By Lauren John
Many of us are aware that men can and do get breast cancer, but few of us know any more than that. That’s not surprising, given that even doctors and cancer researchers admit that they have a lot to learn.
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, so their cases are often merely more advanced at diagnosis. 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 a third of all women who discover breast cancer symptoms themselves are aware of their symptoms for three months or longer before seeking a physician’s evaluation. The rest address their symptoms sooner.2)
Male breast cancer often first appears as a small, hard, painless lump in the nipple area; researchers believe it tends to occur there in men 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 skin around the nipple or the nipple itself: The nipple may be retracted, for example. Discharge or bleeding from the nipple is another warning sign.
Although breast cancer is rare in men, any of these symptoms warrants a visit to a physician. Statistically, most men are diagnosed between the ages of 60 and 70, although men of all ages can develop the disease.
Boris Subbotin, a retired electrical engineer living in California’s San Fernando Valley, noticed a small lump near his left nipple back in 1991. 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 72, 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 I 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.”
Years ago men had to put on a pink gown when they sought care at Memorial Sloan-Kettering Cancer Center. “The entire system is geared for women,” Sloan-Kettering breast surgeon Patrick Borgen told CBS Healthwatch last year. (For what it’s worth, Healthwatch reported that the clinic has since switched to a peach color.)3
Borgen and his team treat about 20 men each year, making Sloan-Kettering one of the leading male breast cancer treatment centers in the United States. Most breast cancers found in men (including Subbotin’s) are estrogen-receptor 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 have historically undergone radiation treatment.)
After his mastectomy in 1991, Subbotin went on a tamoxifen regimen for four and a half years. He made this decision, with his doctor’s help, based on what scientists believed at the time to be improved outcomes for postmenopausal women with Stage I breast cancer.
Subbotin stopped taking tamoxifen before the five-year mark because, he says, “I had heard some talk linking tamoxifen to liver damage, and because no one really knows for sure if five years is too long to be taking the drug safely.” He reasoned that he might have received the maximum benefits from the drug by that point.
Subbotin’s cancer was caught at an early stage. But when men with hormone-receptive tumors have metastatic disease, surgeons can improve the likelihood of survival by performing what the medical community refers to as orchiectomy or hormonal ablation—a process that most laypeople know as castration. The procedure is performed (either surgically or chemically) because the testes produce small amounts of estrogen.
Doctors began treating metastatic breast cancer in men with orchiectomy in 1942.4 (Women were given oophorectomies then, for the same reason.) But more than 50 years later, men’s treatment hasn’t changed. The 1996 edition of the widely consulted textbook Diseases of the Breast presents this surgery as the standard of care for metastatic disease in men.
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 which mutations of the BRCA-2 gene on chromosome 13q has been identified.5 In one study of men with breast cancer in Iceland, a BRCA-2 mutation appeared in 40 percent of reported cases.6
Another study of 142 male breast cancer patients treated between 1973 and 1994 at either the Memorial Sloan-Kettering Cancer Center 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. However, 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.7 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.”
A Danish study of 551 male breast cancer patients, meanwhile, 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. None of the women had mothers with breast cancer.8
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.9
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.
Other risk factors for breast cancer include testicular disorders, exposure to radiation, and benign breast diseases in which the male breast is enlarged.
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 that “the hypothesis warrants evaluation in women.”10
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.11
There are a number of support and information resources available for men with breast cancer. One good medical resource on the Internet is the Male Breast Cancer Information Center, a Web site 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 call 888/80-NABCO toll-free (Monday through Friday, 9:30 a.m. to 5:30 p.m. EST), e-mail NABCOinfo@aol.com, or write to NABCO at 9 East 37th St., 10th floor, New York, NY 10016.
Several cancer organizations—including Y-Me (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 they have been welcomed by prostate cancer support groups.
1 Winchester, David J. “Male Breast Carcinoma: A Multi-Institutional Challenge,” Cancer, August 1, 1998, vol. 83, no. 3, pp. 399-400.
2 Facione, N.C. et al., “Helpseeking for Self-Discovered Breast Symptoms,” Cancer Practice, July/August 1997, vol. 5, no. 4, pp. 220-27.
3 Wilke, Michael, “When Men Get a ‘Woman’s Disease’: Breast Cancer,” http://healthwatch. medscape.com, January 1999.
4 Harris, Jay R., ed., Diseases of the Breast, Philadelphia: Lippincott-Raven, 1996.
5 Thorlacius, S. et al., “Linkage to BRCA-2 Region in Hereditary Male Breast Cancer,” Lancet, 1995, vol. 346, no 8974, pp. 544-45.
6 Thorlacius, 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.
7 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. 821-25.
8 Storm, Han H. and Olsen, Jorn, “Risk of Breast Cancer in Offspring of Male Breast Cancer Patients,” Lancet, January 16, 1999, vol. 353, no. 9148, p. 209.
9 Pritchard, T. et al., “Breast Cancer in a Male-to-Female Transsexual,” Journal of the American Medical Association, 1988, vol. 259, p. 2278.
10 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. 340-47.
11 Rosenbaum, P.F., “Occupational Exposures Associated With Male Breast Cancer,” American Journal of Epidemiology, January 1, 1994, vol. 139, no.1, pp. 30-36.