Clinical Challenges: Diagnosing and Treating Male Breast Cancer

In In The News by Barbara Jacoby

By: Randy Dotinga

From: medpagetoday.com

Tumors tend to be discovered later in men than women, and outcomes are worse

While the male and female forms of breast cancer share many similarities, clinicians who treat the disease in men should keep various nuances in mind. For example, mastectomy is a more common treatment than in women, and there are less data about the effectiveness of certain chemotherapy medications.

And most importantly of all, outcomes in men are worse than in women since males tend to be sicker when the cancer is detected. “There is still a lack of general awareness of male breast cancer, among men as well as among physicians, and that’s one of the reasons that men tend to be diagnosed at a later stage,” said University of California Los Angeles breast surgeon Deanna J. Attai, MD, in an interview with MedPage Today.

About 2,710 cases of male breast cancer will be diagnosed in the U.S. in 2022, accounting for about 1% of all cases, according to the American Cancer Societyopens in a new tab or window. And roughly 530 men will die from the disease. “Breast cancer is about 100 times less common among white men than among white women,” the organization says, and “it is about 70 times less common among Black men than Black women.”

Jose Pablo Leone, MD, an oncologist at Dana-Farber Cancer Institute in Boston, pointed out that “there are no screening programs for breast cancer for men.” As a result, he told MedPage Today, “the way to detect it is through clinical signs and symptoms.”

Patients or physicians may detect lumps or changes in the pectoral area such as dimpling, he said. Another cause for concern is a “nipple inversion” when a nipple turns inside on itself and sinks into the breast. “The reason for this is that the tumor pulls the surrounding tissues toward itself underneath the areola,” he said.

According to UCLA’s Attai, “a workup then involves imaging — mammogram and ultrasound, sometimes MRI — and needle biopsy,” similar to what’s done for women.

Treatment of male breast cancer can include surgery, radiation, chemotherapy, immunotherapy, or a combination of these. “Historically, mastectomy was always recommended, but breast conservation should be considered in selected cases,” Attai said. “As with breast cancer in women, we have found that more aggressive surgery — mastectomy, axillary dissection — does not lead to improved outcomes.”

Surgical procedures should be tailored to the patient, she said, with an eye on “specific tumor factors, such as size of tumor relative to the size of the breast and tumor location.” For example, she said, “a tumor that is not right below or attached to the nipple may not require mastectomy with nipple removal.”

Attai added that “there is an increasing awareness of the impact of breast cancer surgery and chest-wall changes on male psychosocial and sexual health, as we have known for women for many years. Men may be offered chest-wall reconstruction or nipple preservation when oncologically appropriate and when desired.”

However, a 2021 reportopens in a new tab or window co-authored by Attai suggested that reconstruction often isn’t offered to male patients. Her group surveyed 63 patients and 438 surgeons and found that “men undergoing mastectomy without reconstruction are often dissatisfied with their cosmetic outcomes…. [S]urgeons often do not offer reconstruction or even consider it as an option. Likewise, surgeons expressed willingness to perform breast-conserving surgery [BCS] for men with breast cancer, but less than half had experience performing BCS for men.”

Systemic therapy is another treatment option. “Tumor biology dictates treatment decisions,” Attai said. “Genomic tumor assays may be used to help tailor treatment decisions.”

It’s unclear whether men with breast cancer should be treated with aromatase inhibitors, which lower estrogen levels. As the American Cancer Society notesopens in a new tab or window, the drugs “have been very effective in treating breast cancer in women, but they have not been well-studied in men.”

Ten clinics are getting ready to launch an analysis of aromatase inhibitors in men with breast cancer, Dana-Farber’s Leone said. It will take 3 years to complete enrollment, he said.

In another development on the systemic treatment front, a 2020 studyopens in a new tab or window co-authored by Attai found that men were less likely to report side effects from endocrine therapy but were more likely to discontinue treatment early compared to women.

As for outcomes, a 2019 studyopens in a new tab or window of patients diagnosed from 2004-2014 in the U.S. reported that mortality in men with breast cancer is 19% higher than in women after statistics were adjusted to account for factors such as clinical characteristics, age, and race/ethnicity.

“The 5-year survival rates for men were 87.8% (95% CI 86.7%-88.8%; P<0.001) for stage I, 78.9% (95% CI 77.7%-80.2%; P<0.001) for stage II, 63.3% (95% CI 61.0%-65.5%; P<0.001) for stage III, and 21.4% (95% CI 18.4%-24.5%; P=0.007) for stage IV disease,” the researchers reported.

What’s next? Clinicians and researchers are gaining more insight into the psychological effects of male breast cancer. “Many men feel lonely when they’re diagnosed. Everything they read online is information related to breast cancer in women,” Leone said. “Often they’re the only man in the waiting room, and they feel it is a strange place. And many men get surprised by the diagnosis. They don’t think they could have breast cancer.”

Attai has studied the stigma and embarrassment that men feel when they “enter a world of pink.” Moving forward, she said, “we have to do a better job acknowledging that while breast cancer is much more common in women, it is a genderless disease.”