Variation in Surgical Management of Stage IV Breast Cancer: Local/Institutional and Regional Geographic Considerations

INTRODUCTION: Prior studies have demonstrated variation in surgical management of breast cancer. As randomized controlled trials have increasingly shown a limited survival advantage with surgery in stage IV breast cancer, the present study aimed to assess geographic and institutional variations in locoregional surgical management of de novo stage IV breast cancer. METHODS: We conducted a retrospective cohort analysis of 68,670 patients with de novo stage IV breast cancer from 2012 to 2021 using the National Cancer Database. The proportion of patients treated with surgical resection was compared between year of diagnosis, facility type, geographic region, and facility volume while controlling for demographic and clinical variables. RESULTS: Overall, 17,620 patients (25.7%) with de novo stage IV breast cancer underwent breast, axillary, or metastatic site surgical resection. There was a statistically significant decrease from 27.4 to 15.0% in the proportion of patients undergoing primary tumor resection over the included timeframe (p < 0.001). Significant variation was noted in the proportion of patients receiving primary tumor resection among geographic regions, ranging from 14.9 to 23.2% (Northeast and West, p < 0.001). Patients treated at comprehensive community cancer centers were most likely to have primary site surgery, and those treated at academic centers (including National Cancer Institute-designated comprehensive cancer centers) were least likely (22.1 vs. 16.7%, respectively, p < 0.001). CONCLUSION: Significant variation exists in locoregional surgical management of de novo stage IV breast cancer. Surgical intervention has decreased over time, but this study reveals that institutional and geographic factors are associated with the surgical management for these patients.