Primary Locoregional Treatment in Metastatic Breast Cancer: A Reply

Excerpt

We read with interest the Letter to the Editor by Buyukhatipoglu et al. and appreciate the opportunity to respond to their comments (http://​www.​surgonc.​org/​news-publications/​annals-of-surgical-oncology/​letters-to-the-editor). While we agree that there is no convincing evidence that radiation therapy (RT) would provide a survival benefit in stage IV breast cancer, it certainly provides a local control benefit. For patients treated with breast-conserving surgery, the toxicity of RT is typically minimal, especially with hypofractionated whole-breast RT that can be completed in 3–4 weeks with little adverse effect on quality of life. For patients who are post-mastectomy, the toxicity of RT is greater; however, some of the morbidity these patients experience is as a result of surgery, and RT may be justifiable given that some of these patients had locally advanced disease, justifying RT for local control after completing induction chemotherapy and surgery. Locoregional therapy has proven benefit in preventing fungating or bulky disease recurrence, which is clearly detrimental to quality of life. However, determining which patients may progress to this point and benefit from preventive measures is unknown and further studies may be beneficial in this area. In practice, many patients with stage IV disease treated with surgery for an intact primary tumor would be rendered stage IV–no evidence of disease (NED) following surgery. RT may be helpful to improve local control and thus potentially prolong survival for this patient population; hence, we evaluate the potential benefit of post-lumpectomy and post-mastectomy RT for each patient to individualize care in consideration of guideline-based practice for non-metastatic patients. At our institution, postoperative RT is presented as optional for our stage IV patients (outside the Eastern Cooperative Oncology Group [ECOG] trial) because of lack of available evidence; however, most such patients, once on the pathway of aggressive therapy, will also choose RT for the admittedly incremental local benefit. …