Clinical Information and Management Status of De Novo Stage IV Breast Cancer Patients: A Chinese Multicenter Investigation (CSBrS-002)
Breast cancer remains the most prevalent malignancy among women globally, with significant implications for public health. In China, breast cancer accounts for approximately 12.2% of all cancer diagnoses and 9.6% of all cancer-related deaths. Among these cases, de novo stage IV breast cancer, characterized by the presence of distant metastasis at the time of initial diagnosis, represents a particularly challenging subset. This condition, although incurable, has entered an era of individualized treatment and chronic disease management. The management of de novo stage IV breast cancer is complex, involving systemic therapies and, in some cases, surgical interventions. However, the role of surgery in improving survival outcomes remains controversial. This study aims to explore the clinicopathological factors and current management status of de novo stage IV breast cancer in China, providing valuable insights for clinical decision-making.
The study was conducted with the support of the Chinese Society of Breast Surgery (CSBrS) and involved a retrospective analysis of clinical data from 33 centers across China. The data encompassed patients diagnosed with de novo stage IV breast cancer between January 2017 and December 2018. The study enrolled a total of 468 patients, with a median age of 51.5 years. The most common pathological type of the primary lesion was invasive carcinoma, accounting for 97.1% of cases. The molecular subtypes included Luminal A (14.3%), Luminal B (51.8%), HER2 overexpressing (22.1%), and triple-negative breast cancer (TNBC) (11.8%).
The study examined various clinicopathological factors, including age, menstrual status, family history, reproductive history, pathological type, estrogen receptor (ER) status, progesterone receptor (PR) status, human epidermal growth factor receptor 2 (HER2) status, Ki-67 percentage, and molecular subtype. The relationship between these factors and metastasis sites (lung, liver, and bone) was analyzed using Pearson Chi-square tests. The results revealed significant correlations between certain factors and specific metastasis sites. For instance, age, PR status, and HER2 status were correlated with lung metastasis. Pathological type, ER status, PR status, and molecular subtype were correlated with bone metastasis. Age, PR status, HER2 status, Ki-67 percentage, and molecular subtype were correlated with liver metastasis. Notably, HR-negative/HER2-positive patients had a higher proportion of liver metastasis, while Luminal B patients had the highest proportion of bone metastasis. TNBC patients were less likely to have bone metastasis compared to other subtypes.
The study also investigated the management strategies for de novo stage IV breast cancer patients in China. Systemic therapy was the primary treatment approach, with 95.1% of patients receiving systemic therapy. The most common first-line chemotherapy regimen was a combination of paclitaxel and anthracycline, used in 51.7% of cases. Overall, 91.5% of patients received paclitaxel-containing regimens. Among hormone receptor-positive patients, 59.3% underwent endocrine therapy. Targeted therapy was administered to 84.2% of HER2-positive patients, with trastuzumab being the most commonly used agent (85.5%).
The role of surgery in the management of de novo stage IV breast cancer was also explored. The study found that 54.2% of patients underwent surgical removal of the primary lesion. The types of surgeries included modified radical mastectomy, breast-conserving surgery, total mastectomy, and local mastectomy. To assess the impact of surgery on survival outcomes, the study divided 148 patients with follow-up information into two groups: those who received systemic therapy alone and those who underwent primary tumor resection plus systemic therapy. Kaplan-Meier survival analysis showed no significant difference in overall survival (OS) between the two groups (P = 0.250).
The study highlighted several important findings regarding the diagnosis and management of de novo stage IV breast cancer in China. Ultrasound combined with molybdenum target mammography was the most common imaging method for diagnosing primary lesions, used in 57.3% of cases. Core needle biopsy was the predominant pathological diagnostic method, employed in 99.3% of cases. For metastasis diagnosis, whole-body bone scintigraphy and computerized tomography (CT) were the primary methods for detecting bone metastasis, used in 97.0% of cases. Visceral metastasis was mostly diagnosed using magnetic resonance imaging combined with CT (50.0%) or positron emission tomography-computed tomography (31.7%). Notably, only 10.9% of patients had a definitive pathologic diagnosis of metastatic foci, and 17.7% of these patients exhibited different molecular subtypes between the metastatic and primary foci.
The study’s findings underscore the heterogeneity of de novo stage IV breast cancer and the importance of individualized treatment approaches. The correlation between molecular subtypes and metastasis patterns provides valuable insights for predicting disease progression and tailoring treatment strategies. The high rate of systemic therapy adoption reflects the recognition of its central role in managing this advanced stage of breast cancer. However, the ongoing debate regarding the benefits of surgery highlights the need for further research to identify subgroups of patients who may derive survival benefits from surgical interventions.
The study also identified several limitations. The population-based design may have introduced errors in data reporting, and the pathologic data were collected from different local laboratories without central review. The follow-up data were limited, with a mean follow-up period of 16.3 months, and information on other metastasis sites, such as the brain, was not collected. Future studies should aim to expand the follow-up data, record additional metastasis sites, and extend the follow-up duration to provide a more comprehensive assessment of prognostic factors.
In conclusion, this multicenter investigation provides a detailed overview of the clinical characteristics, diagnostic methods, and management strategies for de novo stage IV breast cancer in China. The study highlights the importance of systemic therapy and the ongoing controversy surrounding the role of surgery in improving survival outcomes. The findings offer valuable insights for clinicians and researchers, emphasizing the need for individualized treatment approaches and further research to optimize the management of this challenging condition. The study’s comprehensive analysis of clinicopathological factors and management status serves as a crucial reference for clinical decision-making in the treatment of de novo stage IV breast cancer.
doi.org/10.1097/CM9.0000000000001415
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