Scientific Program.
Results also revealed a 2.5-fold greater risk for local disease progression without locoregional treatment, but treatment of the intact primary tumor did not appear linked to improved patient quality of life.
For those women, local treatments for the intact primary tumor in the breast does not provide a survival advantage,Seema A. Khan, MD, professor of surgery at Feinberg School of Medicine and Robert H. Lurie Comprehensive Cancer Center at Northwestern University, told Healio.
Khan and colleagues enrolled women with de novo stage IV metastatic breast cancer into the study between February 2011, and July 2015. They randomly assigned the 256 eligible patients to receive either optimal systemic therapy alone or optimal systemic therapy plus locoregional treatment .
During follow up , there were 121 deaths and 43 locoregional progression events with no meaningful difference in OS.
When Do People Get A Metastatic Breast Cancer Diagnosis
Metastatic breast cancer can occur at different points:
- De novo metastatic breast cancer: About 6% of women and 9% of men have metastatic breast cancer when theyre first diagnosed with breast cancer.
- Distant recurrence: Most commonly, metastatic breast cancer is diagnosed after the original breast cancer treatment. A recurrence refers to the cancer coming back and spreading to a different part of the body, which can happen even years after the original diagnosis and treatment.
What Can I Expect While Living With Metastatic Breast Cancer
Your care team will monitor you every few months to check if the cancer is responding to treatment, and also to see if you are having any side effects. The process of restaging the cancer includes:
- History/physical exam.
- Blood tests.
- Imaging tests, including CTs and bone scan or PET scan.
Before your scans or tests, its normal to feel anxiety. It may help to bring a friend or family member to the appointment with you.
Metastatic Breast Cancer Incidence
MBC incidence is the number of newly diagnosed cases of metastatic breast cancer in a given year.
Statistics are not collected for metastatic recurrences which comprise the larger portion of MBC cases. Statistics are only gathered for initial diagnosis of Stage IV metastatic disease. See: Where is the Data? The Epidemiology of Metastatic Breast Cancer, retrieved October 2016
Approximately 6-10% of new breast cancer cases are initially Stage IV or metastatic. This is sometimes called de novo metastatic disease, meaning from the beginning. For 2012 this means new cases of Stage IV were in the range of 13,776 22,096.
The number of metastatic recurrences are unknown, but are estimated to range between 20-30% of all existing breast cancerases. This figure is the subject of ongoing controversy. Below are excerpts from some experts papers and public comments.
Dr. Joyce OShaughnessy estimated the rate to be 30% in developed countries
Dr. William Gradishar of Northwestern University : Breast cancer can become metastatic in roughly 30% of patients at 1:30 mark in this 11/2009 interview
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How To Handle Emotions
Coping with the many symptoms that can occur with stage 4 breast cancer can be frustrating and discouraging, and people sometimes wonder if they will have to feel poorly the rest of their lives. Anxiety and depression are also severe for some people with advanced disease.
Fortunately, palliative care team consults are now offered at many cancer centers. While hospice is a form of palliative care, palliative care can be helpful even with early, curable tumors. Working with a palliative care team to address physical and emotional issues frees you up to work with your oncologist on issues that treat your cancer specifically.
While the research is also young, it appears that those people who receive palliative care consults not only have a better quality of life with advanced cancer, but they may actually live longer, too.
Benefits Of Primary Tumor Surgery In Patients Subdivided By Molecular Subtypes And Metastatic Sites
In the whole cohort, primary tumor surgery could prolong OS . In terms of molecular subtypes, surgery provided extra survival benefit in all subtypes . In terms of metastatic burden, BOM, bone and liver metastasis as well as bone and lung metastasis patients could benefit from surgery . However, surgery did not significantly benefit patients with bone and brain metastasis . Similarly, the analysis of BCSS showed consistent results.
Figure 4 Survival of de novo bone metastatic patients in different subtypes according to primary surgery. OS and BCSS in patients with HR+/HER2 tumors OS and BCSS in patients with HR+/HER2+ tumors OS and BCSS in patients with HR/HER2+ tumors OS and BCSS in patients with HR/HER2 tumors.
Figure 5 Survival of de novo bone metastatic patients in different metastatic burdens according to primary surgery. OS and BCSS in patients with bone-only metastasis OS and BCSS in patients with bone and brain metastasis OS and BCSS in patients with bone and liver metastasis OS and BCSS in patients with bone and lung metastasis.
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Symptoms Of De Novo Metastatic Breast Cancer
Symptoms of de novo metastatic breast cancer can vary by individual. Generalized symptoms may include fatigue, unintentional weight loss, loss of appetite, nausea, vomiting, insomnia, depression, sexual dysfunction, and pain.
If you have had these symptoms for some time, speak with your doctor so they can help you figure out the cause of your symptoms and make a diagnosis.
The signs and symptoms may depend on which areas the cancer has spread to. The most common site of metastasis for de novo MBC is the bones , while the least common site is the brain . Over time, 75% of patients will develop metastases to other organs in addition to when they are first diagnosed.
Here is a chart describing the associated symptoms with each possible site of metastasis:
|Site of Metastasis|
Baseline Characteristics And Its Relationship With Risk Stratification
In total, 2,398 de novo BCLM patients were included, of which 1,662 patients were in the training set and 306 patients were in the validation set. In the training set, de novo BCLM patients tended to be younger than 60 years old , insured and unmarried white patients. In addition, most patients had relatively higher T staging but lower N staging . The majority of these patients were identified as high-grade ductal carcinoma . Of the 1,662 patients, 1,109 had hormonal receptors positive disease and 979 had human epidermal growth factor receptor2 negative disease. De novo BCLM patients often had other combined metastases, including bone , lung , and brain metastasis . The majority of patients received first-line chemotherapy , while only few patients underwent surgery of primary site or radiotherapy . Many demographic characteristics and clinicopathological features showed differences among different risk groups, indicating the potential prognostic value of these factors. Detailed baseline characteristics and its relationship with risk stratification are shown in Table 1 and Supplementary Table 1.
Table 1 Characteristics of BCLM and risk stratification in the training set.
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Whats The Outlook For Metastatic Breast Cancer
The right treatment plan can improve survival for people with metastatic breast cancer. However, survival rates vary and are dependent on a number of factors including type/biology of the breast cancer, parts of the body involved and individual characteristics. About 1 in 3 women live at least five years after diagnosis. Some live 10 years or longer. Your care team will discuss your prognosis with you in more detail.
New I Have De Novo Metastatic Cancer
I am waiting for diagnosis hopefully this week to know if it’s breast cancer or else. What I do know is that scans couldn’t find a large lump but plenty metastases in my lungs, liver, spleen and bones.
The doctors and nurses are very friendly but I can’t help but getting the vibe that whatever the primary cancer is, there isn’t much medicine can do. Don’t get me wrong, the pain relief is invaluable. But I understand that my life expectancy is low simply because of the number of organs affected.
I am 44 and a dedicated mum to a 10 yrs old girl and an 8 yrs old boy. I am tormented by the thought that I won’t be there to help them through the pain of losing their precious mum.
I hope to find a reason to believe in miracles on this site. Xx
How Is Stage 4 Breast Cancer Treatedand What’s The Survival Rate
While every stage 4 breast cancer diagnosis is differentwhich means the methods used to treat it will also differthis stage of breast cancer is usually treated systemically , since the cancer has already spread to other areas of the body. Systemic treatments usually include options like hormone therapy, chemotherapy, targeted therapy, and immunotherapy, according to the NCI.
Still, those treatments vary depending on a variety of factors, including where the cancer is located, as well as the patient’s symptoms, overall health, and previous cancer treatmentsand patients are closely monitored throughout treatment for the best outcome. Patients are generally started on the treatment of best reflex or biology and followed closely using scans, with change in treatments as needed if the current treatment is not resulting and either shrinkage or stability of the breast cancer, Dr. Tripathy explains.
In addition to more standard systemic treatment options, Dr. Tripathy explains that there are newer technologies being increasingly usedlike ones that sequence the DNA of cancerous tumor cells for more specified treatmentsas well as various clinical trials designed to offer more options and possibly better outcomes to those dealing with the disease.
Can Metastatic Breast Cancer Go Into Remission
Metastatic breast cancer may never go away completely. But treatment can control its spread. Cancer may even go into remission at some points. This means you have fewer signs and symptoms of cancer.
A treatment break may be considered in certain situations, including if remission occurs or if someone is experiencing intolerable side effects. A pause in treatment can help you feel your best and improve your quality of life.
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Radiation Therapy Alone Vs Surgery Radiation Therapy
Bourgier et al. evaluated the effect of LRT on local control and survival among breast cancer patients with oligometastatic disease . Among 308 de novo stage IV breast cancer patients, 239 were treated with LRT which consisted of LRRT and breast and axillary surgery with/without radiation therapy . The median follow-up duration was 6.5 years. Long-standing locoregional response was obtained among 85% of patients in the radiation therapy group. The 3-year metastasis PFS /OS rates were 20%/39% in the radiation therapy group and 39%/57% in the surgery group, respectively. As the distribution of prognostic factors was quite different between the two groups, a direct comparison of survival was difficult to interpret. Therefore, the researchers adjusted the data according to prognostic factors, and reported no significant differences in MPFS or OS between the two groups. Although it is unclear whether radiation therapy alone or surgery is better as LRT from this study, LRT including radiation therapy alone could provide long-standing locoregional control and could be an important treatment option for selected de novo stage IV patients.
Metastatic Breast Cancer Symptoms And Diagnosis
The symptoms of metastatic breast cancer can vary greatly depending on the location of the cancer. This section covers the symptoms of breast cancer that has spread to the bone, lung, brain, and liver, and the tests used to diagnose metastatic breast cancer.
Bone Metastasis: Symptoms and DiagnosisThe most common symptom of breast cancer that has spread to the bone is a sudden, noticeable new pain. Breast cancer can spread to any bone, but most often spreads to the ribs, spine, pelvis, or the long bones in the arms and legs. Learn more.
Lung Metastasis: Symptoms and DiagnosisWhen breast cancer moves into the lung, it often doesnt cause symptoms. If a lung metastasis does cause symptoms, they may include pain or discomfort in the lung, shortness of breath, persistent cough, and others. Learn more.
Brain Metastasis: Symptoms and DiagnosisSymptoms of breast cancer that has spread to the brain can include headache, changes in speech or vision, memory problems, and others. Learn more.
Liver Metastasis: Symptoms and DiagnosisWhen breast cancer spreads to the liver, it often doesnt cause symptoms. If a liver metastasis does cause symptoms, they can include pain or discomfort in the mid-section, fatigue and weakness, weight loss or poor appetite, fever, and others. Learn more.
Being Your Own Advocate
While there aren’t currently any studies looking at self-advocacy and survival, being your own advocate can’t hurt in maximizing your survival. Oncology is changing rapidly and it’s difficult for any oncologisteven those who specialize in breast cancerto stay aware of all of the latest research and clinical trials taking place.
It can be helpful to research your cancer yourself. Becoming involved via social media such as Twitter is also an excellent way to learn about the latest research, using the hashtag #bcsm, which stands for breast cancer social media.
Getting a second opinion can be helpful as well, especially from one of the larger cancer centers such as a National Cancer Institute-designated cancer center.
There are ways to learn about opportunities, however, that don’t require traveling for opinions. There are now clinical trial matching services in which a nurse navigator can help to match your particular tumor and characteristics with clinical trials in progress all over the world.
Several of the larger cancer centers are now also offering remote second opinions, in which an oncology team can review your medical information and talk to you on the phone about whether there are any opportunities for treatment for you that may not be available elsewhere.
Survival Rate With Metastatic Breast Cancer
Many people wonder about the life expectancy for stage 4 breast cancer . It’s important to note that everyone is different and survival rates vary widely. There are some people who survive many years and even decades with stage 4 disease. At the same time, it’s important to understand that stage 4 breast cancer isn’t curable.
It can be helpful to look at current statistics and consider the many variables that affect life expectancy. While it’s important not to raise false hope, it may help to know the reality that there are some long-term survivors.
Some people want to know the statistics, but many don’t. If you’re living with stage 4 breast cancer, there is absolutely no requirement that you know the prognosis. The information provided here is only for those who truly wish to know what the current research iseven this research has many limitations.
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Risk Stratification And Subgroup Analysis
According to the optimal cut-off value determined by X-tile software, patients were divided into three different risk groups: low-risk , intermediate-risk , and high-risk group . The median OS of the three prognostic groups were 44, 18, and 7 months, with a 3-year survival rate of 56, 23, and 7%, respectively . As was shown in Figure 3, intermediate-risk and high-risk groups demonstrated higher risk of death than low-risk group in both the training and validation sets .
To further assess whether the prognostic score was also effective for treatment guidance, subgroup analysis was performed to explore surgery of primary site and chemotherapy benefit in different risk groups . The results found that patients in low-risk and intermediate-risk groups could benefit from locoregional surgical treatment, but it seemed not to prolong the survival time of patients of high-risk group significantly . However, chemotherapy could produce a significant survival benefit in these three different risk groups .
Figure 5 Subgroup analysis of overall survival for patients who received locoregional treatment or not.
Figure 6 Subgroup analysis of overall survival for patients who received chemotherapy or not.