title: Changing indications for surgery in patients with stage IV breast cancer: a current perspective.
abstract: BACKGROUND
  Evolving concepts of cancer biology and emerging evidence of a potential survival benefit from local surgery have raised the question of an expanded role for surgery in select patients with metastatic breast cancer (MBC). To determine whether such developments have influenced clinical practice, the authors evaluated surgical practice patterns in the study institution over the last 15 years.
  
  
  METHODS
  Two institutional databases were screened to identify patients with MBC who underwent breast surgery (1990-2005). Retrospective review was conducted to assess trends over time and to evaluate the role of surgery in the more modern era (1995-2005).
  
  
  RESULTS
  The overall frequency of mastectomy remained stable over time (1.7%); however, between early (1990-1995) and late (2000-2005) periods the rate of 'symptom control' mastectomy decreased (41% to 25%), whereas the rate of 'local control' mastectomy increased (34% to 66%). Conversely, the overall frequency of wide-local excision (WLE) increased over time (1995-2001), from 1% to 9% (P< .001) with no differences noted between rates of symptom control or local control procedures. In the modern era (1995-2005), 256 of 12,529 patients (2%) with MBC underwent breast surgery (33% mastectomy, 52% WLE); most frequently to 'optimize local control' (50%) and primarily in the setting of limited/stable distant disease. Surgery was performed for palliation in only 19% of patients. At a median follow-up of 33.9 months (range, 0-198.7 months), 136 of 256 patients (53%) in this cohort remained alive; 88% were free of local disease.
  
  
  CONCLUSIONS
  Although surgery in MBC has historically been reserved for palliation, the authors observed a decreasing rate of traditional 'toilet mastectomy' and a broadened surgical approach to the asymptomatic patient. When viewed in parallel with evolving concepts in cancer biology, these data reflect a change in the traditional approach to patients with MBC and warrant further investigation.
authors.affiliation: Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
authors.forename: Mary
authors.initials: M
authors.lastname: Morrogh
authors.forename: Anna
authors.initials: A
authors.lastname: Park
authors.forename: Larry
authors.initials: L
authors.lastname: Norton
authors.forename: Tari A
authors.initials: TA
authors.lastname: King
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001859:Bone Neoplasms / Q000556:secondary / Q000601:surgery; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D015331:Cohort Studies; D003937:Diagnosis, Differential; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology / Q000601:surgery*; D008207:Lymphatic Metastasis / Q000175:diagnosis; D008408:Mastectomy; D008499:Medical Records; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000639:trends*; D012189:Retrospective Studies; D012983:Soft Tissue Neoplasms / Q000556:secondary / Q000601:surgery