Breast Cancer in Men

October 1, 2003

In this issue of ONCOLOGY, Dr.Aman Buzdar provides a timelysynopsis of current perspectiveson breast cancer in men. I would onlyadd or expand upon a few points.

In this issue of ONCOLOGY, Dr.Aman Buzdar provides a timelysynopsis of current perspectiveson breast cancer in men. I would onlyadd or expand upon a few points.Because of its rarity, breast cancerin men has largely taken a backseat tothe worldwide effort to control thisdisease in women. Fortunately, thespotlight on women has included similarlyaffected men in its penumbra.The result has been increased visibili-ty for the problem in men. Biologically,breast cancer is similar in bothsexes, and in comparable stages is noless curable in men. The different featuresseen in men can largely be attributedto the less estrogenic milieuin which the disease arises.The small number of cases doesimpose limitations. Clinical experienceis necessarily anecdotal or retrospective.Knowledge based onrandomized clinical trials is nonexistent,and women provide the modelfor treatment. Screening with mammography,which has contributed toearlier diagnosis and a declining deathrate among women, is not feasible.Nor is the application of breastsparing technology. For the foreseeablefuture, earlier diagnosis in menis dependent on public education,individual awareness, and alertphysicians.Risk Factors in Men
The strongest risk factors for menare age, a family history of breastcancer, and a genetic predisposition. Iwould add that ionizing radiation ofthe chest wall and Ashkenazi Jewishancestry are also suspected of placingmen at increased risk.[1,2] To date,no "Gail model" for calculating individualrisk in men is available. Dr.Buzdar listed benign breast disease asa risk factor (see Table 1 in his article),but benign breast disease is exceedinglyinfrequent in men.Gynecomastia is common and increaseswith age, but gynecomastia isa symptom rather than a disease. Itincreases the glandular substrate forbreast cancer and usually reflects anestrogenic stimulus, but the relationshipof gynecomastia to breast canceris not clear. In the past, surgeons feltobligated to biopsy every case of gynecomastiato rule out cancer. Butunless the clinical examination, mammogram,or ultrasound suggestscancer, biopsy is not necessary. Symptomaticgynecomastia should be investigatedto determine its cause.Surgical Treatment
I would make two comments aboutsurgical treatment of men with earlystages of breast cancer. The first isthat there may be a small place forbreast-sparing therapy. Preservationof the breasts of men ordinarily hasnot been feasible, nor has it been ahigh priority. Cancer almost alwaysoccurs beneath the nipple, necessitatingits removal and eliminating thecosmetic value of breast preservation.Occasionally, however, investigationof nipple discharge in a man leadsto the discovery of a small, low-gradenoninvasive ductal carcinoma in situ(DCIS) that can be widely encompassedsurgically. In such cases, a subcutaneousmastectomy may be, andin the experience of the author hasbeen, sufficient to provide lasting freedomfrom recurrence. For women,Silverstein's carefully analyzed retrospectivedata support wide localexcision alone for cases of small, lowgradeDCIS.[3] Again by analogy,lumpectomy and irradiation may bean option for the occasional man whopresents with a small discrete invasive breast cancer located in a quadrantwide of the nipple if the guidelinesused for treatment of womencan be fulfilled.Sentinel Lymph Node Biopsy
My second comment regarding earlydisease is that axillary sentinellymph node biopsy (SLNB) is now anoption for men with breast cancer. Inwomen with a clinically negative axilla,SLNB has proven to be highlyreliable in identifying the pathologicallyuninvolved axilla so that axillarydissection and the resulting riskof lymphedema can be avoided. Axillarydissection in men results in asimilar frequency of lymphedema ofthe arm. One (20%) of the last fivemen I have treated with mastectomyand axillary dissection developed burdensomelymphedema. Although theexperience with SLNB in men withbreast cancer is scant, it is based on arationale similar to that in women,employs a similar technique, and limitedinformation suggests it has a similarefficacy.Albo et al reported on five men withbreast cancer at M. D. Anderson CancerCenter who underwent SLNB.[4]One man had a positive sentinel node,and axillary dissection revealed additionalpositive nodes. Of the four menwith a negative SLNB, three had axillarydissections, and no positive nodeswere found. In another review of 16male breast cancer patients who underwentaxillary SLNBs at MemorialSloan-Kettering Cancer Center, a sentinelnode was identified in all but onecase, and no false-negative sentinelnodes were reported. The investigatorsconcluded that the procedure is as successfulin men as it is in women, andmay be offered as an option to men withearly-stage breast cancer by surgeonsexperienced with the technique.[5]Postmastectomy chest wall irradiationis appropriate for men at highrisk for local recurrence and generallyfollows the indications establishedfor women, ie, a large or locally advancedprimary or multiple (four ormore) positive nodes. Following thecurrent policy for women, systemicadjuvant chemotherapy would precederadiation.Metastatic Disease
Dr. Buzdar clearly presents the optionsfor treating metastatic disease. Iwould add that in the new TNM stagingsystem, stage IV disease no longerincludes cases with isolated supraclavicularmetastases, a group (amongwomen) that has a better survival ratethan those with more distant metastases.Whether the relatively favorableprognosis is also true for men is uncertain,but this possibility encouragesvigorous locoregional and systemictherapy in these cases. When both hormonaland chemotherapy are used,chemotherapy ordinarily precedeshormonal therapy.

Disclosures:

The author(s) have no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

1.

Eldar S, Nash E, Abrahamson J: Radiationcarcinogenesis in the male breast. Eur JSurg Oncol 15:274-278, 1989.

2.

Mabuchi K, Bross DS, Kessler II: Riskfactors for male breast cancer. J Natl CancerInst 74:371-375, 1985.

3.

Silverstein MJ, Baril NB: In situ carcinomaof the breast, in Donegan WL, Spratt JS(eds): Cancer of the Breast, 5th ed. Philadelphia,WB Saunders, 2002.

4.

Albo D, Ames FC, Hunt KK, et al:Evaluation of lymph status in male breastcancer patients: Role for sentinel lymph nodebiopsy. Breast Cancer Res Treat 77:9-14,2003.

5.

Port ER, Fey JV, Cody HS, et al: Sentinellymph node biopsy in patients with male breastcarcinoma. Cancer 91:319-332, 2001.