'Best Paper of 2021' recommends multidisciplinary approach for metastatic inflammatory breast cancer

Multidisciplinary therapy-including systemic therapy, such as chemotherapy, as well as surgery and radiation-for women with metastatic inflammatory breast cancer (IBC) resulted in improved overall survival, according to a paper co-authored by Winship Cancer Institute of Emory University breast surgical oncologist Lauren McLendon Postlewait, MD. Published in the Annals of Surgical Oncology, the study, "The Role of Mastectomy in De Novo Stage IV Inflammatory Breast Cancer," was recognized by the American Society of Breast Surgeons as one of the best papers of 2021 during its annual meeting in Las Vegas, April 6-10, 2022.

Postlewait, a member of Winship's Cancer Prevention and Control research program and an assistant professor in the Department of Surgery at Emory University School of Medicine, specializes in surgical treatment of patients with breast cancer and breast disease. She explained that the role of surgery in patients with metastatic IBC is controversial. She noted that recent data from Khan et al, looking at outcomes over time on patients presenting with metastatic non-IBC, suggest that surgery does not offer a survival or quality of life benefit. "However," says Postlewait, "patients with IBC were not included in these trials."

Assessing the role of surgery in patients with new metastatic IBC, Postlewait and colleagues found that surgical intervention was, in fact, independently associated with significantly improved overall survival in women with metastatic IBC. "This study represents the most comprehensive retrospective analysis of patients with this condition with limited prospective data," says Postlewait.

The study

Ninety-seven women with stage IV IBC were identified in an institutional database (2007-2016) and stratified by receipt of modified radical mastectomy (MRM), which is surgery to remove the whole breast, or no surgery (non-MRM). All patients initially received chemotherapy. Fifty-two of them underwent MRM; 47 received post-mastectomy radiation. Differences between the non-MRM and MRM groups included tumor receptor subtypes, number of metastatic sites and clinical partial or complete response to chemotherapy. Of the 47 patients who completed trimodality therapy, which included surgical tumor removal followed by radiation combined with chemotherapy, six had a new tumor in the same or nearby site. Median overall survival was 19 months in the non-MRM group and 58 months in the MRM group.

The study concluded that MRM in de novo stage IV IBC patients is an independent factor associated with improved overall survival. The researchers said their findings strongly support the need for randomized trials that watch for outcomes over time, evaluating the possible survival benefits of MRM in de novo stage IV IBC patients.

Implications for future research

Based on their findings, Postlewait says she and her colleagues "recommend a multidisciplinary approach to patient care with systemic therapy and consideration of surgery followed by radiation therapy to the chest wall and nodal basins."

As for future research, Postlewait says, "Moving forward we hope to begin to address the question of why patients had better outcomes with resection of the primary tumor." She says future projects will include assessment of the molecular tumor factors and tumor microenvironment in metastatic IBC in relation to the impact of interventions and each patient's prognosis. "In this way," she says, "we hope to gain a better, optimized treatment for each individual and provide personalized cancer care."

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