Metastatic breast cancer: an updating
Introduction
Many trials have been conducted in advanced or metastatic breast cancer patients and often the two terms have been used as synonymous. Indeed, as we recently reported [1] metastatic disease is one only of the three entities that advanced disease includes, i.e. locally advanced, locoregional and metastatic disease. These three entities differ as to the site, prognosis and therapeutic intervention [1]. Local and/or regional recurrences possibly undergo to radical excision and are easily detected by physical self examination and/or radiological study of the breast. Distant metastases are an incurable disease and systemic treatments are given for palliative rather than curative purposes. They are often detected occasionally in symptomatic or asymptomatic patients. The aim of this paper is to summarise some recent progress in metastatic disease.
Section snippets
Detection of metastatic disease
Current guidelines do not recommend routine use at regular intervals of any instrumental or laboratory test but mammography for early detection of relapse of breast cancer patients [2] and as above mentioned in most of them distant metastases are occasionally found out. This policy followed unfavourable result of two prospective randomised trials that were carried out in the nineties comparing clinical with clinical plus instrumental post-operative follow-up [3], [4]. In one of these two
Clinical outcome
Most patients with distant metastases have fatal outcome. Median survival of metastatic patients has been reported to range from 24 to 30 months with a small percentage of them surviving few months or a few years [12], [13]. Several prognostic factors have been defined to predict survival of patients with metastatic disease. Among them adjuvant chemotherapy, disease-free interval (DFI), dominant site of metastatic involvement, and occasionally menopausal and receptor status, serum LDH levels
Prediction of response to therapy
There are factors that can be useful to predict response to therapy with more accuracy when determined in metastatic cells than in primary tumour. Among them, enough evidence has been accumulated as to cellular expression of ER status and c-erbB2. The available data show that in 70–90% of relapsed patients ER remains as at the time of primary cancer [17], [19]. The 10–30% conversion rate from ER+ to ER– and from ER– to ER+ at the relapse is differently explained. One explanation based on
Therapy
This issue has been discussed in a recent report [1]. Therefore for completion here it will be focused on more recent developments.
Targeted therapy
The main targeted therapies in metastatic breast cancer are shown in Table 1.
Is minimal residual disease (m.r.d.) (‘oligometastatic disease’, stage IV with no evidence of disease (NED), and complete response to chemotherapy) a condition suitable for ‘biological’ maintenance therapy?
Conditions amenable to obtain m.r.d. in metastatic breast cancer are shown in Table 2. Recently, two particular breast cancer disease conditions have been considered: oligometastatic disease and stage IV with NED [72], [73]. Oligometastatic disease has been defined as ‘disease characterised by small tumour burden and by amenability to local therapies capable of controlling the detectable tumour site’. Stage IV with NED also has been defined as ‘locoregional or distant recurrence that have been
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