ABSTRACT
Surgery to remove the primary breast cancer in women presenting with de novo metastatic disease has been a controversial issue for many years. Theoretically, some argued that removal of the source of tumour cells and cytokines would reduce metastatic progression. Numerous observational studies had usually reported survival benefit. However, selection bias, with women with low metastatic burdens and better disease biology being offered surgery, meant that these results were unreliable. It was long believed that a randomised trial in this setting would be impossible due to lack of patient and clinician equipoise. The Tata Memorial Centre trial was the first randomised trial to rigorously evaluate the survival benefit of surgery in de novo stage IV breast cancer. It found no survival benefit and a small benefit to local control. It has since been followed by several other randomised trials including the US-based Eastern Cooperative Oncology Group–American College of Radiology Imaging Network (ECOG-ACRIN) E2108 trial, the Turkish Trial and most recently the Japanese Clinical Oncology Group Trial. With the exception of the Turkish Trial (which had unbalanced groups in favour of surgery), all have found no survival benefit to surgery.
