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ESSENTIALS OF DIAGNOSIS
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ESSENTIALS OF DIAGNOSIS
A painless lump beneath the areola in a man usually over 50 years of age.
Nipple discharge, retraction, or ulceration may be present.
Generally poorer prognosis than in women.
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GENERAL CONSIDERATIONS
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Breast cancer in men is a rare disease; the incidence is only about 1% of all breast cancer diagnoses. The average age at occurrence is about 70 years, and there may be an increased incidence of breast cancer in men with prostate cancer. As in women, hormonal influences are probably related to the development of male breast cancer. There is a high incidence of both breast cancer and gynecomastia in Bantu men, theoretically owing to failure of estrogen inactivation by associated liver disease. It is important to note that first-degree relatives of men with breast cancer are considered to be at high risk. This risk should be taken into account when discussing options with the patient and family. In addition, BRCA2 mutations are common in men with breast cancer. Men with breast cancer, especially with a history of prostate cancer, should receive genetic counseling.
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A painless lump, occasionally associated with nipple discharge, retraction, erosion, or ulceration, is the primary complaint. Examination usually shows a hard, ill-defined, nontender mass beneath the nipple or areola. Gynecomastia not uncommonly precedes or accompanies breast cancer in men and may itself be a risk factor. Nipple discharge is an uncommon presentation for breast cancer in men but is an ominous finding associated with carcinoma in nearly 75% of cases.
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Breast cancer staging is the same in men as in women. Gynecomastia and metastatic cancer from another site (eg, prostate) must be considered in the differential diagnosis. Benign tumors are rare, and biopsy should be performed on all males with a defined breast mass.
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Treatment consists of modified radical mastectomy in operable patients, who should be chosen by the same criteria as women with the disease. Breast-conserving therapy remains underutilized. Irradiation is the first step in treating localized metastases in the skin, lymph nodes, or skeleton that are causing symptoms. Examination of the cancer for hormone receptors and HER2 overexpression is of value in determining adjuvant therapy. Over 95% of men have ER-positive tumors and less than 10% have overexpression of HER2. Androgen receptor is also commonly overexpressed in male breast cancer, though this does not impact systemic therapy decisions. Adjuvant systemic therapy and radiation are used for the same indications as in breast cancer in women.
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Because breast cancer in men is frequently hormone receptor–positive, diagnosed late, and is a disseminated disease, endocrine therapy is of considerable importance in its management. Tamoxifen is the main medication for management of advanced breast cancer in men. Tamoxifen (20 mg orally daily) should be the initial treatment. There are ...