Stage IV Breast Cancer: Can Surgery Improve Survival?
"New research suggests locoregional treatment may offer hope for Chinese women with de novo stage IV breast cancer."
Breast cancer remains a significant health challenge for women worldwide. While advancements in chemotherapy, targeted therapies, and endocrine treatments have extended survival for those with stage IV disease (where the cancer has already spread to other parts of the body at diagnosis), the optimal treatment approach remains a subject of ongoing research. Traditionally, systemic therapies have been the cornerstone of care, but recent studies are exploring the role of local treatments like surgery and radiotherapy.
Approximately 5-10% of patients discover they have stage IV breast cancer when they are first diagnosed. For these individuals, the median survival time has historically been limited to 18-24 months. However, innovations continue, aiming to improve both longevity and quality of life.
Now, a retrospective study focuses specifically on Chinese women with de novo stage IV breast cancer, investigating whether locoregional treatment—surgery to remove the primary tumor and/or radiotherapy—can make a difference in their prognosis. The study seeks to determine if these local interventions, in addition to standard systemic therapies, can offer a survival advantage.
The Current Burden
The CDC reports that 288,494 new breast cancers were diagnosed in females in the United States in 2023, while 43,402 females died from breast cancer in 2024. The CDC also notes that females had much higher rates of breast cancer diagnosis than death from the disease. Federal resources, including the Female Breast Cancer Stat Bite and SEER*Explorer, provide data on incidence, deaths, stage distribution, and five-year relative survival. The National Breast Cancer Foundation estimates that 168,000 U.S. survivors are living with Stage 4 metastatic breast cancer and that 42,140 U.S. women will die from breast cancer in 2026.
Treatment Selection in Stage IV Disease
In stage IV breast cancer, systemic treatment remains central, while the role of surgery is selective and continues to be studied. Reviews have reported that multiple studies suggest resection of the primary tumor may improve survival, but the relationship between surgery and tumor molecular subtype in the era of targeted therapy remains uncertain. Surgical resection of the primary tumor should be discussed within a multidisciplinary team for selected patients who respond to systemic therapy and may achieve no evidence of disease. Research has also examined surgical removal of metastatic sites compared with radiation, including their association with overall survival.
From Ancient Descriptions to Surgery
Breast cancer has been recognized for centuries, including in descriptions associated with the Edwin Smith Surgical Papyrus. Hippocrates and Galen attributed illness to an excess of black bile, and treatments such as opium and castor oil remained part of historical approaches. Surgical resection of breast cancer was introduced in the 18th century. Modern accounts of the field describe a long evolution from these early theories toward genetic markers and precision medicine.
Does Removing the Primary Tumor Help?
The study, published in Gynecologic and Obstetric Investigation, retrospectively analyzed data from 157 Chinese women diagnosed with de novo stage IV breast cancer between 2001 and 2016. Researchers at the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College divided participants into two groups: those who underwent surgery to remove the primary breast tumor and those who did not. They then compared overall survival (OS) and distant progression-free survival (DPFS) between the groups.
- Surgery Linked to Improved Survival: Patients in the surgery group demonstrated longer 5-year overall survival and 5-year distant progression-free survival compared to those who did not undergo surgery.
- Radiotherapy Also Beneficial: Distant progression-free survival was significantly longer in patients who received locoregional radiotherapy.
- Factors Associated with Survival: Response to systemic therapy and surgical treatment were both independently associated with improved survival outcomes.
- Progesterone Receptor Status Matters: Multivariate analysis revealed that progestogen receptor status significantly influenced distant progression-free survival.
An Evolving Evidence Base
Research on surgery for stage IV breast cancer remains an evolving area rather than a settled question. Current discussions generally focus on which patients might benefit from removing the primary tumor or selected metastatic sites after systemic treatment. Because outcomes may depend on disease biology, treatment response, and the distribution of metastases, findings from one patient group may not apply to all patients. Decisions therefore require individualized clinical judgment and multidisciplinary review.
Why Surgery May Not Help Everyone
Surgery may not improve outcomes for every person with stage IV breast cancer because metastatic disease can involve cancer cells beyond the sites that can be removed. An operation can also impose recovery demands and other risks while systemic disease remains active. Evidence may be difficult to interpret because patients selected for surgery can differ from those who are not selected in disease burden, treatment response, and overall health. These limitations make it inappropriate to treat surgery as a universal standard.
Stage IV Requires a Different Framework
The National Cancer Institute identifies breast cancer stage as an important factor in determining which treatment may work best. Comparisons of stage III and stage IV disease have examined overall survival using both established American Joint Committee on Cancer classifications and proposed subgroups for de novo metastatic breast cancer. Stage IV treatment discussions also emphasize symptom management and quality of life alongside disease control. Thus, surgery in stage IV disease should not be evaluated using the same framework applied to earlier-stage breast cancer.
What Does This Mean for Breast Cancer Treatment?
This study adds to the growing body of evidence suggesting that, in some cases, local treatment of the primary tumor can improve outcomes for patients with stage IV breast cancer. While the study is limited by its retrospective nature and specific focus on a Chinese population, it highlights the potential importance of carefully considering locoregional approaches in treatment planning.
Biology Matters Alongside Anatomy
Anatomic extent remains important in classifying breast cancer, but biological subtype is described as a defining feature for predicting overall prognosis. This supports a more individualized interpretation of stage IV disease than anatomy alone can provide. A Dana-Farber Cancer Institute study reported that stage IV breast cancer has increased in both incidence and proportion among breast cancer diagnoses over the last decade. Global research has likewise examined how stage at diagnosis varies by country, age group, calendar period, and socioeconomic status.
Personalized Questions for Future Research
Future research may clarify which people with stage IV breast cancer are most likely to benefit from surgery in addition to systemic treatment. Important questions include how tumor biology, treatment response, metastatic distribution, and patient priorities should influence selection. Better evidence could help distinguish operations that improve meaningful outcomes from those that add burden without sufficient benefit. Until then, treatment decisions are likely to remain individualized and multidisciplinary.
The Wider Burden of Metastatic Disease
Stage IV breast cancer carries substantial physical, psychosocial, and financial burdens across the cancer care continuum. A JAMA Network Open report argues that adults with advanced cancer should receive greater support throughout that continuum. Metastatic breast cancer affects millions of people globally and accounts for the vast majority of breast cancer deaths, according to the Health Policy Partnership overview. That overview also reports considerably poorer outcomes for metastatic disease than for breast cancer detected at an early stage.
Living With Ongoing Treatment
For people living with stage IV breast cancer, treatment decisions involve more than survival estimates alone. Symptoms, treatment effects, emotional strain, financial pressures, and personal goals can all shape what care feels acceptable and worthwhile. A patient-centered discussion should therefore address quality of life as well as disease control. The value of surgery may differ from one person to another depending on these priorities and the expected clinical benefit.
The researchers emphasize that surgical resection should be reserved for carefully selected patients – those with a lower disease burden, a good response to systemic treatment, and a desire to manage potential local complications. More randomized controlled trials are needed to confirm these findings and better define the optimal role of surgery and radiotherapy in stage IV breast cancer management.
Ultimately, the goal is to personalize treatment strategies, incorporating both systemic and local therapies to maximize survival and quality of life for all individuals facing this challenging diagnosis. Further research into genetic factors might also play a vital role in future treatments.