Early Surgery or Standard Palliative Therapy in Treating Patients With Stage IV Breast Cancer

OBJECTIVES:

Primary

- To evaluate whether early local therapy comprising surgery of intact primary disease
compared to local palliative therapy only in patients with stage IV breast cancer, whose
disease does not progress during initial optimal systemic therapy, will result in
prolonged survival.

Secondary

- To compare the time to uncontrolled chest wall disease between patients treated with
these regimens.

- To determine whether there is a difference in health-related quality-of-life (HRQOL)
between patients treated with these regimens.

- To determine whether the absolute value of circulating tumor cells (CTC) burden at 6
months following randomization (time +6) will be lower in the palliative therapy arm
than in early local therapy arm, and whether this value is inversely related to survival
(lower CTC, longer survival).

- To collect tumor and blood specimens for future exploration of the biological
interactions between the primary tumor and metastatic lesions and the effect of primary
tumor resection.

OUTLINE: This is a multicenter study. Patients are stratified according to hormone receptor
and treatment plan (ER+ or PR+, HER2-, endocrine therapy alone vs ER+ or PR+, and HER2-,
chemotherapy and/or endocrine therapy vs ER- or PR-, and HER2- vs HER2+), and number of
involved organ systems with distant disease (regional nodes in the axillary, supraclavicular,
and internal mammary locations are not considered distant sites) (1 vs > 1). Patients are
randomized to 1 of 2 treatment arms.

- Arm I: Patients receive standard palliative therapy, if needed, to address symptoms such
as tumor ulceration, pain, bulky adenopathy causing arm symptoms, and other similar
situations. Therapy may consist of radiotherapy alone, surgery alone, or a combination
of both.

- Arm II: Patients undergo surgery comprising breast-conserving therapy (BCT) or total
mastectomy according to patient and treating physician preference. Surgery is to occur
no later than 10 weeks after completion of 32 weeks of systemic therapy. Free surgical
margins must be achieved with re-excision or mastectomy for patients undergoing BCT.
After completion of BCT, patients undergo radiotherapy once a day, 5 days per week.
Patients who had mastectomy undergo radiotherapy at the discretion of treating
physician.

Patients may undergo blood and tumor tissue sample collection for circulating tumor cells
(CTC) burden and future studies.

Patients complete the Functional Assessment of Cancer Therapy - Breast Trial Outcome Index
(FACT- TOI) and FACT - General (22) and the Breast Cancer Subscale (FACT-B) quality-of-life
questionnaires at baseline and periodically during study.

After completion of study therapy, patients are followed up periodically for 5 years.

DISEASE CHARACTERISTICS:

- Diagnosis of intact primary (not recurrent) invasive carcinoma of the breast

- Stage IV disease

- Confirmation of the primary tumor should be by needle biopsy (preferred)

- Incisional surgical biopsy allowed as long as there is residual palpable or tumor
image in the breast

- Patients must be judged to be candidates for complete resection with free margins
followed by radiation therapy (if radiation therapy is indicated)

- For women not undergoing axillary dissection, sentinel node biopsy should document an
axillary nodal burden of 1-2 involved lymph nodes (i.e., ACOSOG Z-11 criteria may be
applied)

- Prior non-invasive (DCIS) cancer allowed provided there has been no recurrence

- Prior ipsilateral invasive cancer allowed if more than 5 years previous

- No synchronous contralateral breast cancer

- Patients should have at least one organ system involved with distant metastatic
disease

- If patient has only one metastatic lesion/focus, this must be proven by biopsy
and the pathology report confirming the diagnosis of primary breast cancer, as
well as the metastatic site, must be available

- Must have available radiologic reports documenting disease status within the past 6
weeks prior to initiating systemic therapy

- CNS metastases allowed provided projected survival > 6 months

- Patients must have completed at least 16 weeks of optimal systemic therapy
(appropriate to the tumor biological profile and the patient's age and menopausal
status)

- If systemic therapy is discontinued for toxicity, but there is no distant
progression and at least 12 weeks of therapy have been delivered, then the
patient remains eligible

- Radiation therapy (if indicated) must begin within 12 weeks of final therapeutic
surgical procedure (including re-excision for free margins and completion of
axillary dissection)

- Patients may register at any time from the time of diagnosis of stage IV breast cancer
(if eligibility criteria met) to the time when a maximum of 30 weeks of induction
systemic therapy has been completed

- Patients must be randomized within 16-32 weeks after the start of systemic
therapy

- Patients must not have experienced disease progression since the start of systemic
therapy, as evidenced by radiographic documentation of disease status before treatment
and within 4 weeks +/- 2 weeks prior to randomization, including:

- No new sites of disease

- No enlargement of existing sites by 20% or more in longest diameter

- No symptomatic deterioration

- Patients who require radiotherapy to bone metastases during induction systemic therapy
are eligible

- Local disease at the primary site must be asymptomatic

- Hormone receptor status known

PATIENT CHARACTERISTICS:

- See Disease Characteristics

- Menopausal status not specified

- Patients must have adequate organ function to undergo local therapy 4 weeks +/- 2
weeks prior to randomization per investigator discretion and institutional guidelines

- More than 5 years since other primary cancers that were curatively treated

- Not pregnant or nursing

- Negative pregnancy test

- Fertile patients must use an accepted and effective contraception method

PRIOR CONCURRENT THERAPY:

- See Disease Characteristics