Male Breast Cancer

Male breast cancer remains under diagnosed and, due to delays in diagnosis, is often also undertreated. The investigation and management of male breast cancer are based on studies on female patients. At present there is a need for further research into male breast cancer. The symptoms, diagnosis and treatment for male breast cancer are all similar to female breast cancer.

It is estimated that more than 90% of male breast cancers are oestrogen receptor-positive, and an even greater percentage are progesterone receptor-positive. Male breast cancer tissue may also be positive for androgen receptors.

Prevalence

In 2008, the incidence was 0.9 per 100,000 populations, compared with 123.8 per 100,000 for female breast cancer. It has been estimated that the lifetime risk of developing breast cancer is 1 in 1,014 for men and 1 in 8 for women.

Male breast cancer is diagnosed in 1% of cases of male breast enlargement. The incidence of male breast cancer has increased over the past 25 years.

The peak age for presentation of male breast cancer is >60 years.

There is wide variation in incidence – for example, high rates in Zambia (thought to be related to hyper oestrogenism from endemic liver infections). A lower incidence is seen in Japan (for both men and women).

Risk factors

Increasing age.

Genetics.

Up to one fifth of men with breast cancer have a first-degree relative similarly affected.

More commonly associated with BRCA2 mutations.

High-risk groups include sub-Saharan Africa and Ashkenazi Jews.

Lifestyle.

Certain environments – eg, furnace work, exposure to radiation and possibly electromagnetic fields.

Polycyclic aromatic hydrocarbons (as in petrol and exhaust fumes).

Hyperoestrogenism.

Exogenous oestrogen.

Klinefelter’s syndrome (47XXY)- low testosterone and increased gonadotrophins. Breastcancer is up to 50 times more frequent in this group.

Obesity.

Chronic liver conditions.

Pituitary adenomas leading to hyperprolactinaemia (associated with bilateral breast cancer).

Gynaecomastia doesnot lead to an increased risk.

Alcohol consumption

Chest irradiation

Appearance

More than 40% of patients have stage III or IV disease at presentation.

Symptoms

Painless lump,

Pain (rarely),

Nipple inversion or discharge,

Skin changes – eg, ulceration.

Gynaecomastia – very rarely

Signs

Skin change

Palpable mass

Palpable lymph nodes

Red flags which increase suspicion of breast cancer in men who present with gynaecomastia

Unilateral enlargement

Hard or irregular breast tissue Rapidly enlarging

Recent onset Fixed mass

Nipple or skin abnormalities Painful

>5 cm

Axillary lymphadenopathy

Investigations

Imaging: mammography (sensitivity 92% and specificity 90%) or ultrasonography.

Tissue: fine needle aspiration cytology (FNAC) or either core or open biopsy. Biopsy is preferred as malignant cells on FNAC may be a ductal carcinoma in situ rather than more invasive disease.

Staging

Infiltrating ductal cancer is the most common tumour type. Inflammatory carcinoma and Paget’s disease of the breast those found in female breast cancer. The tumour, nodes, metastases (TNM) staging system for male breast cancer is identical to the staging system for female breast cancer:

Stage 0: 10% of male breast cancer is ductal carcinoma in situ.

Stage I: tumour up to 2 cms in diameter and no lymph node involvement or metastasis.

Stage II: tumour between 2 and 5 cms in diameter or there is spread to the axillary lymph nodes on the same side and the nodes are not adherent.

Stage IIIA: tumour is over 5 cms in diameter or the nodes are adherent.

Stage IIIB: invasive breast cancer in which a tumour of any size has spread to the breast skin, chest wall or internal mammary lymph nodes and includes inflammatory breast cancer with peau d’orange.

Stage IV: spread beyond the breast, axilla and internal mammary nodes. It may have spread to supraclavicular nodes, bone, liver, lung or brain.

Wellness Program

Surgery

Surgery: wide local excision or mastectomy (more common in men as there is paucity of breast tissue and the nipple is usually removed). This may be associated with axillary lymph node sampling and clearance. Sentinel node biopsy is being used in clinically node-negative disease. The patient may need skin flap or nipple reconstruction.

Radical mastectomy has now been replaced by less invasive procedures such as modified radical or simple mastectomy. Axillary node dissection may be performed but may cause complications such as lymphoedema and paraesthesia.

Adjuvant hormone therapy

Adjuvant hormone therapy: tamoxifen is used (as in women) and improves survival.

Radiotherapy

Adjuvant local radiotherapy or post-mastectomy. Regional lymph nodes may also be treated with radiotherapy.

Chemotherapy

Chemotherapy: regimens using cyclophosamide, methotrexate, doxorubicin, 5-fluorouracil and taxanes(pacliteaxel, docetaxel)have been used with improved survival rates. The role of taxanes, however, remains to be elucidated.

Trastuzumab is used when more adverse features are present, as in women. However, there is currently no information on the benefits of trastuzumab in male breast cancer.

Advanced disease For metastatic or more advanced disease, hormonal therapies are the main treatments used. Chemotherapy has been used as a second line (and for palliative purposes also). ^{[1] [10]}

Other therapies that have been used include:

Gonadal ablation in metastatic male breast cancer.

Orchidectomy.

Adrenalectomy.

Hypophysectomy.

Adjuvant aromatase inhibitors – eg, anastrozole

Prognosis

There is often a delay in diagnosis of male breast cancer, thus prognosis at presentation is worse in comparison with women.

5-year survival depends on the stage of the disease (75-100% for stage I disease and 30-60% for stage III disease).

The risk of carcinoma in the other breast is also increased.​