Male breast cancer. Report of a series of 50 cases

Male breast cancer: a 30 year retrospective analysis from a tertiary cancer care centre

Background

Male breast cancer (MBC) is one of the rare malignancies that account for less than 1% of all malignancies in males. However, the clinicopathological characteristics of MBC are not entirely similar to female breast cancer; but still, it is treated in line with the female breast cancer protocols.

Aims

To retrospectively analyse trends in MBC as to its distribution, presentation, treatment, and outcome.

Material and method

A total of 106 patients with MBC from 1991 to 2020 were analysed retrospectively. Frequency distribution analysis of the demographic and clinicopathological data and treatment variables was done.

Results

Median age of presentation was 57 years; ranging from 30 to 86 years. Either of the sides was almost equally affected with an R: L ratio of 1.2:1. The average duration of complaint was 26.2 months (range 1-240 months). History of gynaecomastia was noted in 18 patients, significant benign prostate hypertrophy in 13, and hypertension needing medical treatment in 14 patients. The majority of the patients were smokers (72/106) and alcoholics (43/106). Five patients reported positive family history. 21 patients had metastatic disease at presentation and received palliative treatment. Stage II was seen in 36.8%, stage III in 43.4%, and stage IV in 19.8% of patients. Node positives were 63.2%. Pathology was invariably (90.5%) infiltrative ductal carcinoma. Radiation was administered in 85.8% of the patients, chemotherapy in 72.6% of patients, and hormonal treatment was given in 47.2% of patients. The median overall survival (OS) was 78 months. OS at 5 and 10 years was 78% and 58% respectively.

Conclusion

Despite the possibility of MBC being apparent at an early stage, patients present with locally advanced disease. Radical surgery with adjuvant/neoadjuvant chemotherapy and adjuvant radiotherapy remains the gold standard. Cancer education campaigns must be run to catch the early disease and to radically treat the disease.

A Prospective Population-Based Study of Cardiovascular Disease Mortality following Treatment for Breast Cancer among Men in the United States, 2000-2019

Male breast cancer is rare but its incidence and mortality are increasing in the United States, with racial/ethnic disparities in survival reported. There is limited evidence for cardiotoxicity of cancer treatment among men with breast cancer. We evaluated the relation between breast cancer treatment and cardiovascular disease (CVD) mortality among men and investigated the salient roles that race/ethnicity play on this relation. Data were from 5216 men with breast cancer aged ≥ 40 years from the Surveillance, Epidemiology, and End Results program who were diagnosed from 2000 to 2019 and underwent surgery. Competing risk models were used to estimate hazards ratios (HR) and 95% confidence intervals (CI). During a median follow-up of 5.6 years, 1914 deaths occurred with 25% attributable to CVD. In multivariable-adjusted models, men who received chemotherapy had elevated risk for CVD (HR: 1.55, 95%CI: 1.18-2.04). This risk was higher among Hispanic men (HR: 3.96, 95%CI: 1.31-12.02) than non-Hispanic Black and non-Hispanic White men. There was no significant association between radiotherapy and CVD deaths. In this population-based study, treatment with chemotherapy was associated with elevated risk of CVD mortality in men with breast cancer. Racial/ethnic disparities in the association of chemotherapy and CVD mortality were observed.

A systematic literature review of the management, oncological outcomes and psychosocial implications of male breast cancer

BACKGROUND

Although male breast cancer (MBC) is a rare disease, accounting for <1% of all breast cancers, it has significant oncological, survival and psychosocial implications for patients. The aim of this study is to assess the latest literature in the diagnosis, management, oncological outcomes, and psychosocial impact of MBC.

METHODS

A systematic literature review was conducted using the PRISMA guidelines (Moher et al., 2009) [1] to explore the management of MBC, with particular focus on investigative imaging, surgical management, oncological outcomes, survival, genetic screening and psychosocial effects. Electronic databases were searched for randomised control trials, cohort studies and case series involving more than 10 patients. Imaging and surgical techniques, local and distant disease recurrence, survival, genetic screening and psychosocial implications in the setting of MBC were assessed.

RESULTS

The search criteria identified 199 articles, of which 59 met the inclusion criteria. This included 39,529 patients, with a mean age of 64.5 years (55-71), and a mean follow-up of 66.3 months (26.2-115). Mastectomy remains the most frequently used surgical technique, with an average of 89.6%. Loco-regional and distant recurrence rate was 10.1% and 21.4% respectively. Disease-free survival (DFS) at 5 and 10 years was 66.8% and 54.5% respectively. Disease-specific survival (DSS) at 5 and 10 years was 87.1% and 67.1% respectively. Overall survival (OS) at 5 and 10 years was 72.7% and 50.7% respectively. Genetic screening was conducted in 38.6% of patients of which 4.8% and 15.8% were found to be BRCA1 and BRCA2 carriers respectively. Psychosocial studies were conducted mainly using questionnaire and interview-based methodology focusing primarily on awareness of breast cancer in men, support available and impact on gender identity.

CONCLUSIONS

This review demonstrates that men present with later stage disease with subsequent impact on survival outcomes. There remains a paucity of high-level evidence and prospective studies are required. There is a need for increasing awareness amongst the public and health care professionals in order to improve outcomes and reduce stigma associated with MBC.

An updated review of epidemiology, risk factors, and management of male breast cancer

Unlike female breast cancer, male breast cancer (MBC) is rare and not very well understood. Prospective data in the management of MBC are lacking and majority of treatment strategies are adopted from the established guidelines for breast cancer in women. The understanding of biology, clinical presentation, genetics, and management of MBC is evolving but there still remains a large knowledge gap due to the rarity of this disease. Older age, high estradiol levels, klinefelter syndrome, radiation exposure, gynecomastia, family history of breast cancer, BRCA2 and BRCA1 mutation are some of the known risk factors for MBC. Routine screening mammography is not recommended for asymptomatic men. Diagnostic mammogram with or without ultrasound should be considered if there is a suspicion for breast mass. Majority of men with early-stage breast cancer undergo mastectomy whereas breast conserving surgery (BCS) with sentinel lymph node biopsy (SLNB) remains an alternative option in selected cases. Since the majority of MBC are hormone receptor positive (HR+), adjuvant hormonal therapy is required. Tamoxifen for a total of 5 to 10 years is the mainstay adjuvant hormonal therapy. The role of neoadjuvant and adjuvant chemotherapy for early-stage breast cancer is uncertain and not commonly used. The role of gene recurrence scores like oncotype Dx and mammaprint is evolving and can be used as an aid for adjuvant chemotherapy. Majority of metastatic MBC are treated with hormonal therapy with either tamoxifen, gonadotropin-releasing hormone agonist (GnRH) with aromatase inhibitors (AI), or fulvestrant. Chemotherapy is reserved for patients with visceral crisis or rapidly growing tumors.

Adjuvant treatment of early male breast cancer

PURPOSE OF REVIEW

Male breast cancer (MaBC) is a rare disease, and some challenges exist in its management because current treatment recommendations are extrapolated from trials that mostly excluded men. This review will revise all available data that could improve the treatment of MaBC, with a special focus on adjuvant systemic treatments.

RECENT FINDINGS

To date, men with hormone receptor-positive breast cancer, who are candidates for adjuvant endocrine therapy, should be offered tamoxifen (TAM) for five years. Additional five years are possible, according to tolerance and recurrence risk. If TAM is contraindicated, a gonadotropin-releasing hormone (GnRH) agonist or antagonist and aromatase inhibitor should be proposed. Chemotherapy and targeted therapy in the other breast cancer subtypes should be used with the same indications offered to women with breast cancer. All men with breast cancer should be offered genetic counseling and germline genetic testing of cancer predisposition genes.

SUMMARY

For decades, men with breast cancer have been treated suboptimally and denied the participation in clinical trials. Recently, many clinical trials started enrolling both genders, as strongly endorsed by the Food and Drug Administration. Hopefully, this turnaround will help subdue the disparities in the quality of care.

Pharmacological management of male breast cancer

INTRODUCTION

Despite its rarity, male breast cancer shows a steadily rising incidence. Given the absence of ad hoc prospective randomized clinical trials, treatment strategies are based on extrapolation from female breast cancer recommendations or solely on population-based data.

AREAS COVERED

This review discusses the current treatment landscape for male breast cancer in the adjuvant and in the metastatic setting. The authors also discuss the biology and genomic landscape of male breast cancer. Original research and review articles, relative to the period 2010-2019, were included in the review of the literature.

EXPERT OPINION

There is a major medical need to include male patients with breast cancer in prospective clinical trials. The call to equality in breast cancer care can be pursued via two divergent paths: (i) a gender-neutral delivery of breast cancer information and (ii) the creation of separate sections, for the more common female breast cancer and for the rare male ones. We propose to differentiate male breast cancer care, acknowledging unique onco-sexual and social needs that can be only partially shared.

A contemporary review of male breast cancer: current evidence and unanswered questions

Male breast cancer is rare, accounting for 1% of all breast cancer diagnoses in the USA. Because of its rarity, most major breast cancer trials have included only female patients. This has resulted in limited prospective data to guide the clinical management of men with breast cancer. As a result, treatment decisions are typically extrapolated from data generated in female patients. This approach may be suboptimal, particularly considering the differing hormonal milieus between men and women with respect to both breast cancer development and treatment. Herein, we summarize current knowledge of the biology and clinicopathology of male breast cancer and review current approaches to locoregional and systemic management of this rare disease.

Male Breast Cancer

Male breast cancer (MBC) is a rare disease, accounting for less than 1% of all breast cancer diagnoses worldwide. Although breast carcinomas share certain characteristics in both genders, there are notable differences. Most studies on men with breast cancer are very small. Thus, most data on male breast cancer are derived from studies on females. However, when a number of these small studies are grouped together, we can learn more from them. This review emphasizes the incidence, etiology, clinical features, diagnosis, treatment, pathology, survival, and prognostic factors related to MBC.

Hormone Therapy for Breast Cancer in Men

Breast cancer in men is rare, but its incidence is increasing, in keeping with the aging population. The majority of breast cancers in men are estrogen receptor positive. There is a paucity of clinical trials to inform practice, and much has been extrapolated from breast cancer in women. Hormone therapy represents the mainstay of adjuvant and palliative therapy but may have contraindications or poor tolerability. We review the evidence for choice of hormone therapy in both the adjuvant and palliative setting in breast cancer in men.

New approaches in the management of male breast cancer

Male breast cancer (MBC) is a rare condition that accounts for 0.1% of all male cancers. Our current evidence base for treatment is derived from female breast cancer (FBC) patients. Risk factors for MBC include age, genetic predisposition, race, sex hormone exposure, and environmental factors. Most patients present later and with more advanced disease than comparable FBC patients. Tumors are likely to be estrogen receptor and progesterone receptor positive, with the most common histologic type being invasive ductal carcinoma. Triple assessment remains the criterion standard for diagnosis. Primary MBC is mostly managed initially by simple mastectomy, with the option of breast conserving surgery, which carries an increased risk of recurrence. Sentinel node biopsy is recommended as the initial procedure for staging the axilla. Reconstructive surgery focuses on achieving primary skin closure, and radiotherapy largely follows treatment protocols validated in FBC. We recommend chemotherapy for men with more advanced disease, in particular, those with estrogen receptor negative histology. MBC responds well to endocrine therapy, although it is associated with significant adverse effects. Third-generation aromatase inhibitors are promising but raise concerns due to their failure to prevent estrogen synthesis in the testes. Fulvestrant remains unproven as a therapy, and data on trastuzumab is equivocal with HER2 receptor expression and functionality unclear in MBC. In metastatic disease, drug-based hormonal manipulation remains a first-line therapy, followed by systemic chemotherapy for hormone-refractory disease. Prognosis for MBC has improved over the past 30 years, with survival affected by disease staging, histologic classification, and comorbidity.

Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship

BACKGROUND

The causes, optimal treatments, and medical/psychosocial sequelae of breast cancer in men are poorly understood.

DESIGN

A systematic review of the English language literature was conducted to identify studies relevant to male breast cancer between 1987 and 2012 and including at least 20 patients. Searches were carried out on PubMed using the title terms 'male breast cancer' or 'male breast carcinoma'.

RESULTS

Relevant published data regarding risk factors, biological characteristics, presentation and prognosis, appropriate evaluation and treatment, and survivorship issues in male breast cancer patients are presented. BRCA2 mutations, age, conditions that alter the estrogen/androgen ratio, and radiation are proven risk factors. Disease biology is distinct in men, but diagnostic approaches and treatments for men are generally extrapolated from those in women due to inadequate research in men. Survivorship issues in men may include sexual and hormonal side-effects of endocrine therapies as well as unique psychosocial impacts of the disease.

CONCLUSION

Further research is needed to address gaps in knowledge pertaining to care of male breast cancer patients and survivors.

Breast cancer in men: prognostic factors, treatment patterns, and outcome

PURPOSE

The aim of this study was to review the clinical presentation and to evaluate prognostic factors, treatment modalities, outcome, and second malignancy in male breast cancer patients. A chart review was conducted of all men treated for breast cancer between January 1991 and December 2007. Cox proportional hazards regression model and Kaplan-Meier curve were used to determine prognostic factors and plot survival probabilities. Invasive carcinoma was diagnosed in 22 patients and ductal carcinoma in situ in 7 patients. With mortality as the endpoint, tumor size indicated hazard ratio (HR) of 1.5 for each 1-cm increase in tumor size (p = .03). Overall stage and increased age were associated with increased risk of mortality (HR = 2.1, p = .055; HR = 1.09 for a 1-year increase in age, p = .08, respectively). Adjuvant radiation therapy yielded an HR of 0.1 (p = .058), indicating a favorable association with the survival. Advanced age, higher stage, and increasing tumor size were unfavorable to survival in male breast carcinoma. The benefit of adjuvant radiation therapy should be addressed in future collaborative studies.

The impact of post-mastectomy radiation therapy on male breast cancer patients--a case series

OBJECTIVE

To assess the impact of radiation management on male breast cancer (MBC) at London Regional Cancer Program (LRCP).

METHODS AND MATERIALS

Men with a diagnosis of breast cancer referred to LRCP were reviewed. The seventh American Joint Committee on Cancer staging system was used. Patients treated with and without post-mastectomy radiation therapy (PMRT) were analyzed. Disease-free survival (DFS) was defined as time duration from diagnosis to first recurrence. Overall survival (OS) was defined as time duration from pathologic diagnosis to death or last follow-up with any death defined as an event. Survival estimates were obtained using Kaplan-Meier methodology.

RESULTS

From January 1977 to December 2006, 81 men had invasive ductal carcinoma. The median age was 65 (range, 35-87 years). There were 15 Stage I, 40 Stage II, 20 Stage III, and 6 Stage IV patients. Median follow-up time was 46 months (range, 1-225 months). Of the 75 patients treated with curative intent, 29 did not receive PMRT and 46 completed PMRT. Patients who received PMRT demonstrated no benefit in overall survival (p = 0.872) but significantly better local recurrence free survival (p < 0.001) compared with those who did not receive RT. There was trend toward improving locoregional recurrence with PMRT in patients with high-risk features (node-positive, advanced stage, and ≤ 2 mm or unknown surgical margin). The median, 5-year, and 10-year disease-free survival and overall survival for the 75 patients were 77.7 months, 66.3%, 32.7%, and 91.2 months, 73.9%, and 36.6%, respectively.

CONCLUSION

The experience at LRCP suggests that high-risk MBC patients should consider PMRT to improve their chance of local recurrence-free survival.

Male breast cancer

Male breast cancer (MaleBC) is a rare disease, accounting for <1% of all male tumors. During the last few years, there has been an increase in the incidence of this disease, along with the increase in female breast cancer (FBC). Little is known about the etiology of MaleBC: hormonal, environmental and genetic factors have been reported to be involved in its pathogenesis. Major risk factors include clinical disorders carrying hormonal imbalances, radiation exposure and, in particular, a positive family history (FH) for BC, the latter suggestive of genetic susceptibility. Rare mutations in high-penetrance genes (BRCA1 and BRCA2) confer a high risk of BC development; low-penetrance gene mutations (i.e. CHEK-2) are more common but involve a lower risk increase. About 90% of all male breast tumors have proved to be invasive ductal carcinomas, expressing high levels of hormone receptors with evident therapeutic returns. The most common clinical sign of BC onset in men is a painless palpable retroareolar lump, which should be evaluated by means of mammography, ultrasonography and core biopsy or fine needle aspiration (FNA). To date, there are no published data from prospective randomized trials supporting a specific therapeutic approach in MaleBC. Tumor size together with the number of axillary nodes involved are the main prognostic factors and should guide the treatment choice. Locoregional approaches include surgery and radiotherapy (RT), depending upon the initial clinical presentation. When systemic treatment (adjuvant, neoadjuvant and metastatic) is delivered, the choice between hormonal and or chemotherapy (CT) should depend upon the clinical and biological features, according to the FBC management guidelines. However great caution is required because of high rates of age-related comorbidities.

What makes a man a man? The lived experience of male breast cancer

Male breast cancer is a rare condition with scant research into its psychosocial impact. This phenomenologic study sought to elicit its lived experience. Following analysis of interview data, 4 key themes emerged: Living with male breast cancer, concealment as a strategy for managing the diagnosis, a contested masculinity, interacting with health services. Male breast cancer constitutes a unique lived experience for men that is unparalleled in other disease profiles. The idea of living with a feminized illness was very distressing and stigmatizing for some men. Furthermore, treatment resulted in a profound change to the concept of their embodied selves and constituted a significant change to body image and sexuality. This was reinforced in participants who experienced erectile dysfunction related to tamoxifen therapy. Sadly, some health professionals were unable to offer specific psychosocial support, and participants felt marginalized from the potential benefits of the treatment environment. However, participants adapted to the illness by reasserting and renegotiating masculinity and finding ways to accommodate life with a stigmatizing condition and an altered body image.

Racial disparities in treatment and survival of male breast cancer

PURPOSE

Black women with breast cancer have poorer survival than do white women, but little is known about racial disparities in male breast cancer. We analyzed race and other predictors of treatment and survival among men with stage I-III breast cancer.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results (SEER) Medicare database to identify men 65 years of age or older diagnosed with stage I-III breast cancer from 1991 to 2002. Multivariate regression was used to compare those treated with those not treated with either chemotherapy or radiation therapy, adjusting for known clinical and demographic factors. Cox proportional hazards regression models were used to analyze survival.

RESULTS

Of 510 male breast cancer cases (456 white, 34 black), 94% underwent mastectomy, 28% received adjuvant chemotherapy, and 29% received radiation therapy. Among those with known hormone receptors, 95% had hormone-sensitive tumors. In a multivariate analysis, chemotherapy was associated with younger age, advanced stage, and hormone receptor-negative tumors. Radiation therapy was associated with younger age and advanced stage. Black men were approximately 50% less likely to undergo consultation with an oncologist and subsequently receive chemotherapy; however, the results did not reach statistical significance. The breast cancer-specific mortality hazard ratio was more than tripled for black versus white men (hazard ratio = 3.29; 95% CI, 1.10 to 9.86).

CONCLUSION

After adjustment for known clinical, demographic, and treatment factors, there was an association of black race with increased male breast cancer-specific mortality. Although male breast cancer is rare, the reasons for these disparities need to be better understood.

Strategies in treating male breast cancer

Male breast cancer is rare. Median age at diagnosis is approximately 65 years, and > 35% of male breast cancers occur in elderly men. Retroareolar lump is the most frequent symptom, and 25-30% of tumours are T(4) lesions. Infiltrating ductal carcinoma represents almost 90% of the cases, and 10% are ductal carcinoma in situ. Axillary nodal involvement is present in 50-60% of the cases. Estrogen and progesterone receptors are positive in 75-92% and 54-77% of the cases. Mastectomy with axillary dissection remains the standard treatment. Sentinel lymph node biopsy could be proposed in small tumours (< or = 2 cm). Locoregional radiotherapy is very often indicated. Tamoxifen is the standard adjuvant treatment, but chemotherapy is proposed in young men with axillary nodal involvement and/or negative hormone receptors. Tumour size and, more particularly, histopathological axillary involvement are the strongest predictive factors for both locoregional recurrence and metastasis. Globally, the prognosis is similar to that in women (at identical stage), but the intercurrent death rate is higher due to the important impact of comorbidities and second neoplasm.

A prospective study of adjuvant CMF in males with node positive breast cancer: 20-year follow-up

PURPOSE

To determine the long-term overall survival of male patients with stage II node positive breast cancer treated with adjuvant chemotherapy.

PATIENTS AND METHODS

Between 1974 and 1988, 31 male breast cancer patients were prospectively enrolled on study MB-82 in the National Cancer Institute. Following mastectomy, patients were treated with 12 cycles of cyclophosphamide, methotrexate, and fluorouracil (CMF) chemotherapy.

RESULTS

Median patient age was 61 years (38-74 years). Twenty-one patients (68%) had 1-3 positive axillary lymph nodes while ten patients (32%) had four or more positive nodes. Estrogen receptor status was positive in 22 (71%), negative in 1 (3%), and unknown in 8 (26%) tumors. Progesterone receptor status was positive in 18 (58%), negative in 3 (10%), and unknown in 10 (32%) tumors. Median potential follow-up for all patients is 22.5 years with a median survival of 16.3 years. Twenty-one of 31 patients have died; one from a treatment-related complication, nine patients from recurrent breast cancer, five from other cancers, one from non-cancer related causes, and five from unknown causes. Ten patients remain alive at a median of 19.2 years. The overall survival probability at 10 years is 64.5% (95% CI: 46.9-78.9%), at 15 years is 51.6% (95% CI: 34.8-68%), and at 20 years is 42.4% (95% CI: 25.8-60.8%).

CONCLUSION

To our knowledge, 20-year prospective data with adjuvant chemotherapy in male breast cancer has never been reported. Adjuvant chemotherapy may benefit male breast cancer patients with positive nodes.

Cancer du sein chez l'homme : existe-t-il une similitude avec le cancer du sein chez la femme ?

Male breast cancer is an uncommon disease although its incidence has increased over the recent years. Like other orphan diseases, male breast cancer is understudied. This disease has a lot of similarities with female breast cancer. Some differences are yet noticeable. This article describes three cases of carcinoma of the breast in men with a review of the literature on risk factors and treatment. A database must be started with epidemiologic information to understand this disease and its correlation with breast cancer in women.

Adjuvant systemic therapy for male breast carcinoma

BACKGROUND

In the current study, the authors describe the M. D. Anderson experience with adjuvant systemic therapy in male breast carcinoma patients.

METHODS

A total of 156 men with a diagnosis of breast carcinoma registered and were treated at the M. D. Anderson Cancer Center between 1944 and 2001. One hundred thirty-five men had nonmetastatic breast carcinoma at diagnosis and were included in this analysis. Patients' charts were retrospectively reviewed to obtain details of patient characteristics, adjuvant therapy, and outcomes. Analysis was performed with descriptive statistics; the log rank test was used to compare outcomes.

RESULTS

The median patient age was 59 years (range, 25-80 yrs). Median follow-up was 13.8 years (range, 0.6-32.5 yrs). Sixty percent of patients had tumors 2 cm or smaller. Pathologic lymph node involvement was seen in 55% of patients. Tumors were estrogen receptor-positive in 85% of cases and progesterone receptor-positive in 71%. Chemotherapy was administered to 32 men (84% with adjuvant chemotherapy, 6% with neoadjuvant chemotherapy, and 9% with both). Approximately 81% received anthracycline-based regimens; 9% received additional taxanes; and 16% were treated with cyclophosphamide, methotrexate, and 5-fluorouracil (CMF). The median number of cycles was 6 (range, 4-14 cycles). Thirty-eight men received adjuvant hormonal therapy (92% received tamoxifen and 8% were treated with other therapy). The 5-year and 10-year overall survival rates were 86% and 75%, respectively, for men with lymph node-negative disease and 70% and 43%, respectively, for men with lymph node-positive disease. For men with lymph node-positive disease, adjuvant chemotherapy was associated with a lower risk of death (hazards ratio [HR] of 0.78), although this difference was not statistically significant. Overall survival was significantly better for men who received adjuvant hormonal therapy (HR of 0.45; P = 0.01).

CONCLUSIONS

This relatively large series of men with breast carcinoma suggests that men benefit from adjuvant systemic therapy for breast carcinoma, with the greatest benefit from adjuvant hormonal therapy.

A Review of the Diagnosis and Management of Male Breast Cancer

Male breast cancer is an uncommon disease although the incidence has increased over the past 25 years. As with many other rare "orphan" diseases, male breast cancer is understudied. The rarity of the disease precludes prospective randomized clinical trials. In addition, few researchers and minimal funding have focused on breast cancer in men, but further work is clearly needed to better understand this disease. It shares many similarities with breast cancer in women; yet some clear differences have emerged. In this article, the latest information on the epidemiology, biology, and treatment of male breast cancer is reviewed.

Post-mastectomy radiation in male breast cancer

BACKGROUND AND PURPOSE

Previous studies of male breast cancer have suggested that due to the lack of breast tissue, post-mastectomy radiation should be routinely utilized in all stages of this disease. We propose that the pattern of local recurrence in male breast cancer is, stage for stage, similar to female breast cancer and, therefore, the indications for post-mastectomy radiation should be similar.

MATERIALS AND METHODS

We conducted a retrospective analysis of 44 cases of male breast cancer from 1967 to 1995. Primary therapy was surgical in all cases and 13 patients received postoperative radiation.

RESULTS

Tumor, Nodal, Metastasis (TNM) classification revealed 34 Stages I/II and ten Stage III cases. The 5-year overall survival was 75% and the 5-year local recurrence free survival was 70% for the entire group. In patients with Stages I/II disease, 28/34 underwent surgery alone, of whom, at 5-year follow up, only one suffered an isolated local-regional recurrence (3.5%) and one distant failure (3.5%). Of the ten patients with Stage III disease, three underwent surgery alone and none suffered a local failure. While the crude rate of local recurrence (local recurrence at any time in relation to distant failure) for all patients as a whole was 11%, the isolated local recurrence rate (before distant failure) was seen in only 6%, and only 3% amongst those with Stages I/II disease treated with surgery alone.

CONCLUSION

Although postoperative radiation is often routinely utilized in all stages of male breast cancer to help decrease the risk of local recurrence, this review suggests that this risk is small, especially in early stage disease, and, therefore, the same indications for post-mastectomy radiation that apply to female breast cancer, should be utilized in males.

Evaluation of prognostic factors in male breast cancer

We conducted an analysis on 41 cases of male breast cancer (median age 54 y; range 25-82 y) in Kuwait. Most (51%) were stage II cancers with 65% arising in the left breast. There were 5 (12%) T1 tumours, 23 (56%) T2 tumours and 13 (32%) T3/T4 tumours. They were mostly (95%) infiltrating ductal carcinomas; 97% were grade 2 or 3. Axillary lymph node involvement was found in 69%. Estimated 5-year survival rates were 67% and 58% for overall and relapse free survival respectively. Favourable prognosis was associated with age below 50y, clinical stage I and II, small tumour size (T1, T2), low tumour grade and absence of nodal involvement or distant metastases; nodal status and grade were independent factors for relapse free survival in multivariate analysis. In 18 cases, an immunohistochemical study showed some degree of tumour antigen reaction for ER in 89% of cases, PR in 61%, pS2 in 44%, CathD in 72%, p53 in 56%, c-erbB-2 in 50%, Ki67 and PCNA in 100% and bcl-2 in 78%. There were significant associations between several of these factors but none influenced survival. Despite the high incidence of staining of ER, our data do not support the concept of an endocrine pathway that could be usefully antagonized with antioestrogens for therapeutic benefit, as in women.

Prognostic Variables in Male Breast Cancer

The prognostic role of ploidy status, S phase fraction, estrogen and progesterone receptor status, and the expression of p53 and erbB-2 protein in male breast carcinoma (MBC) remains controversial. The primary objective of this study was to determine which of the common prognostic factors for female breast cancer predict prognosis in MBC. A secondary objective was to assess the impact of comorbid illnesses on survival. A retrospective review of demographic data, surgical treatment, pathological staging, adjuvant treatment and follow-up was completed for 16 patients with MBC (1 intraductal and 15 invasive). Formalin-fixed, paraffin-embedded tissue was processed for ploidy, S phase fraction, and immunohistochemical detection of estrogen and progesterone receptors plus expression of p53 and erbB-2 protein. Six of 15 patients with infiltrating ductal carcinoma are currently alive without evidence of disease and a median survival of 61 months. Nine patients died after a median survival of 52 months, with 6 patients having no evidence of recurrent breast cancer. Two of 3 deaths secondary to advanced breast cancer occurred in patients who initially presented with T4 lesions and were staged IIIB. Two of 15 tumors were erbB-2 positive, whereas only 1 tested weakly positive for p53 protein. We observed that MBCs express erbB-2 and p53 proteins infrequently. Neither ploidy status, S phase fraction, nor erbB-2/ p53 status provided any apparent improvement in establishing prognosis beyond routine pathological staging. Advanced TNM stage was associated with diminished survival. The majority of MBCs express estrogen and progesterone receptors. Survivals in MBC were reduced in association with comorbid medical conditions.

Male breast carcinoma: a review of 229 patients who presented to the Princess Margaret Hospital during 40 years: 1955-1996

BACKGROUND

A single-institution review of clinical presentation, treatment, and outcome of male breast carcinoma was conducted.

METHODS

Data obtained by chart review of 229 cases were analyzed with respect to clinical presentation, treatment choice, significant prognostic factors, and survival. The patients were analyzed both as a single cohort and as four cohorts grouped according to decade of diagnosis.

RESULTS

Presentation occurred at a median age of 63 years, most often with a self-detected lump. Pathology consisted of subtypes similar to those of female breast carcinoma. The majority of tumors were larger than 2 cm in greatest dimension. Lymph node status, hormone receptors, and histologic and nuclear grade were underreported. Primary, adjuvant, and advanced disease treatment practices were reviewed over time. The 5-year disease free survival (DFS), overall survival (OS), and local control were 47%, 53%, and 91%, respectively. No difference in outcome by decade of diagnosis was observed. Negative lymph nodes and adjuvant hormone treatment predicted for better DFS and OS. Younger age and Stage 0 also predicted for better OS.

CONCLUSIONS

Compared with data from female breast carcinoma patients, 5-year OS for this series was low; however, when these patients were separated by lymph node status, survival was similar for those with axillary lymph node metastases. Despite a change in standard primary surgical treatment and an increased use of chemotherapy and hormone therapy over the study period, no difference in outcome was observed among these males. In the absence of prospective, randomized clinical trials, collection of comprehensive data on the presentation and management of male breast carcinoma may help to optimize clinical care.

Carcinoma of the breast in males: a multiinstitutional survey

BACKGROUND

Breast carcinoma in males is infrequent, and information regarding the results of modern treatment is limited. Cases of breast carcinoma in males were accrued from multiple hospitals in one region to determine treatment, survival, and prognostic factors.

METHODS

A retrospective review was performed of 217 cases of breast carcinoma in males accessioned at tumor registries of 18 health care institutions in eastern Wisconsin between 1953 and 1995.

RESULTS

Of the 217 cases, 215 (99.1%) were carcinomas. The majority of carcinomas were of invasive ductal type and presented as masses. Carcinoma in situ accounted for 5.5% of cases. The 5- and 10-year observed survivals for men were 50.6% and 23.7%, respectively. A high rate of post-treatment mortality from comorbid disease was found. Stage, axillary lymph node status, number of lymph nodes with metastases, and tumor hormone receptors were significant indicators of prognosis. Adjuvant systemic chemotherapy and hormone therapy improved the prognosis of patients with axillary lymph node metastases and hormone receptor positive tumors. Earlier stage at presentation and improved 5-year survival were found in cases occurring between 1986-1995 compared with those occurring in earlier years. Use of modified radical mastectomy and systemic adjuvant therapy also increased since 1986.

CONCLUSIONS

The clinical, pathologic, and prognostic features of breast carcinoma in men are similar to those reported for women. The poorer prognosis of men is related to older age at diagnosis, more advanced stage of disease at presentation, and high mortality from comorbid disease. Earlier diagnosis, less radical surgery, and use of systemic adjuvant therapy are coincident with an improved prognosis for men.

Male breast cancer: a review of the literature

Although breast cancer is uncommon in men, it can cause significant morbidity and mortality. The current review was undertaken to determine whether strategies applied for the evaluation and treatment of breast cancer in females are appropriate in male breast cancer. Male breast cancer has biological differences compared with female breast cancer, including a high prevalence in certain parts of Africa, a higher incidence of oestrogen receptor positivity and more aggressive clinical behaviour. It responds to hormonal manipulation and chemotherapy, but optimal treatment regimens in males are unknown. Male breast cancer remains an uncommon disease. Most of our current knowledge regarding its biology, natural history and treatment strategies has been extrapolated from its female counterpart. Much research is needed to further characterise the molecular biological properties of male breast tumours and their prognostic significance, and to devise treatment strategies, including optimal chemotherapy regimens.