Do you ever consider local therapy to oligometastatic hormone-receptor positive breast cancer?

Surgery or radiation therapy in metastatic breast cancer patient is one of hot topics in care of the patients with stage IV disease, especially since the survival of oligometastatic breast cancer and widely spread metastatic breast cancer is vastly different. For instance, the 5 year survival of oligomet is around 80% vs non-oligomet is around 40-50%, and while the exact mechanism of survival difference is unknown, the local control and improved survival in oligometastatic breast cancer has been frequently reported. A 20 year follow up study reported by Kobayashi et al, showed that more than half of patients who were treated with local therapy for their oligometastatic breast cancer were alive at 20 years (especially patients who had only o...

For truly oligometastatic breast cancer, hormone positive or hormone negative, I do consider aggressive local therapy. Obviously, every case is individualized based on the extent of the oligometastasis, response to systemic therapy, and the process of shared decision making. However with low volume oligometastatic disease, while the literature is mixed, I would discuss with the patient and offer local-regional therapy in a majority of cases, depending on the discussion with the patient and the multidisciplinary team. The most important factor, in my view, is that the patient feels comfortable with the management, since the data on benefit is not clear. In most cases, I find patients most comfortable with the more aggressive approach, and pr...

I think routine use of SBRT for oligometastatic breast cancer is probably no longer supported given the results of NRG-BR002 (pending final publication). However, for those clinical situations for which local control is a priority, SBRT versus hypofractionated 3DCRT/IMRT/IGRT, could be considered. Such a situation might include painful bone metastases. A prospective, randomized, phase 2 noninferiority study from MDACC suggested better pain control with SBRT for non-spine bony metastases (Nguyen et al., PMID 31021390). Similarly, the SC24 study showed better pain control with 2-fraction SBRT vs. 20 Gy/5 fractions conventional treatment for spine metastases (Sahgal et al., PMID 34126044). RTOG 0631 (not yet published) did not show a benefit o...

I think that tumor biology and natural history of a patient's disease are important factors. As noted above, each case should be reviewed in a multi-disciplinary way. When faced with cases such as this, one can favor systemic therapy up front and evaluate the patient's response. If the patient progresses, then the role of local therapy beyond palliation if needed is limited.

However, if patient has response then local therapy can be considered. However, whether that means local site only or addressing oligometastatic disease as well (with surgery or SBRT) remains controversial.

The question made me wonder local therapy to WHAT? Depending on how I read this, I interpreted it in 2 different ways:

1) Do you ever consider definitive local therapy to the breast and all known oligometastatic site(s) (e.g. surgery and/or XRT) in the setting of oligometastatic breast cancer?

2) Do you ever consider local therapy to the breast PRIMARY (e.g. surgery and/or XRT) in the setting of oligometastatic breast cancer?

@Dr. First Last addressed concerns about selection bias and better outcomes for de novo disease and differences in oligometastatic biology. Retrospective series typically show an overall survival advantage from ‘local’ management of the primary tumor, either by surgery or definitive RT , in patients presenting with MBC. T...

We have scaled down significantly after the publication of negative trials including the ECOG study. Sometimes it is driven by the patient and the only advantage not unexpectedly seen in ECOG data was local progression but no impact on QOL.