Breast Cancer in Men: Summary of Knowledge

Breast Cancer In Men

Lauren John

San Francisco Medical Society Online

About 1,300 men were diagnosed with breast cancer last year, according to the American Cancer Society.

Researchers once believed that the disease was more aggressive in men than in women, but, as it turns out, men are generally diagnosed later than women, at which point their cases may be more advanced. A study of 217 men with breast cancer who were treated at 18 different U.S. hospitals showed that the men waited an average of ten months after symptoms appeared before consulting a doctor.(1)

(According to another study, at least two thirds of all women who discover breast cancer symptoms themselves seek a physician evaluation within three months) (2) "If a man notices a lump or swelling in his breast, there's no excuse not to evaluate it," says oncologist Hope S. Rugo, M.D., associate clinical professor of medicine at UCSF's Carol Frank Buck Breast Care Center.

Today, a man presenting to his primary care physician with a suspicious lump in his breast could be referred for testing with a fine needle aspiration or a core biopsy.

Symptoms in Men

Although men of all ages can develop breast cancer, statistically, most men are diagnosed between the ages or 60 and 70. Male breast cancer often first appears as a small, hard, painless lump in the nipple area; researchers believe it tends to occur there because most men have small, undeveloped vestiges of milk ducts beneath the areola and nipple. (Women have these ducts throughout their breasts.) Some men notice changes in the appearance of the nipple or the skin around the nipple; the nipple may be retracted, for example. Discharge or bleeding from the nipple is another warning sign. Rugo describes one patient, a man who noticed a swelling in his breast, but was told by his doctor that he had gynecomastia-a relatively more common benign swelling of breast tissue.

In fact, the patient did have breast cancer, but years went by before he was tested for it. But by the time the diagnosis was made at UCSF, the cancer had spread and he was diagnosed with metastatic disease.

One Man's Story

Boris Subbotin, a retired electrical engineer living in California's San Fernando Valley, was diagnosed far earlier. In 1991 he noticed a small lump near his left nipple. He says that he didn't suspect that it might be breast cancer-- even though his mother had died of the disease in 1947 at age 53. Still, Subbotin, now 71, decided that the lump probably didn't belong there. His physician suggested a biopsy, which revealed cancerous cells.

Following a total mastectomy on the left side, including lymph node removal, Subbotin learned that he had Stage 1 breast cancer with no muscle wall involvement. His tumor turned out to be eight-tenths of a centimeter in diameter; his cancer was caught at an early stage.

"At the time, my surgeon, Frank Candela, had done two prior breast cancer surgeries on men at Sloan-Kettering," says Subbotin. "Not a lot was known about the management of breast cancer in men, and then, as now, it was not likely for men to join support groups for this."

Most breast cancers found in men (including Subbotin's) are estrogen-receptor (ER) positive, meaning the tumors are sensitive to hormones and associated with a better prognosis than ER-negative tumors.

Researchers are still trying to figure out why that might be and to determine optimal drug therapies for men with breast cancer. Today, most recommendations are based on what women's clinical trials have shown. (Because most men undergo mastectomies, few if any undergo radiation treatment.)

After his mastectomy in 1991, Subbotin went on a tamoxifen regimen for four and a half years. Subbotin's cancer was caught at an early stage, but hormonal drug therapies such as tamoxifen have also been found to lengthen the survival times of men with hormone-receptive tumors who have metastatic disease.

Family History an Issue

According to the National Cancer Institute, a family history of male or female breast cancer is one risk factor for the disease in men. In fact, an increased risk of male breast cancer has been reported in families in whicmutations of the BRCA-2 gene on chromosome 13q has been identified (3). In one study of men with breast cancer in Iceland, a BRCA-2 mutation appeared in 40 percent of reported cases. (4)

Another study of 142 male breast cancer patients treated between 1973 and 1994 at either the Memorial Sloan-Kettering Cancer in New York or the Ochsner Clinic in New Orleans showed that 15 percent of the men had a first-degree relative with the disease. More significantly, the study suggested that the presence of a family history did not affect the age at diagnosis, the duration of symptoms, the stage of disease at diagnosis, nor the overall survival.

Instead, the most powerful predictor for outcome for all of the men was the status of the axillary lymph nodes (5). The study, published in the journal Cancer last year, concluded that "BRCA-2 testing in males with breast carcinoma is not warranted, as it would not change therapeutic approaches, and treatment should not be changed based on family history." Dr. Rugo notes that axillary lymph node status is the most powerful predictor in how well women do, as well.

Still, she believes that when there is a strong family history of breast cancer, men with breast cancer might wish to consult a genetic counselor and/or undergo genetic testing.

This suggestion makes sense in light of a Danish study of 551 male breast cancer patients that found that daughters of men with breast cancer might be at higher risk of developing the disease. Researchers began tracking their subjects in 1968; over the next 30 years the men had a total of 119 daughters. Three cases of breast cancer were identified in these women, at ages 26, 34, and 36 (which may not seem like a particularly dramatic finding but is considered statistically significant). None of the women had mothers with breast cancer. (6)

Environmental Exposure

Studies have shown that men who take estrogen-based medications (to treat prostate cancer, for example) might also be at greater risk of subsequently developing breast cancer. A 1988 study in the Journal of the American Medical Association, meanwhile, reported on a case of breast cancer in a male-to-female transsexual who had taken estrogen to promote female sexual characteristics. (7)

Men who have a rare chromosomal disorder called Klinefelter's syndrome (characterized by two X chromosomes and one Y chromosome) may also be at greater risk for the disease. And because liver disease has been associated with relatively high estrogen levels, men with cirrhosis of the liver may be at greater risk as well.

This may explain why breast cancer rates are higher in parts of Africa and Egypt, where liver disease is more common, than they are in the United States or in European countries.

Another risk factor for breast cancer is exposure to radiation. Several studies have examined, with conflicting results, whether occupational exposure to electromagnetic fields is linked to male breast cancer. One study looked at the occupations of 227 men who were diagnosed with breast cancer between 1983 and 1987. The results, published in the American Journal of Epidemiology in 1991, showed elevated risk among men who held any job with exposure to electromagnetic fields, with higher risks found in electricians, telephone linemen, electric power workers, and radio and communications workers.

The risk was highest among subjects who were first employed in jobs with exposure before age 30 and who were initially exposed 30 years prior to diagnosis. Researchers at the University of Washington in Seattle, who led the study, concluded, "the hypothesis warrants evaluation in women." (8)

A later study, meanwhile, published in 1994 by the Department of Social and Preventive Medicine at the State University of New York at Buffalo, showed that there was no increase in disease risk for males believed to have occupational exposure to electromagnetic fields. The study compared 71 men diagnosed with breast cancer between 1979 and 1988 with 256 healthy male controls.

Interestingly, the Buffalo study showed that men with occupations involving heat exposure were more likely to get the disease. Researchers theorize that exposure to heat on the job could influence testicular function, which in turn would influence hormone levels affecting breast tissue. (9)

Further Information and Support

There are a number of support and information resources available for men with breast cancer. One good medical resource is the Male Breast Cancer Information Center (http://interact.withus.com/interact/mbc/), a website designed by the late Bob Stafford, an Indiana man who was diagnosed with breast cancer at age 37 and lived with the disease for more than ten years before he died in 1998.

The National Alliance of Breast Cancer Organizations, meanwhile, runs an information service; you can send questions via e-mail to NABCOinfo@aol.com. You can also call (888) 80-NABCO Mon-Fri (9:30 to 5:30 EST) address: 9 East 37th Street 10th floor NY NY 10016. Several cancer organizations-including Y-Me (http://www.y-me.org), the Community Breast Health Center in Palo Alto, California (650/326-6686), and the American Cancer Society-try to help men with breast cancer connect with each other across the United States.

Some male breast cancer patients seeking emotional support also say prostate cancer support groups have welcomed them.

References:

Winchester, David J. "Male Breast Carcinoma: A Multi-Institutional Challenge," Cancer, August 1, 1998, vol. 83, no. 3. pp 399-400

Facione, N.C. et al., "Helpseeking for Self-Discovered Breast Symptoms," Cancer Practice, July/August 1997, vol. 5, no. 4, pp. 220-27.

Thorlacius S. et al., "Linkage to BRCA-2 Region in Hereditary Male Breast Cancer," Lancet, 1995, vol. 346, no. 8974 pp. 544-545.

Thoriacius, S. et al., "Study of a Single BRCA-2 Mutation With High Carrier Frequency in a Small Population," American Journal of Human Genetics, 1997, vol. 60 pp. 1079-84.

Hill, Arnold et.al. "Localized Male Breast Carcinoma and Family History: An Analysis of 142 patients," Cancer, September 1, 1999, vol. 86, no. 5 pp 821-825

Storm, Han H. and Olsen, Jorn, Risk of Breast Cancer in Offspring of Male Breast Cancer Patients. Lancet, January 16, 1999, vol. 353(9148):209

Pritchard, T. et al., "Breast cancer in a Male-to-Female Transsexual," Journal of the American Medical Association, 1988, vol. 259 p. 2278

Demers, P.A. et.al. "Occupational Exposure to Electromagnetic Fields and Breast Cancer in Men." American Journal of Epidemiology, August 15, 1991, vol. 134, no. 4, pp. 340-347

Rosenbaum, P.F., "Occupational Exposures Associated With Male Breast Cancer," American Journal of Epidemiology, January 1, 1994, vol. 139, no.1, pp. 30-36.

Lauren John is a free lance medical and science writer in the Bay Area.


Bob Stafford's Site

LINK (more LINKS on About the Links page)

72 kDa Glycoprotein:Male Bca Tumor Assoc Antigen

Int J Cancer, 6/03

Breast Cancer in Men 2003

BMJ Editorial, 8/03

References for Breast Cancer in Men 2003
Response Letter to Editorial, 8/03 Men and Breast Cancer
Experiences of Men w/Breast Ca

Brit J Cancer, 10/03 Focus Group

Incidence of Male Breast Cancer RISING

Cancer, 7/04

Men w/BCA Better Disease-Specific Survial than Women

Arch Sugr, 10/04

Men w/BCa May Receive TOO Much Radiation

Annals of Oncology, 6/05


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