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Equal opportunity cancer

Author: Laurie Wertich

The two foul balls that hit Tony Blackmon in the chest when he was umpiring a youth baseball game in April 2007 just might have been a blessing. “I get hit by foul balls all the time,” says the former Cornell University defensive back from Peoria, Arizona. “But it’s kind of unusual to get hit twice in the same place. A few days later, it was still sore.”

It turns out those foul ball s drew attention to something more serious than a bruise; when Tony palpated his right breast near where he was sore, discharge was released from his nipple, and he grew concerned. After a visit to his dermatologist and then a surgeon, he underwent a biopsy and received the diagnosis: breast cancer. Like most men, breast cancer was nowhere on his radar, so Tony was shocked to learn that men too can get the disease. Less than a week later, he underwent a mastectomy to have his breast removed. Determined that other men be made aware that breast cancer can affect them, Tony, a college academic recruiter, committed himself to sharing his story and educating other men. Now, almost five years since his diagnosis, he continues to work to spread awareness about the disease.

Yes, men get breast cancer too

Although much of what we hear about breast cancer in the media is bathed in the glow of the now-ubiquitous pink ribbon, breast cancer is an equal opportunity cancer. Approximately 2,000 men are diagnosed with breast cancer in the United States each year compared with nearly 200,000 women. Although the disease is rare in men, rates have been on the rise since about 1983, according to data from the Surveillance, Epidemiology, and End Results (SEER) database.1

Breast cancer in men mirrors female breast cancer in most ways, except incidence rates and stage at diagnosis. Men are often diagnosed with later-stage disease for two reasons: lack of screening and lack of awareness about the disease and its symptoms.

Diagnosing male breast cancer

Because male breast cancer incidence rates are so low, there are no screening recommendations for the disease. While many female breast cancers are detected through mammography screening and breast exams, most male breast cancers are detected when there is a palpable mass in the chest wall. In fact, men with breast cancer typically end up in the doctor’s office because they have noticed a lump beneath the nipple or they have experienced nipple discharge.

“Men present with higher-stage cancer than women do, probably because we don’t have screen-detected cancer in men,” explains Kathryn Ruddy, MD, MPH, a medical oncologist at Dana-Farber Cancer Institute. “Their cancer is diagnosed because it’s palpable.”

Once men present with those symptoms, the diagnostic process generally moves forward in the same way it does for women, including mammography, ultrasound, and needle biopsy.

Who gets male breast cancer?

Many men who are diagnosed with breast cancer have a family history of the disease. “One of the first things I ask any patient is whether there is a family history of breast cancer,” explains John V. Kiluk, MD, FACS, a breast surgical oncologist at H. Lee Moffitt Cancer Center in Tampa, Florida. The question can elicit emotional responses, Dr. Kiluk says. “It’s not uncommon for the patient to start crying because his mom died of breast cancer.”

Sometimes this family history can be the result of a genetic mutation called BRCA2, which accounts for 10 percent of all male breast cancers in the United States. (Interestingly, the statistics are different elsewhere; for example, BRCA2 accounts for 40 percent of all male breast cancers in Finland.) In addition, Klinefelter syndrome, a genetic condition in which men have an extra X chromosome, is associated with a higher risk of male breast cancer.

A cluster of male breast cancer cases at Camp Lejeune Marine Base in North Carolina has fueled speculation that the disease could be linked with environmental causes. Thus far 70 men from Camp Lejeune have been diagnosed with breast cancer. Evidence is inconclusive but continues to be evaluated.

Treating male breast cancer

Surgical options for breast cancer include mastectomy (removal of the breast) and lumpectomy (removal of the mass) plus radiation. “With male breast cancer, the cancer is generally just underneath the nipple, and there is not a whole lot of breast tissue there anyway,” explains Dr. Kiluk. “Almost invariably, we do a mastectomy on these guys.”

Men who have later-stage disease with lymph node involvement may undergo radiation in addition to surgery. Most men will undergo follow-up treatment with the hormonal therapy tamoxifen, which is a selective estrogen receptor modulator that blocks estrogen receptors within breast cells and reduces estrogen-stimulated growth.

“At least 90 percent of male breast cancers are estrogen fed,” explains Dr. Kiluk. “Everyone makes estrogen—men and women— just in different proportions.” Tamoxifen has been shown to be an effective treatment for estrogen-fed breast cancers.

Emotional impact of male breast cancer

Treating male breast cancer is only the tip of the iceberg. The disease can really throw men for an emotional loop. “They’re grappling with something generally viewed as a female cancer,” explains Dr. Kiluk. “And they’re often grappling with the fact that their mom had the disease, too.”

The diagnosis can come as a shock because most men aren’t aware they can get the disease. “Men who are diagnosed feel really isolated,” explains Dr. Ruddy. “It’s harder for men to find connection and support because they’re in the minority.”

Dr. Ruddy explains that everything about breast cancer is geared toward women, which can serve to further isolate men with the disease. “They’re filling out forms and they’re being asked if they are pre- or postmenopausal,” she says.

To add injury to insult, the disease can be disfiguring. While women often wear prosthetics or undergo reconstructive surgery, most men are left with a missing nipple and a visible scar. Dr. Kiluk recalls one patient whose wife insisted he wear his shirt at the pool.

Tony, on the other hand, proudly removes his shirt, whether he’s at the beach or attempting to raise awareness about the disease by showing people his scar. Survivors like him serve as torchbearers for men with the disease. “I don’t have a negative stigma about being a male with breast cancer because I know I survived,” he says.

Preventing male breast cancer

Because incidence rates are so low, it doesn’t make sense to screen men for breast cancer. Instead, awareness and education are the key. “One thing I’ve noticed is that guys have a tendency to blow it off when they present with a palpable mass,” says Dr. Kiluk. “If a female has a pea in her breast, she is jumping up and down to have it evaluated, but most people aren’t aware that men can develop breast cancer.”

Dr. Kiluk counsels his female patients who are genetic carriers to talk to their sons about the disease and educate them about the signs and the symptoms. As a survivor, Tony works tirelessly to increase awareness of the disease. “I talk to people about it,” he says. “Men die of breast cancer simply because they see it and think it can’t be breast cancer and decide they’ll take care of it later. Before you know it, it has spread.”

Men are often diagnosed with laterstage disease because they aren’t aware that they can develop breast cancer and therefore ignore warning signs. Laterstage disease is harder to treat and has a higher recurrence rate than early-stage breast cancer.

“You know your body,” Tony insists. “If you feel like something is wrong, something is probably wrong.” He encourages men to get immediate medical attention. “It may be nothing, but go to your doctor right away, not next month, not next summer. Go right away,” he says.

The future of treating male breast cancer

One challenge in the treatment of male breast cancer is that there are few studies and little data from which to work. “Everything we do, we extrapolate from women,” explains Dr. Ruddy. “We’re operating in a data-free zone.”

That means doctors have to use their best judgment when it comes to treatment protocols and follow-up care. For example, Dr. Ruddy generally recommends screening mammography on the other breast for men who have survived breast cancer; however, this is not based on any data indicating that it is necessary— it’s her personal judgment as a physician.

Dr. Ruddy is currently analyzing the results of an online study of male breast cancer patients. Next she hopes to open a multi-institutional study at three large cancer centers. She would like to enroll 150 patients with male breast cancer to be able to better study and understand the disease. More data will help physicians be better able to tailor treatment for men in the future.

Reference

  1. Ries LAG, Eisner MP, Kosary CL, et al. (eds). SEER Cancer Statistics Review, 1975-2001. National Cancer Institute website. Available at: http://seer.cancer.gov/ csr/1975 2001. Accessed August 12, 2011.
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