Correspondence

Bone Marrow Micrometastases in Breast Cancer

N Engl J Med 2005; 353:2191November 17, 2005

Article

To the Editor:

Braun and colleagues (Aug. 25 issue)1 report that the presence of micrometastases in the bone marrow of patients with breast cancer is an independent predictor of a poor prognosis. The authors cite the fact that this finding held true for patients with early-stage (pT1N0) disease as a potential rationale for further substratification with respect to the use of systemic adjuvant therapy. It is notable that 1036 patients in this study had pT1N0 disease and did not receive systemic adjuvant therapy. With regard to counseling patients with pT1N0 disease, it would be helpful to know the precise outcomes for the 22.1 percent of patients who also had bone marrow micrometastases and to know whether tumor size within the pT1N0 group retained independent prognostic significance. Specifically, what percentage of patients with pT1N0 disease and bone marrow micrometastases had a recurrence or died in the absence of systemic therapy (i.e., in what percentage of these patients would we expect cytotoxic therapy to be unnecessary)? Treatment can be justified only when the potential benefits in the majority of patients in this subpopulation outweigh the potential risks.

Jacqueline S. Jeruss, M.D., Ph.D.
Henry Mark Kuerer, M.D., Ph.D.
University of Texas M.D. Anderson Cancer Center, Houston, TX 77230-1402

1 References

1. 1

   Braun S, Vogl FD, Naume B, et al. A pooled analysis of bone marrow micrometastasis in breast cancer. N Engl J Med 2005;353:793-802
   Full Text | Web of Science | Medline

Author/Editor Response

With regard to the comments of Drs. Jeruss and Kuerer: Among patients with pT1N0 disease with bone marrow micrometastasis, we have shown increased rates of death from breast cancer and an increased risk of distant metastasis during the first five years after treatment. During this time, distant metastases had occurred in 25 of 229 patients with bone marrow micrometastasis (10.9 percent) and 46 of 807 without such micrometastasis (5.7 percent); 20 of 229 (8.7 percent) and 20 of 807 (2.5 percent), respectively, died from breast cancer. The presence of micrometastasis remained a significant prognostic factor when we controlled for significant confounding variables: the hazard ratio for death from breast cancer, when adjusted for tumor grade, was 3.83 (95 percent confidence interval, 1.88 to 7.81; P<0.001); when adjusted for tumor size (in millimeters), grade, and hormone-receptor expression, the hazard ratio for distant metastasis was 2.27 (95 percent confidence interval, 1.24 to 4.17; P=0.008). Despite this finding, we would discourage anybody from using these figures when counseling patients against receiving chemotherapy and, rather, would stress the need for a prospective clinical trial to test this interesting hypothesis.

Stephan Braun, M.D.
Innsbruck Medical University, A-6020 Innsbruck, Austria
stephan.braun@uklibk.ac.at

Florian D. Vogl, M.D.
General Hospital, I-39100 Merano, Italy

Citing Articles (1)

Citing Articles

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   V. Buxhofer-Ausch, C. Ausch, E. Kitzweger, M. Mollik, A. Reiner-Concin, E. Ogris, M. Stampfl, G. Hamilton, R. Schiessel, W. Hinterberger. (2010) Spontaneous changes in tumour cell dissemination to bone marrow in colorectal cancer. Colorectal Disease 12:8, 776-782
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