Breast cancer is not such a common type of cancer among males. The causes are poorly understood, and most studies addressing male breast cancer are minimal with a limited sample size. The majority of information regarding the diagnosis and treatment of male breast cancer has been extrapolated from published literature on female breast cancer.
With some minor variations, breast cancer in men is treated the same way as breast cancer in women; however, the outcomes may not be the same.
Table of Contents
Diagnosis of breast cancer in males
Following are the various ways of diagnosing breast cancer in males:-
1. Triple Assessment Test
1. Clinical examination of the patient
2. After that, radiological tests such as mammography and ultrasonography of bilateral breast and axilla are performed
Quick Note - What is Axilla?
Axilla is a clinical terminology for armpits. It consists of lymph nodes are which are examined as a part of the triple assessment test.
3. Finally, pathological tissue examination is done with the help of:-
- Fine-needle aspiration cytology (FNAC)
- Biopsy of the tumor
A biopsy is preferred over FNAC as it provides a complete pathological assessment of the tumor such as
- Tumor type and its subtype
- The grade of the tumor
- Ancillary pathological features of the tumor,
- Provide the hormone receptor status of the patient.
- Additionally, it acts as a base for further molecular & genetic testing, which may be needed for a patient with a strong family history of breast cancer.
2. Computed Tomography and Positron Emitted Tomography
For diagnosing the staging of breast cancer in men following scans are done:-
CT (Computed tomography)
Computed tomography is done to detect the spread of disease in the thorax, abdomen and pelvis region.
Whole-body PET-CT (Positron emitted tomography)
Whole-body PET-CT (Positron emitted tomography) is done to detect disease spread elsewhere in the body.
3. Magnetic Resonance Imaging (MRI)
MR (Magnetic Resonance) Imaging is a lesser preferred choice for diagnosing male breast cancer. This is because the disease is generally detected while it has already progressed to an advanced stage, and mammography, ultrasound, and CT scan can easily detect male breast cancer in such cases.
Further, MRI is a preferred choice of diagnosis for female breast cancer. It is essential to know the precise size and location of the tumor for breast conservation surgery as compared to male breast cancer cases where, in most patients, even with early-stage disease, mastectomy may be required2GJ;, S. K. (2019). 'Male Breast Magnetic Resonance Imaging: When is it Helpful? Our Experience Over the Last Decade' Source.
4. Routine Blood Tests
Specific routine blood tests are required to assess the medical fitness of the patient before treatment. These include:-
Since men with breast cancer are diagnosed at an advanced age, therefore, assessment of comorbidities is essential for the success of cancer-specific treatment
Different Stages of Male Breast Cancer
Staging any cancer helps determine the extent of disease, the stage-appropriate treatment strategy, and predicting the overall treatment outcome.
The staging of breast cancer is the same for males & females. It follows the standard American Joint Committee on Cancer (AJCC) staging system version 8, which includes
- carcinoma in situ, which is stage 0, and
- 4 stages of invasive breast cancer
The original AJCC system of cancer staging is complex and challenging for patients to understand; however, all patients have the utmost curiosity to determine the disease stage. Below is the most straightforward description of AJCC staging the eighth edition for a better understanding of readers3Amin MB;Greene FL;Edge SB;Compton CC;Gershenwald JE;Brookland RK;Meyer L;Gress DM;Byrd DR;Winchester DP;. (2017). 'The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging'. Source
Stage 0 means carcinoma in situ. The tumor cell is still inside the ducts and has not invaded the breast tissue. It is called as the pre-invasive stage of cancer.
It is an early stage of invasive cancer. The breast tumor is small ≤ 2cm in greatest dimension with none or microscopic spread of the tumor to adjacent axillary lymph nodes.
It is also an early stage of invasive breast cancer; however, the tumor tends to be larger than stage 1 i.e., 2-5 cm in greatest dimension with or without spread to adjacent axillary lymph nodes.
It is an advanced stage invasive breast cancer in which either the tumor is more than 5 cm in maximum dimension and/or has the involvement of the underlying chest wall and overlying skin along with the axillary lymph nodes
It is the metastatic stage where cancer has spread from its local site to a distant part of the body. Breast cancer mainly spreads to the lung, bone, liver, and brain.
Also Read - Breast Cancer in Men (Myths Answered)
Treatment of male breast cancer
Following are the various ways to treat male breast cancer:-
1- Surgery for Male Breast Cancer
There are two types of surgery done in patients with male breast cancer for removal of the tumor
Breast conservation surgery (BCS)
It is also called lumpectomy/quadrantectomy/wide local excision. It is a partial removal of breast tissue containing the lump/tumor and is usually done for early breast cancer patients.
It is a common surgery conducted in female patients with early breast cancer; however, it is rarely an option in male breast cancer cases as most male breast cancers are located behind the nipple. Further, quite frequently, the tumor in male breast cancer patients grows into the nipple-areola complex or the overlying skin or chest wall, requiring more extensive surgery such as a mastectomy. If Breast Conservation Surgery (BCS) is done, it is typically followed by radiation therapy4BL;, G. M. (2016). 'Breast conservation for male breast carcinoma'. Source
It involves the removal of the entire breast and adjacent axillary lymph nodes. The surgical procedure is called as modified radical mastectomy because the breast is removed; however, the nerve, vessels, and chest wall muscles are spared.
Most men with breast cancer will undergo a mastectomy since men have a small amount of breast tissue, making breast conservation surgery less feasible. Also, the chances of local recurrence are less with mastectomy then with breast conservation surgery5Awayshih, M. M., Nofal, M. N., & Yousef, A. J. (2019, September 09). 'Modified Radical Mastectomy for Male Breast Cancer'. Source
Side effects of surgery for Male Breast Cancer
Acute side effects of Male Breast Cancer Surgery
Post-surgery, post-operative pain, seroma or hematoma formation may develop that may last for a few weeks. It includes prolonged bleeding or pus discharge at the operative site
Quick Note - Post Operative pain seroma and hematoma are pus formations, which generally develop post-surgery due to an inflammatory response because of the injured or dying cells.
Long term side effects of Male Breast Cancer Surgery
Long term side effects include:-
- Chronic pain
- Numbness in the arm
- Limited movement of hand and shoulders
- Lymphedema of the arm involved, leading to swelling in hand, neck, and shoulder
These complications are usually seen in patients undergoing more extensive surgery like mastectomy and axillary lymph node dissection, followed by radiotherapy6Cheville AL. Chapter 39: Preserving and Restoring Function after Local Treatment. In Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 5th ed. Philadelphia: Wolters Kluwer Health; 2014
2- Radiation therapy for Male Breast Cancer
Since male breast cancer usually is detected while it’s in advanced stages, most of the men do need adjuvant radiation therapy; however, patients with very early-stage tumor, i.e., stage 0, 1 and 2 who have opted for mastectomy can be exempted from radiation therapy7Remick, J. (2020, August 10). 'Postmastectomy Breast Cancer Radiation Therapy' Source
Why is radiation therapy needed when my tumor is completely removed by surgery?
The purpose of radiation therapy is to reduce the chances of the reappearance of a tumor at its local site, which is medically termed as ‘Tumor Relapse or Recurrence’8Remick, J. (2020, August 10). 'Postmastectomy Breast Cancer Radiation Therapy' Source
3- Systemic Therapy For Male Breast Cancer
Systemic Therapy includes chemotherapy, hormonal therapy, and targeted therapy
Purpose of systemic therapy
Long back, various theories were proposed to understand the biology of breast cancer. One among them was Bernard fisher theory, which states that Breast cancer is a systemic disease. The microscopic tumor cell is already present in circulation when the disease is detected in breast tissue9Fisher, B. (2006, June 27). 'Biological and clinical considerations regarding the use of surgery and chemotherapy in the treatment of primary breast cancer' Source,10Redig, A. J., & McAllister, S. S. (2013, July 12). 'Breast cancer as a systemic disease: A view of metastasis' Source.
Therefore despite aggressive local treatment in the form of surgery and radiation therapy, many breast cancer patients develop disease elsewhere in the body and die due to metastatic disease. In other words, despite reasonable local control, the chances of overall survival is reduced because of the systemic spread of cancer. Hence the systemic treatment is essential for distant organ control.
Systemic treatment is based on the principle of reduction or elimination of the microscopic tumor burden in men with breast cancer (where all the grossly visible tumor is already, effectively eliminated with the help of surgery & radiotherapy)
Chemotherapy as a Part Of Systemic Therapy for Male Breast Cancer Treatment
Chemotherapy treatment includes cytotoxic drugs given orally or via intravenous injections weekly or at intervals of 3 weeks. The drugs travel through the bloodstream to reach cancer cells’ in the entire body to provide systemic control11Kreidieh, F. Y., Moukadem, H. A., & El Saghir, N. S. (2016, February 10). 'Overview, prevention and management of chemotherapy extravasation' Source
Hormonal Therapy as a Part Of Systemic Therapy for Male Breast Cancer Treatment
Breast cancer is a hormone-sensitive tumor, and therefore various drugs are given to block the action of hormones to inhibit tumor growth, which is called hormonal therapy.
Around 90 percent of male breast cancer express as hormone receptor-positive disease; hence hormonal therapy is an effective treatment12Rudlowski, C. (2008, June 24). 'Male Breast Cancer' Source. The medication is usually given in the form of oral tablets or iv injections.
Hormonal therapy usually has fewer side-effects than chemotherapy and is very well tolerated by patients with all stages of breast cancer.
Targeted therapy as a Part Of Systemic Therapy for Male Breast Cancer Treatment
Cancer cells express specific genes and proteins that signal the tumor’s growth and survival. Targeted therapy act on these genes and proteins, inhibit their activity and thereby prevent cancer’s growth.
Targeted therapy works on the tumor microenvironment and makes it unfavorable for tumor growth by targeting genes and proteins expressed on either cancer cells or blood vessels, supplying nutrients to cancer cells.
Tumor microenvironment is an environment present around that includes cells, tissues, blood vessels, immunity cells etc.
As per a study conducted, it was found that, around 20-25% of the total breast cancer cases are due to HER2 protein (Human Epidermal Growth Factor Receptor 2)13Ottini, L., Capalbo, C., Rizzolo, P., Silvestri, V., Bronte, G., Rizzo, S., & Russo, A. (2010, October 04) 'HER2-positive male breast cancer: An update: BCTT.' Source
Criteria for Choosing Targeted Therapy for Treating Male Breast Cancer
The human epidermal growth factor receptor 2 (HER2) protein enables breast cancer tumor cells to develop. If the cancer is “HER2 positive”, then such patients are candidates for targeted therapy. The most common anti-HER2 targeted agent used in male breast cancer treatment is Trastuzumab, also called Herceptin. It attaches itself to the HER-2 receptors expressed on breast cancer cells’ surface and blocks its action and thereby inhibits tumor’s growth.
Breast cancer in men is considered a rare disease. Although the risk factors, clinical presentation, staging & management for male breast cancer are the same as that of female breast cancer, the overall prognosis is worse because of lack of awareness among society and healthcare workers. This is the main cause of a time lapse between the onset of symptoms and male breast cancer diagnosis. By the time a male breast cancer approaches an oncologist, the disease is usually in advanced stages, thus reducing their chances of cure.
Nevertheless, the scenario is changing. In the last 25 years, the incidences of male breast cancer are increasing, and so is the awareness among healthcare workers.
With the advancement in surgery, radiation therapy & the development of novel chemotherapy and molecular targeted agents, the outcome of treatment is further improved.
Hence, the outcome is that male breast cancer’s overall survival is the same as stage-matched female breast cancer patient14Contractor KB;Kaur K;Rodrigues GS;Kulkarni DM;Singhal H;. (2008). 'Male breast cancer: Is the scenario changing' Source.
- 1Rudlowski, C. (2008).
Male Breast Cancer.
Retrieved October 24, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2931115/
- 2GJ;, S. K. (2019).
Male Breast Magnetic Resonance Imaging: When is it Helpful? Our Experience Over the Last Decade.
Retrieved October 24, 2020, from https://pubmed.ncbi.nlm.nih.gov/29454681/
- 3Amin MB;Greene FL;Edge SB;Compton CC;Gershenwald JE;Brookland RK;Meyer L;Gress DM;Byrd DR;Winchester DP;. (2017).
The Eighth Edition AJCC Cancer Staging Manual: Continuing to build a bridge from a population-based to a more "personalized" approach to cancer staging.
Retrieved October 25, 2020, from https://pubmed.ncbi.nlm.nih.gov/28094848/
- 4BL;, G. M. (2016).
Breast conservation for male breast carcinoma.
Retrieved October 25, 2020, from https://pubmed.ncbi.nlm.nih.gov/17606375/
- 5Awayshih, M. M., Nofal, M. N., & Yousef, A. J. (2019, September 09).
Modified Radical Mastectomy for Male Breast Cancer.
Retrieved October 25, 2020, from https://doi.org/10.12659/AJCR.916947
- 6Remick, J. (2020, August 10).
Postmastectomy Breast Cancer Radiation Therapy.
Retrieved October 25, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK519034/
- 7Fisher, B. (2006, June 27).
Biological and clinical considerations regarding the use of surgery and chemotherapy in the treatment of primary breast cancer.
Retrieved October 25, 2020, from https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/1097-0142(197707)40:1 3.0.CO;2-O
- 8Redig, A. J., & McAllister, S. S. (2013, July 12).
Breast cancer as a systemic disease: A view of metastasis.
Retrieved October 25, 2020, from https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12084
- 9Kreidieh, F. Y., Moukadem, H. A., & El Saghir, N. S. (2016, February 10).
Overview, prevention and management of chemotherapy extravasation.
Retrieved October 25, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734939/
- 10Rudlowski, C. (2008, June 24).
Male Breast Cancer.
Retrieved October 25, 2020, from https://www.karger.com/Article/Abstract/136825
- 11Ottini, L., Capalbo, C., Rizzolo, P., Silvestri, V., Bronte, G., Rizzo, S., & Russo, A. (2010, October 04).
HER2-positive male breast cancer: An update: BCTT.
Retrieved October 25, 2020, from https://www.dovepress.com/her2-positive-male-breast-cancer-an-update-peer-reviewed-article-BCTT
- 12Contractor KB;Kaur K;Rodrigues GS;Kulkarni DM;Singhal H;. (2008).
Male breast cancer: Is the scenario changing.
Retrieved October 25, 2020, from https://pubmed.ncbi.nlm.nih.gov/18558006/