Is Metastatic Breast Cancer Curable?
Metastatic breast cancer is no longer considered incurable. It is now classified as oligometastatic and poly-metastatic disease. There have been major advances with improved survival even in oligometastatic disease. ‘Oligos’ is Greek word for ‘few’, and the term oligometastasis typically refers to less than five metastases, usually limited to a single organ. Most of these patients have better outcomes with a radical curative intent to treat both the sites of disease. At least 1-10% cases of newly diagnosed metastatic breast cancers present with oligometastatic disease and a higher number in recurrent setting. As imaging modalities have become more advanced, such as high-resolution computed tomography with positron emission tomography and magnetic resonance imaging, we have far greater ability to detect these metastases.
A 37 year old premenopausal lady presented with a lump in right breast lower central quadrant with no significant ipsilateral axillary lymph nodes (Early Breast Cancer). Initial staging workup did not show any other site of metastases. The patient and family were counselled regarding her treatment plan. She underwent right breast conserving surgery, axillary clearance and oncoplastic reconstruction in October 2017. As per final histopathology report she was advised to undergo adjuvant chemotherapy and radiotherapy. She completed her chemotherapy however due to family circumstances defaulted on her radiotherapy schedule.
She now presented to us with a recurrent swelling in a different quadrant of the same breast, biopsy from the lump confirmed cancer. PET CT scan was done for staging which unfortunately picked up a single site of metastases in her pelvic bone.
In view of oligometastatic disease (single sight of bone metastases) the case was discussed in multispecialty tumor board in the presence of oncopathologist, radiologist, nuclear medicine specialist, surgical, medical and radiation oncologist. Patient and her husband were counselled regarding the extent of disease and possibility of cure with aggressive local treatment at both sites. Subsequently she underwent wide excision of the recurrent breast lump with oncoplastic reconstruction followed by stereotactic radiotherapy to the lesion in pelvic bone with curative intent. The patient is now receiving chemotherapy in order to prevent any further recurrence. She is further planned for radiation to her right breast upon completion of chemotherapy.
The treatment of breast cancer requires a multimodality approach with strict adherence to the protocol of surgery, chemotherapy and radiotherapy in the correct sequence according to the stage of disease. Oligometastastatic breast cancer may be cured with aggressive local treatment followed by systemic therapy (chemotherapy + targeted therapy + hormone therapy). However the treatment approach must be individualized and performed by a multidisciplinary team after tumor board discussion and proper patient counselling. Better outcomes are expected in future due to availability of advanced local treatment options, oncoplastic breast conserving surgery, stereotactic radiotherapy and a better understanding of tumor biology at molecular level and availability of personalised targeted medicines.