Surgery for Stage IV Breast Cancer?
Presenting at the 2007 meeting of the Society of Surgical Oncology (SSO), Jennifer Gnerlich of the Washington University School of Medicine, St. Louis reports that
Data from an epidemiologic study have provided support for the surgical removal of the primary breast cancer in patients diagnosed with stage IV breast cancer. According to the study, women who underwent surgery were 37% less likely to die than women who did not undergo surgery after controlling for demographic and clinical factors known to affect survival.
Although the current indication for surgery in these patients is to control local wound complications, she suggested that benefit beyond palliation may be possible.
Stage IV breast cancer is one which has evidence of spread to distant sites from the breast. Examples would include lung, liver, bone and brain. Usually these patients would be treated palliatively (meaning, to treat with the aim of comforting the patient rather than to aim for cure). The choice as to whether to perform surgery to remove the tumour or the breast depends on whether it will help to make life more comfortable for the patient.
This report, however, makes the surgical community think again… perhaps operating on the tumour might help some of these patients in terms of survival.
This data was from a retrospective (looking back at patients on record) review of patients who were newly diagnosed with stage IV breast cancers entered into the Surveillance, Epidemiology and End Results (SEER) program database in the US between Jan. 1, 1988 and Dec. 31, 2003. Of the 9,734 patients who met this description, 4,578 (47%) underwent surgery (including mastectomy, complete removal of the breast, and partial excision).
The median survival is longer, averaging 36 months for those who received surgery versus 21 months for those who did not. (Median survival is the length of time that the 50% of the population is still alive from the time of the diagnosis.) It is still contraversial and is not yet clear that it will help until prospective studies address the issue (i.e. studies that follow patients from the time a diagnosis is made, not looking back at records).
This is an issue that, unfortunately, is too commonly seen. When a patient has a breast cancer, she is anxious to do “all that can be done”, even if it is diagnosed in the advanced stage. To most doctors, the quality of life is of primary concern in this situation, and the length of survival has become secondary. Nevertheless, if surgery can prolong good quality survival for advanced breast cancer patients, I don’t see why it should not be offered. I guess we’ll have to wait for other, stronger, evidence to understand whether it should be offered and to whom (what group of patients) it should be offered.
Perhaps those who do not have a taboo against discussing this subject might want offer a glimpse of how you feel about this issue?
General surgery on the net
On the lighter side, I would like to recommend a surgical blog by colleagues from around the globe: Rambodoc. It’s a humerus (sic) look at surgery. 
The authors are familiar names on Surginet, a general surgical mailing list where we discuss general surgical issues. Surgeons and trainees will benefit from the discussions on this mailing list on surgical issues and non-surgical issues, some of them hilarious. I personally have been following this mailing list for many years.
I’d recommend a using separate webmail account to receive mail from this list though, ‘cos it’s high-volume and sometimes the busy surgeon could easily get swamped by the sheer volume of the emails. That, of course, is relative :-). Follow the Surginet link above to register.
As a potential cancer victim(?), not necessarily breast, might I ask what is exactly good quality of living, if for me, having the tumour causes immense amount of pain? Am I going to drown myself with painkillers?
I think even if the odds weren’t so good for Stage 4 cancer to be removed…I’d remove it.
i believe that this question would and should be best answered by the individual patients. a good doctor should lay all the cards on the table, provide as much information as they possibly have, inform them of the risks and consequences as they know it…and let the patient make the decision. the doctor should of course include his personal recommendations and opinions but ultimately, only the patient knows what he/she wants. the patient should not be devoid of a second chance just because a doctor feels that her quality of life will be affected. some patients response may be..”heck! we just want to be alive! one step at a time!” and yet others may be “i rather die a peaceful death”. to each their own…and their wishes should be respected
I agree with ME..We are supposed to inform the patients everything there is to know about the condition..and the decision finally is for the patients to make..
Have you ever experience this?..despite every means to convince pt that this is the best treatment for his/her condition ( according to guidelines/protocol)and the pt agrees but the outcome is exactly the opposite? There is no definite answers in medicine. And that is the most difficult.
Mott, usually what the surgeon offers is based on the condition of the patient. There are various methods of treating breast cancer.
1. For curative treamtment, under current technology and drugs available, surgery is still necessary, followed by various “adjuvant” or “adjunct” therapy like chemotherapy, radiotherapy, hormonal therapy and another group called “targeted therapy”.
2. However, if the tumour has already spread to other areas but is not troubling the patient in the breast, then treatment may not need to concentrate on the original tumour itself. This is the situation where surgery might not be offered to the patient.
In this case, we might use chemotherapy, hormonal therapy or “targeted therapy” depending on the patient and cancer characteristics.
3. There is also a situation where the cancer has spread AND the tumour is also giving the patient trouble… such as ulcerating (breaking out of the skin), or inflammed etc… then there is a place for palliative surgery. “Palliative” means treatment to provide relief for the patient.
The methods of palliative treatment for the breast itself are:
- surgery
- radiotherapy
So, there are still other avenues to treat the cancer without surgery.
You’re right that if the primary tumour is giving pain.. one of the options is to excise it. However, to control pain, there are also other options such as radotherapy and pain relief. It depends very much on the situation of the patient.
Also, as you have said, there’s the patient’s personal preference. Some people feel better and more in control if the primary tumour had been excised. Some people feel that they want their breasts intact.
ME, true. In palliative care (more than any other area of medical care), the patient ultimately has the decision in her hands. My job is to tell her what are the realistic benefits and hazards of therapy or witholding therapy and let her choose.
Even her family members’ opinion are secondary. Although they are important, ultimately the patient’s decision is the one that counts.
Regarding choosing prolonging life compared to quality of life, there might be a reason that she will sometimes share and sometimes keep to herself… perhaps she wants to see her grandchild, or her child to graduate, or reconcile some family problems.. .etc. Or just to live as long as she can.
For me, there’s one situation where it frustrates me. It’s when there’s a potentially curable cancer being diagnosed and the patient declines evidence-based treatment in order to try out complementary medical techniques and come back later with progressing disease. I just say.. “This door is always open for you to come back.” It’s sad but somehow respecting the patient’s wishes is still paramount.
Eve, yes I have.. and I’m sure every doctor has seen that too. But protocols and guidelines are just that.. guidelines… they do not dictate what the doctor or the patient must do.
Protocols and guidelines give the best recommendations based on available evidence collected thus far. And these recommendations are based on statistically significant differences between two methods of treatment….. that in itself already implies that neither are foolproof nor completely useless.
Otherwise there wouldn’t need to be any study in the first place.
yes, i’ve heard of it. blame it on those wildfire rumours and well-meaning advises you hear from 3 ku 6 poh when they know you are diagnosed with cancer. everybody knows of something or someone who can help ‘cure’ them….but it rarely does. what i think really works is western medicine to treat the cancer and chinese medicine to strengthen the body and immunity during the course. i can imagine your frustration….but short of tying them up in you clinic and kidnapping them….you can’t force theraphy on them, can you? if they do go for theraphy, but the disease wins in the end….they’ll come back and say….”see! i wanted to try the alternative medicine route!!! it would have worked!”. there’s no winning. be comforted in the knowledge that you have tried your very best, given them all you could and provided them with all the knowledge they needed. don’t let it dampen your enthusiasm to save those that you can still save.
thank you dr bernard, on behalf of the next family whose mother / wife you are going to save.
Bernard,
Thanks for saying you like my blog! You are the only one in the world to publicly admit to this ma-lady, and will soon be in the Guinness Book! Talking of which, have you heard of an Indian surgeon-gynec couple who proudly announced to a group of doctors that their 15 year-old son had done a C section and that he would claim to be the youngest to do so in the G book? If you want to read about this amazing event, don’t visit my blog….I haven’t written on this yet!
If you want to read about the vibrating condom, yes, do come (pun intended, as always)!!
Ramana, hey, I do :-). Wowww.. the things people do to get into the G book, eh?
Ok.. coming! (pun not intended, hehe)