Annals of Surgical Oncology

, Volume 15, Issue 12, pp 3384–3395 | Cite as

Matched Pair Analyses of Stage IV Breast Cancer with or Without Resection of Primary Breast Site

  • B. CadyEmail author
  • N. R. Nathan
  • J. S. Michaelson
  • M. Golshan
  • B. L. Smith
Breast Oncology



Reports demonstrate improved survival of stage IV breast cancer patients with primary cancer resection. This may result from selection for surgery, rather than biological processes.


We performed matched-pair analysis that minimized potential bias in selecting surgery for primary cancer. Chart review was also performed of 5-year survivors to assess selection bias affecting breast surgery.


19,464 breast cancer patients were identified; 808 (4.2%) were stage IV: 622 were analyzed after eliminating wrong diagnoses or staging, and limiting patients to Massachusetts residents.

Matched-pair analysis narrowed or eliminated apparent survival benefit associated with primary site surgery in several comparisons. When the impact of the sequence of systemic and surgical treatments was studied in stage IV patients, 90% 2-year survival occurred in patients receiving chemotherapy first, in contrast to receiving chemotherapy simultaneously with or after surgery, suggesting selection for delayed surgery after excellent response to initial chemotherapy. In bone metastases, the 2-year survival advantage occurred with chemotherapy before surgery; no difference in survival with or without surgery occurred when these treatments were simultaneous.

Among 5-year survivors, frequency of primary site surgery after excellent response to systemic therapy, breast surgery in stage III patients incorrectly classified as stage IV, and frequency of oligo metastases all indicated selection bias.


Case selection bias in primary breast cancer resection in state IV patients may explain most, if not all, the apparent survival advantage of such surgery.


Primary Breast Cancer Estrogen Receptor Status Male Breast Cancer Complete Clinical Response Supraclavicular Node Metastasis 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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Copyright information

© Society of Surgical Oncology 2008

Authors and Affiliations

  • B. Cady
    • 1
    • 2
    • 3
    Email author
  • N. R. Nathan
    • 1
    • 4
  • J. S. Michaelson
    • 1
    • 5
    • 6
  • M. Golshan
    • 1
    • 7
  • B. L. Smith
    • 1
    • 5
  1. 1.Department of Surgery, Division of Surgical Oncology, Gillette Center for Breast Cancer, Massachusetts General HospitalHarvard Medical SchoolBostonUSA
  2. 2.Cambridge HospitalCambridgeUSA
  3. 3.BrooklineUSA
  4. 4.Harvard UniversityCambridgeUSA
  5. 5.Gillette Center for Breast CancerMassachusetts General HospitalBostonUSA
  6. 6.Department of Pathology, Massachusetts General HospitalHarvard UniversityBostonUSA
  7. 7.Department of Surgery, Division of Surgical Oncology, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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