Department of General Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Road, Huangpu District, Shanghai 200025, China.
Breast J. 2022 Aug 25;2022:5049445. doi: 10.1155/2022/5049445. eCollection 2022.
Uncertainty still remains regarding the survival improvement derived from immediate surgery or subsequent surgery in addition to systemic therapy for patients with de novo metastatic breast cancer. The current study aimed to examine the effect of combined treatment administered in different sequences on the survival of these patients.
We conducted a retrospective cohort study of patients with de novo stage IV breast cancer in the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2019. Patients were categorized into 3 groups: (1) systemic therapy without primary surgery, (2) systemic therapy after primary surgery, and (3) systemic therapy before primary surgery. Cumulative incidence curves with Gray's test were used to compare breast cancer-specific death (BCSD) between groups. Kaplan-Meier curves with the log-rank test were applied to compare overall survival (OS) between groups. A competing risk model and a proportional hazards model were generated to adjust for important prognostic factors. Propensity score matching (PSM) was performed in the primary survival analysis. Stratified analysis was also performed.
Patients who underwent systemic therapy after primary surgery and who underwent systemic therapy before primary surgery both showed a significantly reduced risk of BCSD compared to patients who received systemic therapy without primary surgery [subdistribution hazard ratio (SHR): 0.74; 95% confidence interval (CI): 0.69-0.79; and < 0.001, and SHR: 0.62; 95% CI: 0.56-0.67; and < 0.001, respectively]. A statistically significant disparity was also noted in OS. In the setting of single-organ metastasis, including the bone, lung, and liver, patients receiving the combination therapy showed an improved prognosis compared with patients receiving systemic therapy without primary surgery.
Additional primary tumour excision, whether before or after systemic therapy, may provide survival benefits for patients presenting with de novo metastatic breast cancer, especially for patients with single-organ disease involving the bone, lung, and liver but not the brain. Further investigations mainly focused on these carefully selected candidates are required to improve personalized treatment for metastatic breast cancer.
对于初诊转移性乳腺癌患者，除全身治疗外，立即手术或后续手术是否能提高生存率仍存在不确定性。本研究旨在探讨不同治疗顺序的联合治疗对这类患者生存的影响。
我们对 2010 年至 2019 年 SEER 数据库中初诊 IV 期乳腺癌患者进行了回顾性队列研究。患者分为 3 组：（1）无原发手术的全身治疗；（2）原发手术后的全身治疗；（3）原发手术前的全身治疗。采用 Gray 检验比较累积发病率曲线，以比较各组间乳腺癌特异性死亡（BCSD）。采用对数秩检验绘制 Kaplan-Meier 曲线，比较各组间总生存（OS）。采用竞争风险模型和比例风险模型调整重要预后因素。在主要生存分析中进行倾向评分匹配（PSM）。还进行了分层分析。
与未行原发手术的全身治疗组相比，行原发手术后的全身治疗组和行原发手术前的全身治疗组的 BCSD 风险均显著降低[亚分布风险比（SHR）：0.74；95%置信区间（CI）：0.69-0.79；P<0.001 和 SHR：0.62；95%CI：0.56-0.67；P<0.001]。OS 也存在显著差异。在单器官转移（包括骨、肺和肝）的情况下，联合治疗组的患者比未行原发手术的全身治疗组患者的预后更好。
无论原发肿瘤切除是在全身治疗之前还是之后进行，都可能为初诊转移性乳腺癌患者带来生存获益，尤其对于骨、肺和肝单器官疾病但无脑转移的患者。需要进一步的研究主要集中在这些精心挑选的患者，以改善转移性乳腺癌的个体化治疗。
