Annals of Surgical Oncology

, Volume 14, Issue 12, pp 3345–3351 | Cite as

Surgical Resection of the Primary Tumor is Associated with Increased Long-Term Survival in Patients with Stage IV Breast Cancer after Controlling for Site of Metastasis

  • Ryan C. Fields
  • Donna B. Jeffe
  • Kathryn Trinkaus
  • Qin Zhang
  • Carey Arthur
  • Rebecca Aft
  • Jill R. Dietz
  • Timothy J. Eberlein
  • William E. Gillanders
  • Julie A. MargenthalerEmail author
Breast Oncology



The benefit of surgical resection in patients presenting with metastatic breast cancer is not established. We hypothesized that surgical excision of primary tumors in patients with stage IV breast cancer would be associated with increased survival.


Chart review identified 409 patients with stage IV breast cancer treated from 1996 to 2005; 187 received surgical excision of their primary tumor and 222 did not. One hundred and two patients had bone-only metastases, 281 had metastases to other organs ± bone, and 26 had no metastases recorded. Patient characteristics were compared between groups using the chi-squared test. Cox regression models were used to calculate adjusted hazard ratios (aHR). The log-rank test compared the differences in survival between patients who did or did not undergo surgical resection.


Mean age at diagnosis of all 409 patients was 57.8 ± 15.0 years. After controlling for age, comorbidity, tumor grade, histology, and sites of metastasis, patients who underwent surgical resection had longer median survival when compared with patients who did not undergo surgical resection (31.9 vs. 15.4 months, p < 0.0001; aHR 0.53 [95% CI 0.42-0.67]).


Surgical excision of the primary breast tumor was associated with significantly longer survival in this cohort of stage IV breast cancer patients, even after controlling for other factors associated with survival. Randomized clinical trials are needed to validate these findings.


Breast cancer Surgery Metastasis Survival 



This work was supported in part by National Cancer Institute Cancer Center support grant #P30 CA91842 to the Alvin J. Siteman Cancer Center at the Washington University School of Medicine and the Barnes-Jewish Hospital in St. Louis, Missouri. We acknowledge the Siteman Cancer Center’s health behavior and outreach core and biostatistics core for research design and statistical consulting services.


  1. 1.
    Ries LAG, Harkins D, Krapcho M, et al. (eds). SEER Cancer Statistics Review, 1975–2003, National Cancer Institute. Bethesda, MD,, based on November 2005 SEER data submission, posted to the SEER web site, 2006
  2. 2.
    National Cancer Institute: Breast cancer (PDQ): Treatment, stage IIIB, inoperable IIIC, IV, recurrent, and metastatic breast cancer (2007). Available: [accessed February 25, 2007]
  3. 3.
    Babiera GV, Rao R, Feng L, et al. Effect of primary tumor extirpation in breast cancer patients who present with stage IV disease and an intact primary tumor. Ann Surg Oncol 2006; 13:776–782PubMedCrossRefGoogle Scholar
  4. 4.
    Carmichael AR, Anderson ED, Chetty U, Dixon JM. Does local surgery have a role in the management of stage IV breast cancer? Eur J Surg Oncol 2003; 29:17–19PubMedCrossRefGoogle Scholar
  5. 5.
    Khan SA, Stewart AK, Morrow M. Does aggressive local therapy improve survival in metastatic breast cancer? Surgery 2002; 132:620–626; discussion 626–627PubMedCrossRefGoogle Scholar
  6. 6.
    Rapiti E, Verkooijen HM, Vlastos G, et al. Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. J Clin Oncol 2006; 24:2743–2749PubMedCrossRefGoogle Scholar
  7. 7.
    Singletary SE, Walsh G, Vauthey JN, et al. A role for curative surgery in the treatment of selected patients with metastatic breast cancer. Oncologist 2003; 8:241–251PubMedCrossRefGoogle Scholar
  8. 8.
    Greene FL, Page DL, Fleming ID, et al. AJCC Cancer Staging Manual, Sixth Edition. New York: Springer-Verlag, 2002Google Scholar
  9. 9.
    Piccirillo JF, Creech CM, Zequeira R, Anderson S, Johnston AS. Inclusion of comorbidity into oncology data registries. J Registry Manage 1999; 26:66–70Google Scholar
  10. 10.
    Johnston AS, Piccirillo JF, Creech CM, Littenberg B, Jeffe D, Spitznagel ELJ. Validation of a comorbidity education program. J Registry Manage 2001; 28:125–131Google Scholar
  11. 11.
    Demicheli R, Valagussa P, Bonadonna G. Does surgery modify growth kinetics of breast cancer micrometastases? Br J Cancer 2001; 85:490–492PubMedCrossRefGoogle Scholar
  12. 12.
    Retsky M, Bonadonna G, Demicheli R, Folkman J, Hrushesky W, Valagussa P. Hypothesis: Induced angiogenesis after surgery in premenopausal node-positive breast cancer patients is a major underlying reason why adjuvant chemotherapy works particularly well for those patients. Breast Cancer Res 2004; 6:R372–374PubMedCrossRefGoogle Scholar
  13. 13.
    Hormbrey E, Han C, Roberts A, McGrouther DA, Harris AL. The relationship of human wound vascular endothelial growth factor (VEGF) after breast cancer surgery to circulating VEGF and angiogenesis. Clin Cancer Res 2003; 9:4332–4339PubMedGoogle Scholar
  14. 14.
    McCulloch P, Choy A, Martin L. Association between tumour angiogenesis and tumour cell shedding into effluent venous blood during breast cancer surgery. Lancet 1995; 346:1334–1335PubMedCrossRefGoogle Scholar
  15. 15.
    Jubert AV, Lee ET, Hersh EM, McBride CM. Effects of surgery, anesthesia and intraoperative blood loss on immunocompetence. J Surg Res 1973; 15:399–403PubMedCrossRefGoogle Scholar
  16. 16.
    Meakins JL. Surgeons, surgery, and immunomodulation. Arch Surg 1991; 126:494–498PubMedGoogle Scholar
  17. 17.
    Salo M. Effects of anaesthesia and surgery on the immune response. Acta Anaesthesiol Scand 1992; 36:201–220PubMedCrossRefGoogle Scholar
  18. 18.
    Dauplat J, Le Bouedec G, Pomel C, Scherer C. Cytoreductive surgery for advanced stages of ovarian cancer. Semin Surg Oncol 2000; 19:42–48PubMedCrossRefGoogle Scholar
  19. 19.
    Hotta T, Takifuji K, Arii K, et al. Potential predictors of long-term survival after surgery for patients with stage IV colorectal cancer. Anticancer Res 2006; 26:1377–1383PubMedGoogle Scholar
  20. 20.
    Young SE, Martinez SR, Essner R. The role of surgery in treatment of stage IV melanoma. J Surg Oncol 2006; 94:344–351PubMedCrossRefGoogle Scholar
  21. 21.
    Doglietto GB, Pacelli F, Caprino P, et al. Palliative surgery for far-advanced gastric cancer: a retrospective study on 305 consecutive patients. Am Surg 1999; 65:352–355PubMedGoogle Scholar
  22. 22.
    Flanigan RC, Salmon SE, Blumenstein BA, et al. Nephrectomy followed by interferon alfa-2b compared with interferon alpha-2b alone for metastatic renal cell cancer. N Engl J Med 2001; 345:1655–1659PubMedCrossRefGoogle Scholar
  23. 23.
    Rosen SA, Buell JF, Yoshida A, et al. Initial presentation with stage IV colorectal cancer: how aggressive should we be? Arch Surg 2000; 135:530–534PubMedCrossRefGoogle Scholar
  24. 24.
    Martin R, Paty P, Fong Y, et al. Simultaneous liver and colorectal resections are safe for synchronous colorectal liver metastasis. J Am Coll Surg 2003; 197:233–241PubMedCrossRefGoogle Scholar
  25. 25.
    Abdalla EK, Vauthey JN, Ellis LM, et al. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. Ann Surg 2004; 239:818–825PubMedCrossRefGoogle Scholar
  26. 26.
    Tanaka K, Shimada H, Matsuo K, Nagano Y, Endo I, Sekido H, Togo S. Outcome after simultaneous colorectal and hepatic resection for colorectal cancer with synchronous metastases. Surgery 2004; 136:650–659PubMedCrossRefGoogle Scholar
  27. 27.
    Hallissey MT, Allum WH, Roginski C, Fielding JWL. Palliative surgery for gastric cancer. Cancer 1988; 62:440–444PubMedCrossRefGoogle Scholar
  28. 28.
    Esteva FJ, Valero V, Pusztai L, Boehnke-Michaud L, Buzdar AU, Hortobagyi GN. Chemotherapy of metastatic breast cancer: what to expect in 2001 and beyond. Oncologist 2001; 6:133–146PubMedCrossRefGoogle Scholar

Copyright information

© Society of Surgical Oncology 2007

Authors and Affiliations

  • Ryan C. Fields
    • 1
  • Donna B. Jeffe
    • 2
  • Kathryn Trinkaus
    • 3
  • Qin Zhang
    • 3
  • Carey Arthur
    • 1
  • Rebecca Aft
    • 1
    • 4
  • Jill R. Dietz
    • 1
  • Timothy J. Eberlein
    • 1
  • William E. Gillanders
    • 1
  • Julie A. Margenthaler
    • 1
    • 5
    Email author
  1. 1.Department of SurgeryWashington University School of MedicineSt. LouisUSA
  2. 2.Department of MedicineWashington University School of MedicineSt. LouisUSA
  3. 3.Division of BiostatisticsWashington University School of MedicineSt. LouisUSA
  4. 4.John Cochran Veterans Administration HospitalSt. LouisUSA
  5. 5.Department of SurgeryWashington University School of MedicineSt. LouisUSA

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