By Linda Girgis MD
While everyone is aware that breast cancer in woman exists, many do not know men can be similarly afflicted. Breast cancer in women has its own awareness month (October) and its own symbol of awareness, the pink ribbon. Breast cancer in men, on the other hand, do not even have treatments tailored to them but rather use the same as women, despite there being no gender-specific clinical trials. Additionally, men often need to seek treatment in medical facilities designated as women’s health facilities.
True, breast cancer is a rare malignancy in men, but it is a deadly one nonetheless. Men often pursue medical care later in their disease process than women simply because many do not know that breast cancer is even a possibility in men. And since, it is diagnosed at later stages, it is more difficult to treat and cure. Many stigmas also abound regarding this cancer in men. All people, male and female alike, are born with some breast tissue. During puberty, high levels of testosterone and low levels of estrogen halt breast development in men. While men’s breasts do not go on to form milk-producing ducts, they can still develop cancer in this breast tissue.
In the US, about 1 % of all breast cancer occurs in men. This translates into a 1 in 1,000 lifetime risk of men developing breast cancer compared to a 1 on 8 lifetime risk in women. Survival rates in men are the same as women at the same stage of disease. However, men often present at a later stage as they are less likely to report symptoms leading to a delayed diagnosis.
What are the current statistics regarding breast cancer in men?
- In 2016, it is estimated that approximately 2 600 cases of invasive cancer will be diagnosed in men, compared to 246,660 in women.
- It is estimated that approximately 440 men will die this year as a result of breast cancer.
- For Stage 0 and I breast cancer, men have a 100% 5 year survival rate.
- For Stage II and III, the 5-year survival rate is 72%.
- For Stage IV, the survival rate is 20%.
While there is a plethora of statistics regarding breast cancer in women, the same data is sparse in men. It is clear that we need better tabulations regarding this disease in men.
Screening for breast cancer in women is a well- known fact of life. However, there are no proven screening tests or recommendations established for men. In fact, mammograms are often difficult to perform in men because of the small amount of breast tissue. Some recommend performing screening mammograms on men with increased risk of developing breast cancer. But, there is no evidence-based recommendation available.
RISK FACTORS for breast cancer in men
- Family history of breast cancer or genetic mutation: About 1 out of every 5 men who develop breast cancer has a family history. Men with BRCA 1 or BRCA 2 gene mutations may also be at an increased risk for prostate cancer as well. Men with the BRCA 2 gene mutation have a 6 in 100 chance of developing breast cancer while men with the BRCA 2 gene mutation have a 1 in 100 risk.
- Age: the average age at the time of diagnosis of breast cancer is 65.
- Elevated levels of estrogen: Certain diseases such as Klinefelter’s Syndrome and liver cirrhosis can caused increased levels of estrogen. Also, certain medications, such as certain estrogen-related drugs used in the treatment of prostate cancer, may slightly increase the risk as well.
- Lifestyle factors: obesity, lack of exercise, and drinking 2 or more alcoholic drinks per day may also increase the risk.
- History of radiation exposure the chest.
- Diseases of the testicle, undescended testes, or testicular injury.
Symptoms of breast cancer in men are often similar to those in women. A painless lump or thickening in the breast tissue may be observed. Skin changes overlying the affected area may be seen, such as dimpling, redness or scaling. Changes in the nipple may also be seen, including nipple inversion. Also, nipple discharge may be noted.
Breast cancer in men can be divided into several types with infiltrating ductal carcinoma (IDC) being the most common. This type starts in the milk duct and invades the wall growing into the fatty tissue. At this point, it can metastasize. At least 8 out of 10 breast cancers in men are this type alone or combined with other types. Because men have less breast tissue, their breast cancers are more likely to present close to the nipple and spread to the nipple than those in women. Ductal carcinoma in-situ accounts for 1 out of every 10 breast cancers in men. About 2% of male breast cancers are infiltrating lobular carcinoma (ILC). Paget disease of the nipple comprises 1% of female breast cancers but slightly higher in men. Inflammatory breast cancer is very rare in men.
The diagnosis of breast cancer in men is made in quite the same way as it is in women. A history and physical exam is done. A lump in men often mimics gynecomastia further delaying the diagnosis. A diagnostic mammogram and/or ultrasound is then performed and further diagnostic tests are done to make a definitive diagnosis. A surgical biopsy is done in suspicious cases. In most cases, fine needle aspiration or core needle biopsy can confirm the diagnosis. In some cases, an open biopsy is necessary. MRI also has some utility although it has not become mainstay of treatment currently. In certain populations, genetic testing is indicated.
Breast cancer often presents with certain subtypes. Hormone receptor status must also be determined, and for the most part, this can be done on the sample collected at the time of biopsy. Breast cancers showing estrogen (ER) or progesterone (PR) receptors are referred to hormone receptor + and require these hormones to grow. Men are more likely to be hormone receptor +. Approximately 20-25% of breast cancers also exhibit human epidermal growth factor receptor 2 (HER2). The HER2 gene produces a protein that exists on the cancer cell and is important for the cell’s growth. HER2 + cancers tend to be faster growing. But, the fastest growing subtype seems to be the triple negative cancers, those that do not express any of the receptors. This appears to be more common in younger men with breast cancer.
Because there have been few clinical trials on the treatment of breast cancer in me, most doctors follow the recommendations for treatment in women.
Treatment of male breast cancer:
- Stage 0 (ductal carcinoma insitu): this is often considered precancerous. It is treated with surgery and most often in men, a mastectomy is done. If breast conversing surgery was done, it is followed with radiation therapy to the remaining breast tissue. If the tumor is ER +, tamoxifen is often given.
- Stage 1: These cancers are small and either there is no spread or only a tiny focus of spread to the sentinel lymph node (N1mi). Treatment is surgical excision and, in men, mastectomy is done including removal of the nipple. Either an axillary lymph node dissection or sentinel biopsy will be done as well. Depending on the tumor size and results of lab tests, hormonal therapy and chemotherapy are often used as adjuvant therapies.
- Stage II: These cancers are larger and have spread to the lymph nodes. Mastectomy is needed for treatment and sometime a full axillary lymph node dissection. Adjunvant chemotherapy and hormonal therapy are often needed as well. Radiation therapy may be given following the surgery if the tumor was large or it spread to several lymph nodes. This prevents recurrence.
- Stage III: These involve large tumors with possible growth into surrounding tissues. Many lymph nodes may be involved. Most often, chemotherapy is given before surgery. For HER2 + tumors, trastuzumab is given frequently along with pertuzumab. Most patients then have mastectomy with full axillay lymph node dissection. Following surgery, radiation therapy is usually given. In hormone receptor + tumors, tamoxifen is given for 5 years. Men with HER2 + tumors will likely receive a year of trastuzumab.
- Stage IV: These cancers have metastasized to other parts of the body. With breast cancer, it most likely spread to the bones, liver or lungs. In more advance disease, it can spread to the brain but it can spread to any organ. While surgery may be needed in some case, systemic therapy remains the gold standard of therapy. Depending on many factors, this may include chemotherapy, targeted therapy, hormonal therapy or some combination of these.
While men may have the same outcomes as woman at the same stage of treatment, they often fare worse because they are diagnosed later. It is imperative that the medical community do a better job diagnosing men with breast cancer and every student taught the differences between gynecomastia and breast cancer, as it is prone to misdiagnosis. It is clear that clinical trials are needed exclusive to men as they have different ranges of hormones than women and perhaps treatments targeted at the male hormone status would be more effective if better studied. But, most importantly, we need to raise awareness in the general public that breast cancer does occur in men as well and any lump needs immediate medical evaluation. Only when we start bringing men in earlier can we prevent many of the delayed diagnoses we are seeing. And lastly, we need to make mammogram facilities and breast centers more gender neutral or open to men. No patient should be stigmatized by the medical centers they depend on for their medical care.
Linda Girgis MD, FAAFP is a family physician practicing in South River, New Jersey. She was voted one of the top 5 healthcare bloggers in 2016. Follow her on twitter @DrLindaMD.