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    • In this study we applied

    2019-04-16

    In this study, we applied a more general approach along these lines, which has previously been used only in few reports in the literature [8]. Based on a prospective BC database including all newly diagnosed BC cases at a large Swiss breast center over a 20-year period, we aimed to give a comprehensive overview regarding the frequency of BM and systematically evaluated how the non-systemic BM-related therapy options radiotherapy and surgery were actually clinically implemented in an unselected cohort of patients with DMD. We use the term non-systemic locoregional therapy to draw a clear distinction between radiotherapy/surgery and systemic bone-targeted agents such as bisphosphonates and denosumab. By doing so, we answer basic questions such as “How many BC patients with BM can be expected to receive BM-related radiotherapy and/or surgery during their palliative disease courses, at which metastatic sites, at what age, and in which phase of the disease course?”
    Patients and methods Data from the prospective relational Basel Breast Cancer Database (BBCD), which includes all newly diagnosed primary invasive BC cases treated at the University Women׳s Hospital Basel, Switzerland since 1990, provided the basis for this study. This institution comprises the largest breast center in the canton of Basel and is representative of the buy flumazenil of the region. For this study, data from all female patients who were diagnosed with BC up to and including 2009 was analyzed (n=1459). Out of 369 patients with confirmed distant metastatic BC, we were able to obtain information regarding the time of diagnosis of metastatic disease and date of death but we did not have complete information about the disease course and palliative therapy details for six patients (PMD, n=1; SMD, n=5). Thus, these patients were not considered for analysis, and ultimately 363 patients were included in the study. The patients in this cohort were followed until death. Patients who remained alive were followed until 2013, thus all surviving patients had a follow-up time of at least 24 months. The outcome status of the cohort (n=363) was as follows: (1) died of metastatic BC: 316 patients (87.1%); (2) died of other causes: 24 patients (6.6%); (3) alive with metastatic disease: 20 patients (5.5%); and (4) alive, no evidence of disease: 3 patients (0.8%). In order to analyze patterns of distant metastatic disease and to examine metastatic BM-related radiation oncology and surgical procedures during the palliative therapy course, we examined only the 340 patients who ultimately died of their metastatic disease (PMD, n=78; SMD, n=262). In other words, we analyzed only completed disease and treatment courses.
    Results In our study cohort of 340 patients, 237 patients (69.7% of all patients with completed DMD courses; Table 1) were diagnosed with BM. Table 1 shows the distribution of the metastatic sites. BMs were the most frequent metastatic location, followed by metastases of the lung (51.5%), liver (43.8%), lymph nodes (28.5%) and brain (18.8%).
    Discussion On the other hand, there it is a particular strength to our study: the complete documentation of the study cohort. This valuable feature of complete documentation of BC disease courses is essential to reach our study goals, namely to give a comprehensive overview regarding the incidence of BM and to give a detailed description regarding metastases-related non-systemic locoregional therapy. Most studies regarding locoregional therapy of BM evaluated certain orthopedic interventions or feasibility of different radiation schedules and reported their respective outcome data [2,5–7]. In doing so, these studies primarily reflect the perspective of one oncological subdiscipline, namely orthopedic surgery or radiation oncology. However, they did not utilize control groups of patients with BM who were not radiated or did not receive surgery (in some cases, they included “non-therapy”-control groups which were mostly more or less arbitrarily selected subgroups). Furthermore, these studies usually do not take into account the overall course of DMD. Thus, they failed to answer basic questions such as “How many BC patients with BM can be expected to have radiotherapy and/or surgery during their palliative disease course?” or “How are these procedures embedded in the entire disease and therapy course?”. These questions require a general oncologic perspective and can only be answered through examination of a complete cohort of unselected patients with metastatic disease and by thorough analysis of metastatic patterns [8]. In a recently published study, Kuchuk et al. analyzed a comparable comprehensive approach; however, the authors focused more on the use of systemic bone-targeted agents [9].