9. Breast cancer in men – Breast Cancer
The diagnosis and treatment of breast cancer in men should be interdisciplinary and requires gynaecological and oncological expertise due to the tumor biological characteristics and similarity to breast cancer in women. Interdisciplinary cooperation between breast centers, practicing gynecologists, urologists and andrologists is particularly recommended for the treatment of sexual dysfunction by tamoxifen therapy, for men with BRCA mutations [1598] with an associated increased risk of prostate cancer, and for men with breast cancer for whom treatment of benign prostate syndrome should be performed [1599].
Early medical consultation should be encouraged by informing men about the disease, especially about symptoms and changes in the breast, and by encouraging self-observation.
- Consensus
- Strong consensus
The basic diagnostics should be carried out in case of suspected malignant findings by anamnesis, clinical examination, mammography and ultrasound diagnostics of the breast and the lymph drainage regions. No data are available on the diagnostic use of KM-MRI.
- Consensus
- Consent
Further diagnostics and staging/spreading diagnostics should be carried out for breast and axilla findings according to the recommendation for women, although no data are available on the diagnostic use of KM-MRI.
- Consensus
- Consent
The surgery aims at the complete removal of the tumour and should be performed as a mastectomy. If the size ratio between tumour and breast is favourable, breast preservation should be considered.
- Consensus
- Strong consensus
In the case of clinically unremarkable axilla (cN0), sentinel lymph node removal should be performed according to the same rules as in women.
- Consensus
- Consent
In the case of larger tumours (≥ 2cm), in the case of axillary lymph node involvement and in the case of a negative hormone receptor, adjuvant radiotherapy of the chest wall and, if necessary, of the lymph drainage channels (indication as for women) should be carried out independently of the surgical procedure.
- Consensus
- Strong consensus
Adjuvant chemotherapy as well as antibody therapy (anti-HER2) should be indicated and carried out according to the same rules as in women.
- Consensus
- Consent
Patients with hormone receptor-positive breast cancer should receive adjuvant endocrine therapy with tamoxifen, usually for 5 years. No data are available for treatment beyond 5 years. As with female breast carcinoma, this may be considered in individual cases.
- Consensus
- Strong consensus
a.) Therapy for metastatic disease should follow the same rules as for women.
b.) It is unclear whether aromatase inhibitors are sufficiently effective without suppression of testicular function in men. Therefore aromatase inhibitors should be given in combination with suppression of testicular function.
- Consensus
- Strong consensus
Participation in studies/registers should be offered and made possible for men with breast cancer.
- Consensus
- Consent
Genetic counseling should be recommended to all men with breast cancer.
- Consensus
- Consent
The design of aftercare, including imaging diagnostics, should be analogous to the approach taken by women.
- Consensus
- Strong consensus
Qualified and relevant gender-specific information (print and Internet) should be made available to the patient by the treating professionals and access to the special offers of the self-help groups should be made possible.
- Consensus
- Strong consensus
Background 9.1 to 9.13
Male breast cancer has an incidence of approximately 0.5 - 1.0% of all diagnosed breast cancer cases. In Germany every year about 600 new cases of breast cancer are diagnosed in men [43]. Factors that increase the risk of breast cancer in men are shown in table 20 [1600]. The median age at first diagnosis is 67 years [43]. No special screening procedures or early detection measures are recommended for men. Most breast cancer cases are detected by men themselves. The initial diagnosis is made 40% in advanced stages UICC III and IV [43], [1601]. The reasons for this are a lack of knowledge about the disease on the part of the patients, with a resulting delay in the medical presentation. In addition, there are also knowledge deficits on the medical side regarding the possibilities of imaging diagnostics and clarification as well as the coordination of care through the care in certified breast centers [1602], [1603], [1604].
Table 16: Risikofaktoren für Männer, an einem Mammakarzinom zu erkranken
|
Age |
unimodal age distribution with the highest incidence in 71 years of age |
|
Origin |
Increased risk in African and Caribbean men, usually also in advanced stages at initial diagnosis |
|
Germ line mutations |
2.5 times the risk of disease in the case of a positive family history of both sexes; BRCA2 mutations can be detected in 4 % - 40 % of all cases; RAD51B gene alteratons increase the risk by 50 |
|
Endocrine causes
|
exogenous oestrogen exposure e.g. through hormone therapy for transsexuals, treatment of prostate cancer, occupational exposure |
|
increased endogenous estrogen synthesis: Klinefelter syndrome, obesity |
|
|
decreased androgen levels: orchidectomy, undescended testicles, mumps-associated orchitis, liver cirrhosis |
|
|
Environment
|
Lifestyle: obesity, lack of exercise, excessive alcohol consumption |
|
radiation exposure: nuclear weapons, radiotherapy, diagnostic radiology |
|
|
occupational exposure: high temperatures, petroleum, exhaust fumes |
There is very little evidence from randomized studies on specific diagnostics, biological parameters and therapy of male breast cancer. Currently, the data are mainly based on epidemiological data, retrospective case reports, retrospective small cohorts and inhomogeneous study collectives. There are no treatment standards that could refer to larger randomized studies.
At present, the recommendations for the treatment of men with breast cancer are mainly based on the recommendations for the diagnosis, treatment and aftercare of the disease in postmenopausal women [1604], [1605]. Well knowing that the disease in men has other biological potentials that have to be considered in the care of patients [1606], [1607], [1608]. There is an international consensus to increase the knowledge base on breast cancer in men by participating in registry studies [1605], [1609], [1610].
In male breast cancer patients a similar breast cancer mortality rate is found as in older postmenopausal women. A genetic disposition is more frequent in men, especially mutation BRCA1 and BRCA2 [1611]. Furthermore, men with breast cancer have an up to 20% increased risk constellation for second malignancies [1612].
Over 90% of patients are diagnosed with ER-positive invasive ductal carcinoma. The HER2 overexpression is inconsistently reported in the literature as 12-37%. A recent study found 97% ER-positive and only 10% HER2-positive tumors in a unicentric cohort of 61 invasive mammary carcinomas in men [1613]. 39-95% of the cases showed androgen receptor expression. In contrast to the histopathological similarities to breast cancer in women, molecular biological examinations show significant differences in [1607], [1608], [1610], [1613].
Most men have so far been treated by mastectomy and axillary lymphonodectomy (ALND) and possibly with chest wall irradiation [1601], [1614], [1615] Current data suggest in particular less radical surgical measures with the aim of reducing therapy-related morbidity [1616], [1617], [1618], [1619].
Men with breast cancer with lymph node involvement benefit from adjuvant chemotherapy with improved prognosis (disease-free survival, overall survival) [1620]. When deciding on adjuvant therapy, comorbidities and tolerance as well as patient preferences must be considered. The substances and regimens commonly used in women including anti-HER2-therapy are used if indicated. Tamoxifen is currently the standard therapy for hormone receptor-positive breast cancer. The side effects such as sexual dysfunction lead to a high therapy discontinuation rate [1621]. The use of aromatase inhibitors in adjuvant therapy is not recommended; aromatase inhibitors were associated with a significantly increased mortality in a retrospective analysis of German cancer registries [1622].
There is no evidence from clinical studies on the treatment of HER2-positive breast cancer in men; however, there is consensus that, following the successes in HER2-positive breast cancer in women, men with HER2-positive breast cancer should also be treated adjuvantly with trastuzumab [1623].
In metastasis, aromatase inhibitors can be used second-line, most likely in combination with drug suppression of the gonadal function [1624], [1625], [1626], [1627], [1628].
In advanced metastatic disease, studies show treatment options for fulvestrant, aromatase inhibitors and eribulin from [1625], [1626], [1628], [1629], [1630].
Rehabilitation and aftercare, including imaging diagnostics, are carried out in accordance with the recommended aftercare for women. Aftercare for men focuses on the specific risks, comorbidities, short and long-term side effects to be considered and includes psychosocial as well as psycho-oncological aspects [1387], [1631].
References
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[1618] Fogh, S., Kachnic, L. A., Goldberg, S. I., Taghian, A. G., Powell, S. N., Hirsch, A. E., Localized therapy for male breast cancer: functional advantages with comparable outcomes using breast conservation, Clin Breast Cancer, 2013. 13(5): p. 344-9.
[1619] Zaenger, D., Rabatic, B. M., Dasher, B., Mourad, W. F., Is Breast Conserving Therapy a Safe Modality for Early-Stage Male Breast Cancer?, Clin Breast Cancer, 2016. 16(2): p. 101-4.
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[1623] Board, PDQ Adult Treatment Editorial, Male Breast Cancer Treatment (PDQ®), 2016.
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[1628] Kuba, S., Ishida, M., Oikawa, M., Nakamura, Y., Yamanouchi, K., Tokunaga, E., et.al. Aromatase inhibitors with or without luteinizing hormone-releasing hormone agonist for metastatic male breast cancer: report of four cases and review of the literature, Breast Cancer, 2016. 23(6): p. 945-949.
[1629] Masci, G., Gandini, C., Zuradelli, M., Pedrazzoli, P., Torrisi, R., Lutman, F. R., et.al. Fulvestrant for advanced male breast cancer patients: a case series, Ann Oncol, 2011. 22(4): p. 985.
[1630] Giotta, F., Acito, L., Candeloro, G., Del Medico, P., Gadaleta-Caldarola, G., Giordano, G., et.al. Eribulin in Male Patients With Breast Cancer: The First Report of Clinical Outcomes, Oncologist, 2016.
[1387] Ferzoco, R. M., Ruddy, K. J., Optimal delivery of male breast cancer follow-up care: improving outcomes, Breast Cancer (Dove Med Press), 2015. 7: p. 371-9.
[1631] Wernberg, J. A., Yap, J., Murekeyisoni, C., Mashtare, T., Wilding, G. E., Kulkarni, S. A., Multiple primary tumors in men with breast cancer diagnoses: a SEER database review, J Surg Oncol, 2009. 99(1): p. 16-9.