Breast Cancer in Men

In this issue of ONCOLOGY, Dr. Aman Buzdar provides a timely synopsis of current perspectives on breast cancer in men. I would only add or expand upon a few points. Because of its rarity, breast cancer in men has largely taken a backseat to the worldwide effort to control this disease in women. Fortunately, the spotlight on women has included similarly affected men in its penumbra. The result has been increased visibili- ty for the problem in men. Biologically, breast cancer is similar in both sexes, and in comparable stages is no less curable in men. The different features seen in men can largely be attributed to the less estrogenic milieu in which the disease arises. The small number of cases does impose limitations. Clinical experience is necessarily anecdotal or retrospective. Knowledge based on randomized clinical trials is nonexistent, and women provide the model for treatment. Screening with mammography, which has contributed to earlier diagnosis and a declining death rate among women, is not feasible. Nor is the application of breast sparing technology. For the foreseeable future, earlier diagnosis in men is dependent on public education, individual awareness, and alert physicians. Risk Factors in Men
The strongest risk factors for men are age, a family history of breast cancer, and a genetic predisposition. I would add that ionizing radiation of the chest wall and Ashkenazi Jewish ancestry are also suspected of placing men at increased risk.[1,2] To date, no "Gail model" for calculating individual risk in men is available. Dr. Buzdar listed benign breast disease as a risk factor (see Table 1 in his article), but benign breast disease is exceedingly infrequent in men. Gynecomastia is common and increases with age, but gynecomastia is a symptom rather than a disease. It increases the glandular substrate for breast cancer and usually reflects an estrogenic stimulus, but the relationship of gynecomastia to breast cancer is not clear. In the past, surgeons felt obligated to biopsy every case of gynecomastia to rule out cancer. But unless the clinical examination, mammogram, or ultrasound suggests cancer, biopsy is not necessary. Symptomatic gynecomastia should be investigated to determine its cause. Surgical Treatment
I would make two comments about surgical treatment of men with early stages of breast cancer. The first is that there may be a small place for breast-sparing therapy. Preservation of the breasts of men ordinarily has not been feasible, nor has it been a high priority. Cancer almost always occurs beneath the nipple, necessitating its removal and eliminating the cosmetic value of breast preservation. Occasionally, however, investigation of nipple discharge in a man leads to the discovery of a small, low-grade noninvasive ductal carcinoma in situ (DCIS) that can be widely encompassed surgically. In such cases, a subcutaneous mastectomy may be, and in the experience of the author has been, sufficient to provide lasting freedom from recurrence. For women, Silverstein's carefully analyzed retrospective data support wide local excision alone for cases of small, lowgrade DCIS.[3] Again by analogy, lumpectomy and irradiation may be an option for the occasional man who presents with a small discrete inva sive breast cancer located in a quadrant wide of the nipple if the guidelines used for treatment of women can be fulfilled. Sentinel Lymph Node Biopsy
My second comment regarding early disease is that axillary sentinel lymph node biopsy (SLNB) is now an option for men with breast cancer. In women with a clinically negative axilla, SLNB has proven to be highly reliable in identifying the pathologically uninvolved axilla so that axillary dissection and the resulting risk of lymphedema can be avoided. Axillary dissection in men results in a similar frequency of lymphedema of the arm. One (20%) of the last five men I have treated with mastectomy and axillary dissection developed burdensome lymphedema. Although the experience with SLNB in men with breast cancer is scant, it is based on a rationale similar to that in women, employs a similar technique, and limited information suggests it has a similar efficacy. Albo et al reported on five men with breast cancer at M. D. Anderson Cancer Center who underwent SLNB.[4] One man had a positive sentinel node, and axillary dissection revealed additional positive nodes. Of the four men with a negative SLNB, three had axillary dissections, and no positive nodes were found. In another review of 16 male breast cancer patients who underwent axillary SLNBs at Memorial Sloan-Kettering Cancer Center, a sentinel node was identified in all but one case, and no false-negative sentinel nodes were reported. The investigators concluded that the procedure is as successful in men as it is in women, and may be offered as an option to men with early-stage breast cancer by surgeons experienced with the technique.[5] Postmastectomy chest wall irradiation is appropriate for men at high risk for local recurrence and generally follows the indications established for women, ie, a large or locally advanced primary or multiple (four or more) positive nodes. Following the current policy for women, systemic adjuvant chemotherapy would precede radiation. Metastatic Disease
Dr. Buzdar clearly presents the options for treating metastatic disease. I would add that in the new TNM staging system, stage IV disease no longer includes cases with isolated supraclavicular metastases, a group (among women) that has a better survival rate than those with more distant metastases. Whether the relatively favorable prognosis is also true for men is uncertain, but this possibility encourages vigorous locoregional and systemic therapy in these cases. When both hormonal and chemotherapy are used, chemotherapy ordinarily precedes hormonal therapy.