Male Breast Cancer - John Link, MD
John Link is one of the top breast cancer doctors in the world. He is the author of The Breast Cancer Survival Manual and Take Charge of Your Breast Cancer. He is a passionate campaigner for the importance of a second opinion and Optimal Care for women with breast cancer.
If you are a man with breast cancer, you are in very special company. In fact, male breast cancer (MBC) is so rare that few oncologists have significant experience of it. Because our practice is specifically committed to the treatment of breast cancer, we diagnose and treat a few men (between five and 10) each year. I will summarize what we know about male breast cancer in regard to predisposing factors, diagnosis, treatment and prognosis.
Breast cancer generally occurs later in a man’s life than in a woman’s, with the average age at diagnosis being 60 (10 years older than the age of diagnosis in women). Several factors appear to predispose men to breast cancer and much appears to concern hormone metabolism. Men who have an excess of estrogen or decreased levels of androgen appear to be more susceptible. It may actually be the ratio of male hormone to female hormone that results in an increased risk. Conditions that cause too little androgen, such as congenital hypogonadism (underdevelopment of the testicles), Klinefelter’s syndrome (a genetic condition with an extra X chromosome, liver disease (cirrhosis), are all characterized by increased estrogen and decreased testosterone (androgen), and an increased incidence of breast cancer. Hereditary breast cancer that involves the BRCA2 gene also affects men and about 15% of men, with breast cancer will have this gene which they have inherited from one of their parents.
In addition, men with excess breast tissue, a condition known as gynecomastia, also have a higher incidence of breast cancer. Again, we presently believe that a predisposing factor may be an abnormal estrogen/testosterone ratio which is associated with both MBC and gynecomastia.
The first sign of MBC is almost always a hard lump that develops just behind the nipple. Rarely, a nipple discharge or lump in the armpit is the first sign. Diagnosis is confirmed by a biopsy. A needle biopsy is preferred to an excisional biopsy. The reason for this preference is that once you know that you are dealing with a cancer, you may approach it in a surgically comprehensive manner, giving the greatest assurance of clear margins and appropriate lymph node dissection. This optimizes the chance for local control of the tumor.
MBC is almost always the “ductal” type. It is usually hormone receptor positive (>90%). It tends to be of intermediate grade under the microscope and about 10% of all cases overexpress the Her2 oncogene. Lymph node involvement occurs more frequently in MBC than a cancer of similar size in females. This may have something to do with the more common central location of the tumor, generally near the nipple, with more possibility of access to lymphatics within the breast.
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Treatment:
The same principles of treatment apply to MBC as the female counterpart: local control and treatment of possible microscopic systemic spread. Local control almost always involves a mastectomy with the removal of the nipple and all of the breast tissue beneath. Breast preservation makes little sense in that most of the cancers are so centrally located. Issues surrounding body image, sexuality and deformity, though a concern, tend to be less central to decision making. We recommend a sentinel lymph node sampling in order to spare many men a more extensive dissection with an associated increased risk of lymphedema. If there is muscle or skin involvement or heavy lymph node involvement, radiation to the affected breast/side is recommended.
The mainstay of systemic protection is hormonal in that a vast majority of the cancers are hormone receptor positive. Tamoxifen has been the treatment of choice, but based on the ability of the new types of hormonal treatment (aromatase inhibitors, or AI) to treatment advanced MBC, we and others are using the AIs in place of tamoxifen. Interestingly, we have treated a number of men with gynecomastia with AIs with excellent results.
Because there are not enough cases of MBC at a single center to allow for reliable clinical trials, we don’t have absolute evidence regarding the role of chemotherapy in early MBC. We do know that in metastatic disease chemotherapy can make the disease regress. Based on this, many of us use chemotherapy in men at high risk of relapse (Her2 positive, node positive), in an attempt to prevent systemic relapse.
Breast cancer treatment centers need to join together to study MBC, so that we can accrue enough cases of male breast cancer to conduct meaningful clinical trials and base treatment decisions on evidence rather than drawing treatment inferences from the behavior of female breast cancer. Men with breast cancer, unlike women, do not have others in their situation to turn to, although their suffering with the existential, emotional, physical and spiritual demands of this disease and its treatment are just as profound. There are not enough men diagnosed with MBC to have support groups and our male patients often feel some embarrassment in having a disease that is more commonly associated with females.
On a positive note, the majority of men will survive this disease. The keys to survival are early diagnosis and early treatment.
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