Massimo Cristofanilli, MD: One more thing about this case. This patient, being stage IV, had breast surgery up front. What’s the role of breast surgery in metastatic disease, especially in ER [estrogen receptor] positive?

Sara Tolaney, MD, MPH: That’s an excellent question. Generally speaking, I haven’t been taking patients with de novo metastatic disease to surgery. We’ve seen at least 3 large, randomized trials addressing this question in patients who present with de novo disease and have a good response to upfront therapy, and then they randomize them to surgery or not. There’s 1 study that seems to have a survival advantage, but for the most part, these studies have shown no survival advantage. We saw that again at the plenary session at ASCO [American Society of Clinical Oncology Annual Meeting]. We’re not seeing a clear advantage to local therapy in patients with de novo metastatic disease. We’re getting better systemic therapies, particularly in the HER2 [human epidermal growth factor receptor 2]–positive setting, where we’re seeing high complete response rates with systemic treatment. In a subtype like that, if we studied HER2+ de novo only, could we see a survival advantage for local therapy? We don’t know. We’ve never done a study like that that was powered to address that question in the modern era of HER2-directed drugs.

We have all these randomized trials that suggest no survival advantage, but they haven’t addressed it in that specific question. The jury is out on that, particularly in a HER2+ setting. But in ER+ disease, I don’t think there’s a role for local therapy. It’s hard to have this conversation with patients when they present with de novo disease because they’re questioning why you aren’t removing it: “At first, you told me you were going to remove the tumor, but now you’re saying you’re not.” Without a survival advantage, it’s hard to put them through surgery and have them even think about local radiation. How have you approached this?

Massimo Cristofanilli, MD: This is a case where I would not have done surgery. It’s interesting. More of these patients are coming to our clinic, maybe because we use PET [positron emission tomography]–CT or we’re more careful staging the patients up front. You find this disease in different locations. There is always the issue of oligometastatic disease. If you have 1 or 2 lesions in a bone and they’re HER2+, would you be more aggressive? Retrospective data seem to suggest that when you put a careful selection of some criteria, some patients may do better. In general, though, the question remains open. I wouldn’t propose surgery for a patient like this or a similar patient with ER+ disease. Certainly not for triple negative [disease]. These patients have a very aggressive disease where surgery has no impact. The presentation at ASCO last year was very clear with regard to the lack of benefit across the 3 subtypes, but for triple negative [disease], it was very obvious.

Sara Tolaney, MD, MPH: I agree. It’s a challenge, and hopefully we’ll see as things change, particularly in the HER2+ setting, where that could be a different answer in the future.

Transcript edited for clarity.