Breast cancer in men is rare, accounting for less than 1% of all breast cancer cases. Although breast cancer in men occurs less frequently than breast cancer in women, the diseases are similar in many ways.
The breast is mainly composed of fatty tissue. Within this tissue is a network of lobes, which are made up of tiny, tube-like structures called lobules that contain milk glands. Tiny ducts connect the glands, lobules, and lobes to the nipple, located in the middle of the areola (darker area that surrounds the nipple of the breast). Blood and lymph vessels run throughout the breast; blood nourishes the cells, and the lymph system drains bodily waste products. The lymph vessels connect to lymph nodes, which are tiny, bean-shaped organs that normally help fight infection.
The main types of breast cancer are the same for men and women. About 90% of all breast cancer cases start in the ducts or lobes. Almost 75% of all breast cancers begin in the cells lining the milk ducts and are called ductal carcinomas. Approximately 30% of male breast cancers are lobular carcinoma (cancer that begins in the lobules) that is found in both breasts.
A type of breast cancer that has spread outside of the duct and into the surrounding tissue is called invasive or infiltrating ductal carcinoma (IDC). The majority of male breast cancer cases are IDC. If the cancer begins at the end of the ducts, it is called infiltrating lobular carcinoma, a rare type of breast cancer.
Disease that has not spread is called in situ, meaning "in place." The course of in situ disease, as well as its treatment, depends on where in the breast the cancer started. Currently, oncologists recommend that ductal carcinoma in situ (DCIS), which accounts for the majority of in situ breast cancers, be surgically removed to help prevent the cancer from spreading to other parts of the breast or the body. DCIS is uncommon in men.
Inflammatory breast cancer makes up about 1% to 5% of all breast cancers. Paget's disease of the nipple begins in the ducts, but spreads to the skin of the nipple. Paget’s disease is more common in men than in women. Other, less common cancers of the breast include medullary, mucinous, tubular, or papillary.
Cancer may begin as a single, genetically abnormal cell. As this one cell divides, it eventually becomes a tumor (a mass of cells) and develops a blood supply to nourish its continued growth. At some point, cells may break off from the primary mass and move to other parts of the body in a process called metastasis.
Breast cancer spreads when breast cancer cells move to other sites in the body through the blood vessels and/or lymph vessels. A common site of spread is the regional lymph nodes. The lymph nodes can be axillary (located under the arm), cervical (located in the neck), or supraclavicular (located just above the collarbone). The most common sites of distant metastasis are the bones, lungs, and liver. Less commonly, breast cancer may spread to the brain. The cancer can also recur (come back after treatment) locally in the skin, in the same breast (if it was not removed as part of treatment), other tissues of the chest, or elsewhere in the body.
Breast cancer in men is detected the same way as breast cancer in women is—through self-examination, clinical examination, or mammography (x-ray of the breast). Changes in the breast may be easier to detect because men have less breast tissue. However, the awareness of breast cancer in men is much lower than it is in women; therefore, men may not perform regular breast self-examinations or talk with their doctor about the disease.
Statistics
In 2008, there will be an estimated 1,990 new cases of breast cancer diagnosed in men in the United States. An estimated 450 men will die of breast cancer this year.
Breast cancer in men and women has similar survival rates. For the earliest stages of breast cancer, stages 0 and I, the five-year relative survival rate (the percentage of patients who survive at least five years after the cancer is detected, excluding those who die from other diseases) is 98%. Survival rates drop as the stages (see Staging) increase. Men with breast cancer that has spread regionally have an 84% five-year relative survival rate, and men with cancer that has spread to other parts of the body have a 24% five-year survival rate. Even if the cancer is found at a more advanced stage, new therapies enable many people with breast cancer to experience the same quality of life as before their diagnosis.
Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with breast cancer. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.
Statistics adapted from the American Cancer Society's publication, Cancer Facts Figures 2008.
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor can help you make more informed lifestyle and health-care choices.
The following factors can raise a man’s risk of breast cancer:
Family history of breast disease or presence of a genetic mutation. About 20% of breast cancers in men occur in those who have a family history of the disease. Men with breast cancer gene 2 (BRCA2) gene mutations may be at increased risk for breast cancer or other types of cancer. Learn more about The Genetics of Breast Cancer.
Age. The average age for men to be diagnosed with breast cancer is 65.
Elevated estrogen levels. The presence of certain diseases, conditions, or treatments can increase estrogen (female hormones) levels.
Klinefelter’s syndrome, a genetic condition in which men are born with an extra X chromosome, may increase the risk of male breast cancer because men with Klinefelter’s syndrome have higher levels of estrogens and lower levels of androgens (male hormones).
Liver disease, such as cirrhosis, can disrupt hormone levels and cause low levels of androgens and higher levels of estrogens. Low doses of estrogen-related drugs that are given for the treatment of prostate cancer may slightly increase the risk of breast cancer.
Radiation. High doses of radiation may increase the risk of breast cancer. An increased risk of breast cancer has been observed in long-term survivors of atomic bombs, people with lymphoma treated with radiation therapy to the chest, people undergoing large numbers of x-rays (such as for tuberculosis or to treat residual thymic disease or acne), non-malignant (non-cancerous) conditions of the spine, and children treated with radiation therapy for ringworm.
Lifestyle factors. As with other types of cancer, studies continue to show that various lifestyle factors may contribute to the development of breast cancer.
Obesity. According to a recent study, being obese or even overweight increases the risk of breast cancer.
Lack of exercise. Exercise lowers hormone levels and boosts the immune system; lack of exercise also contributes to obesity.
Alcohol use. Drinking more than one alcoholic drink per day may raise the risk of breast cancer.
Currently, there is no proven method for preventing male breast cancer. A person’s best chance of surviving breast cancer is early detection through regular self-examinations, clinical breast examinations, and mammography. Therefore, all men should be familiar with the feel of their breast tissue normally, so they can bring any lump or change to their doctor’s attention. During an annual physical examination, the health-care professional will perform a clinical examination of the breast. Mammograms are not routinely offered to men and may be difficult to perform because of the small amount of breast tissue. For men with a strong family history of breast cancer or the presence of a genetic mutation that increases their risk of developing the disease, regular mammography may be recommended.
Men with breast cancer may experience the following symptoms. Sometimes, men with breast cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor.
A lump or swelling in the breast tissue. Because men generally have small amounts of breast tissue, it is easier to feel small lumps.
Any new irregularity (redness, scaliness, puckering) on the skin or nipple, or a discharge from the nipple
Doctors use many tests to diagnose cancer and determine if it has metastasized. Some tests may also find out which treatments may be the most effective. For most types of cancer, a biopsy (the removal of a small amount of tissue for examination under a microscope) is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
The type of cancer suspected
Severity of symptoms
Previous test results
In addition to a physical examination, the following tests may be used to diagnose breast cancer in men:
Clinical breast examination. During this procedure, the doctor will systematically feel for lumps in the breast tissue and under the arm.
Diagnostic mammography. If a lump or suspicious area is found, the doctor will order a diagnostic mammogram (x-ray of the breast). Diagnostic mammography is similar to screening mammography except that more views (pictures) of the breast are taken.
Ultrasound. An ultrasound uses high-frequency sound waves to create an image of the breast tissue. An ultrasound may distinguish between a solid mass, which may be cancer, and a fluid-filled cyst, which is not usually cancer.
Nipple discharge examination. Fluid from the nipple can be examined under a microscope to look for cancer cells.
Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).
Image guided biopsy is used when a distinct lump can't be felt. It can be done with a fine needle aspiration biopsy (FNAB, uses a small needle to remove the tissue sample), stereotactic core biopsy (uses x-rays to find the area of tissue to be removed), or a vacuum-assisted biopsy (uses a thicker needle to remove multiple large cores of tissue). During this procedure, a needle is guided to the area of concern with the help of mammography, ultrasound, or MRI. A small metal clip may be put into the breast to mark the site of biopsy, in case the sample tissue proves cancerous and additional surgery is required. An advantage of this technique is that a patient may only need one operation for treatment or staging.
Core biopsy can obtain tissue or FNAB can obtain cells in masses that can be felt, and these can then be analyzed for the presence of malignant (cancerous) cells.
Surgical biopsy removes the largest amount of tissue. This biopsy may be incisional (removal of part of the lump) or excisional (removal of the entire lump).
If cancer is diagnosed, a second surgery may be needed to get a clear margin (area of tissue around the tumor where there are no cancer cells) and/or remove lymph nodes.
Doctors may also test the tissue from a biopsy to help guide treatment decisions. The tests include:
Tumor features. Examination of the tumor under the microscope determines if it is invasive or in situ; ductal or lobular; grade (how different the cancer cells look from healthy cells); and whether the cancer has spread to the blood vessels or lymph vessels. The margins of the tumor are also examined.
Estrogen receptor (ER) and progesterone receptor (PR) tests. Breast cancer cells with these receptors depend on the hormones estrogen and progesterone to grow. The presence of these receptors helps determine both the patient’s prognosis (chance of recovery) and whether the cells are likely to respond to hormone therapy. Generally, ER-positive or PR-positive tumors respond to hormone therapy.
HER2 tests. There is too much of the protein HER2 in about 25% of breast cancers. The HER2 status helps determine whether a drug, such as trastuzumab (Herceptin), might be useful for treating breast cancer. Read more in the ASCO Patient Guide: HER2 Testing for Breast Cancer.
Genetic description of the tumor. Tests that look at the biology of the tumor are becoming more common to understand more about the breast cancer. Oncotype Dx is a type of test that measures the risk of distant recurrence (return of the cancer in a place other than the breast) at 10 years for patients with stage I or stage II node-negative, ER-positive breast cancer that may be treated with hormone therapy. This information may also be used to plan treatment. Talk with your doctor for more information.
Blood tests
The doctor may also need to do blood tests to learn more about the cancer.
Complete blood count (CBC). CBC is a blood test done to determine the following:
Hemoglobin level (a measure of the number of oxygen-carrying cells)
Hematocrit level (the percentage of red blood cells in whole blood)
The number of white blood cells (cells that help to fight infection)
The number of platelets (cells that help blood to clot as necessary)
Differential (the percentage of several types of white blood cells)
Alkaline phosphatase levels. High levels of this enzyme could indicate the disease has spread to the liver, bone, or bile ducts.
Total bilirubin count, serum glutamic-oxaloacetic transaminase(SGOT), and serum glutamate pyruvate transaminase (SGPT) levels. These tests evaluate liver function. High levels of any of these substances can indicate liver damage, a signal of possible spread to that organ.
Tumor marker tests. A tumor marker (also called a serum marker or biomarker) is a substance found in a person's blood, urine, or body tissue. The presence of a tumor marker, or having higher or lower than normal levels of a tumor marker, may indicate an abnormal process in the body, which could be because of cancer or a noncancerous condition. Tumor markers may be used for diagnosis, treatment planning, and/or treatment monitoring. For more information, read the ASCO Patient Guide: Tumor Markers for Breast Cancer.
Additional tests
The doctor may order additional tests (depending on the individual’s medical history and results of the physical examination) to evaluate the stage of the cancer. Read the Staging section for more information. These tests are not recommended for all patients.
A chest x-ray may be used to look for cancer that has spread from the breast to the lung.
A bone scan may be used to look for spread to the bones. A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark.
A computed tomography (CT or CAT) scan may be used to look for distant tumors. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium is injected into a patient’s vein to provide better detail.
A positron emission tomography (PET) scan may be used to determine whether the cancer has spread. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images.
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis. There are different stage descriptions for different types of cancer.
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How large is the primary tumor and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Tumor. Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail.
TX: The primary tumor cannot be evaluated.
T0: There is no evidence of cancer in the breast.
Tis: Refers to carcinoma (cancer) in situ. In this case, the cancer is confined within the natural boundaries of the breast tissue and has not spread into the surrounding tissue of the breast. There are three types of breast carcinoma in situ:
Tis (DCIS): Ductal carcinoma in situ (DCIS) is a precancer, but it can later develop into an invasive type of breast cancer. A designation of DCIS means that only a few cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began.
Tis (LCIS): Lobular carcinoma in situ (LCIS) describes abnormal cells found in the lobules or glands of the breast. LCIS is not cancer, but it increases the risk of developing invasive breast cancer.
Tis (Paget’s): Paget’s disease of the nipple is a rare form of early breast cancer. This designation is used only if there is Paget’s disease but no tumor present. If there is a tumor, it is classified according to the size of the tumor.
T1: A tumor in the breast is 2 centimeters (cm) or smaller in size at its widest dimension.
T1mic: Microinvasion, or micrometastases, means a few cancer cells have spread to surrounding tissue, but none larger than 0.1 cm.
T1a: The tumor is larger than 0.1 cm but smaller than 0.5 cm.
T1b: The tumor is larger than 0.5 cm but smaller than 1 cm.
T1c: The tumor is larger than 1 cm but not larger than 2 cm.
T2: The tumor is larger than 2 cm but not larger than 5 cm.
T3: The tumor is larger than 5 cm.
T4: The tumor has spread to the chest wall or to the skin or is diagnosed as inflammatory breast cancer.
T4a: The tumor has spread into the chest wall.
T4b: There is edema (swelling), thickening of the skin (as in peau d'orange), or ulceration (a sore, painful area where the breast skin/tissue is breaking down) of the breast skin or surrounding skin nodules of the same breast.
T4c: There are signs of both T4a and T4b.
T4d: Refers to inflammatory carcinoma. This is an aggressive type of breast cancer where the breast is red, swollen, and warm.
Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes located under the arm, above and below the collarbone, and under the breastbone are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.
NX: The lymph nodes cannot be evaluated.
N0: No cancer was found in the lymph nodes.
N1: The cancer has spread to one to three axillary lymph nodes.
N2: The cancer has spread to four to nine lymph nodes under the arm or to the internal mammary lymph nodes (lymph nodes to the right or left of the sternum [breastbone] on the inside of the chest) without axillary node involvement.
N2a: The cancer has spread to four to nine lymph nodes under the arm (at least one tumor deposit is larger than 2 mm).
N2b: The cancer has spread only to the internal mammary lymph nodes.
N3: The cancer has spread to 10 or more lymph nodes under the arm or to the infraclavicular lymph nodes (located under the collarbone) or to the internal mammary nodes with axillary node involvement.
N3a: The cancer has spread to 10 or more lymph nodes under the arm or to the infraclavicular lymph nodes.
N3b: The cancer has spread to internal mammary nodes and axillary nodes.
N3c: The cancer has spread to the supraclavicular lymph nodes.
If there is cancer in the lymph nodes, it also helps doctors to plan treatment to know how many lymph nodes are involved. The pathologist can determine the number of lymph nodes affected by cancer.
Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.
MX: Distant spread cannot be evaluated.
M0: The disease has not metastasized.
M1: There is metastasis to another part of the body.
Cancer stage grouping
Doctors assign the stage of the cancer by combining the T, N, and M classifications.
Stage 0: Disease that has not spread past the natural boundaries of the breast. It is also called noninvasive cancer.
Stage I: The tumor is small and has not spread to the lymph nodes (T1, N0, M0).
Stage IIa: Any one of these conditions:
The tumor is smaller than or equal to 2 cm and has spread to the axillary lymph nodes under the arm (T1 or T1mic, N1, M0).
The tumor is larger than 2 cm but not larger than 5 cm and has not spread to the axillary lymph nodes (T2, N0, M0).
There is no evidence of a tumor in the breast, but there is cancer in the axillary lymph nodes (T0, N1, M0).
Stage IIb: Any one of these conditions:
The tumor is larger than 2 cm but not larger than 5 cm and has spread to the axillary lymph nodes (T2, N1, M0).
The tumor is larger than 5 cm but has not spread to the axillary lymph nodes (T3, N0, M0).
Stage IIIa: Any of these conditions:
The tumor is smaller than 5 cm and has spread to the axillary lymph nodes (T1, N2, M0 or T2, N2, M0).
The tumor is larger than 5 cm and has spread to the axillary lymph nodes (T3, N1, M0 or T3, N2, M0).
Stage IIIb: The tumor has spread to the chest wall or caused swelling or ulceration of the breast or is diagnosed as inflammatory breast cancer. It may or may not have spread to the lymph nodes under the arm, but has not spread to other parts of the body (T4, N0, M0; T4, N1, M0; or T4, N2, M0).
Stage IIIc: A tumor of any size that has not spread to distant parts of the body but has spread to the lymph nodes in the N3 group (any T, N3, M0).
Stage IV: The tumor can be any size and has spread to distant sites in the body, usually the bones, lungs or liver, or chest wall (any T, any N, M1).
Recurrent: Recurrent cancer is cancer that comes back after treatment.
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
The treatment of male breast cancer depends on the size and location of the tumor, whether the cancer has spread, and the man’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan. Male breast cancer may be treated with surgery, chemotherapy, radiation therapy, and hormone therapy. Each option is described below.
This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, read the clinical trials section.
Overview of breast cancer treatment
The biology and behavior of a breast cancer affects the treatment. Some tumors are small but grow fast, while others are large and grow slower. When planning the treatment for breast cancer, the doctor will consider many factors, including:
The stage and grade of the tumor
The tumor’s hormone receptor status (ER, PR) and HER2 status (see Diagnosis)
The patient’s age and general health
The presence of known mutations to breast cancer genes
Even though the doctor will specifically tailor the treatment for breast cancer for each patient, there are some general steps for treating breast cancer.
For DCIS and early-stage breast cancer, doctors generally recommend surgery to remove the tumor. To ensure the area around the tumor is free of cancer, the surgeon may also remove a small area of tissue around the tumor. The next step in the management of early-stage breast cancer is to lower the risk of recurrence (return of the cancer) and to get rid of any remaining cancer cells. This is called adjuvant therapy. Adjuvant therapies include radiation therapy, chemotherapy, hormone therapy, and targeted therapy. Although adjuvant therapy lowers the risk of recurrence, it does not necessarily eliminate it.
Along with staging, other sophisticated tools can help determine prognosis and help you and your doctor make decisions about adjuvant therapy. The website Adjuvant! Online (www.adjuvantonline.com) is one such tool that your doctor can access to interpret a variety of prognostic factors. This website should only be used with the interpretation of your doctor.
When surgery to remove the cancer is not possible, chemotherapy, radiation therapy, hormone therapy, and/or targeted therapy may be used.
The treatment of recurrent cancer and metastatic cancer depends on how the cancer was first treated and the characteristics of the cancer mentioned above (such as ER, PR, and HER2 status).
More complete descriptions of each treatment option are listed below.
Surgery
If the tumor is small, a biopsy may be all that is needed to remove the tumor completely. However, if more surgery is required, a mastectomy may be necessary. A simple (total) mastectomy involves removing the entire breast, but not the lymph nodes under the arm or underlying chest muscles. A modified radical mastectomy removes the breast tissue and lymph nodes, and a radical mastectomy removes the breast tissue, lymph nodes, and chest wall muscles under the breast.
Because men do not have much breast tissue, a lumpectomy, which remove only the tumor, is generally not an option.
Men may also have surgery to remove and examine the lymph nodes for cancer.
Axillary lymph node dissection involves the surgeon removing lymph nodes from under the arm and having them examined by a pathologist for cancer cells. The actual number of nodes removed may vary.
Sentinel lymph node biopsy is a procedure in which the surgeon finds and removes the sentinel (first) lymph node (generally one to three nodes) that receives drainage from the breast. The pathologist then examines it for cancer cells. To identify the sentinel lymph node, the surgeon injects a dye and/or a radioactive tracer into the area around the nipple. The dye or tracer will travel to the lymph nodes, arriving at the sentinel node first. The surgeon can find the node when it turns color (if the dye is used) or emits radiation (if the tracer is used). Sentinel lymph node biopsy often has a lower risk of lymphedema (swelling of the arm) than axillary lymph node dissection. If the sentinel node is cancer-free, research has shown that there is a good possibility that the subsequent nodes will also be free of cancer and no further surgery of the lymph nodes is performed. If the sentinel lymph node shows cancer is present, then the surgeon will perform an axillary lymph node dissection. For more information, read the ASCO Patient Guide: Sentinel Lymph Node Biopsy in Early Stage Breast Cancer.
The most significant side effect of surgery is lymphedema (arm swelling), which can occur when lymph nodes are removed or damaged during surgery. Because the lymph nodes are part of the channels that drain the lymphatic fluid from the arm, damage to the area may hold back the flow of lymphatic fluid and cause it to back up in the arm. The use of sentinel node biopsy has been shown to reduce the incidence of lymphedema.
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the drug and the dose used, but can include fatigue, hair loss, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers, but studies have shown that these side effects do not shorten the survival time.
Chemotherapy may be given orally (by mouth) or intravenously (injected into a vein) and is usually given in cycles. Chemotherapy generally does not require a hospital stay; it is given in an outpatient setting. Chemotherapy may be neoadjuvant therapy (given before surgery to shrink a large tumor) or adjuvant therapy (given after surgery to reduce the risk that the cancer returns). Chemotherapy may also be given at the time of a breast cancer recurrence. Patients in clinical trials may be offered new drugs or new combinations of existing drugs.
Different drugs are useful for different cancers, and research has shown that combinations of certain drugs are more effective than individual ones. The most common combinations for male breast cancer include:
CAF: cyclophosphamide, doxorubicin (Adriamycin), and 5-FU
AC: doxorubicin (Adriamycin) and cyclophosphamide
Cyclophosphamide and doxorubicin in combination with paclitaxel (Taxol) or docetaxel (Taxotere)
Other chemotherapy that may be prescribed includes paclitaxel, docetaxel, vinorelbine (Navelbine), gemcitabine (Gemzar) and capecitabine (Xeloda). Trastuzumab (see Targeted therapy below) is used to treat HER2-positive breast cancer (see Diagnosis).
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions. Learn more about your prescriptions through Cancer.Net’s Drug Information Resources, which provides links to multiple drug databases.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Adjuvant radiation therapy is given regularly for a number of weeks after a lumpectomy or partial mastectomy to eliminate any remaining cancer cells near the tumor site or elsewhere within the breast. Adjuvant radiation therapy is also recommended for some patients after a mastectomy depending upon the size of their tumor, number of cancerous lymph nodes under the arm, and width of the tissue margin around the tumor removed by the surgeon. Adjuvant radiation therapy is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is rare.
Radiation therapy can cause side effects, including fatigue, swelling, and skin changes. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related pneumonia, is rare. Modern techniques are now able to spare most of the heart from radiation damage. While exposure to radiation is thought to be a risk factor for cancer after many years, less than one in 500 survivors will develop a different kind of cancer, other than a breast cancer, within the area that was treated. Clinical trials comparing lumpectomy and adjuvant radiation therapy with mastectomy have not shown a difference in the number of patients developing or dying of other cancers within a 20-year time span.
The most common type of radiation treatment is called external beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. In this treatment, small radioactive pellets are placed in or near the site of the breast tumor within plastic catheters placed temporarily in the breast. A balloon catheter placed near the breast that delivers radiation therapy (called Mammosite) is another type of radiation therapy.
Standard radiation therapy after a lumpectomy or partial mastectomy is external-beam radiation therapy given for five days (Monday through Friday) for six to seven weeks. This usually includes radiation therapy to the whole breast first for four and a half to five weeks, followed by a more focused treatment to the site of the tumor bed in the breast for the remaining treatments. This focused part of the treatment, called a boost, is standard for patients with invasive breast cancer because it reduces the risk of a recurrence in the breast. This boost is also usually given for patients with in situ breast cancer and is the subject of an ongoing international clinical trial. Standard radiation therapy after a mastectomy is given to the chest wall for five days (Monday through Friday) for five to six weeks. If there is evidence of cancer in the underarm lymph nodes, radiation therapy may also be given to the lymph node areas in the neck or underarm near the breast or chest wall.
There has been growing interest in newer radiation methods to shorten the length of treatment from six to seven weeks to periods of three to four weeks. In one method (called hypo-fractionated radiation therapy), a higher daily dose is given to the whole breast each day so that the overall length of treatment is shortened to three to four weeks. This can also be combined with a higher dose given to the tumor bed in the breast either during or after the whole breast radiation treatments. Clinical trials from Canada and the United Kingdom have shown that these shorter schedules can be equally accepted by patients with the same cancer control rates and side effects as longer radiation treatment schedules. These shorter schedules may become more accepted in the United States and are one way to improve the convenience and time required to complete a course of radiation (see also partial breast irradiation below).
Partial breast irradiation
Partial breast irradiation (PBI) is radiation therapy that is given directly to the tumor area, usually after a lumpectomy, instead of the entire breast, as is routinely done with standard radiation therapy. This treatment can be done with external-beam radiation therapy or internal radiation therapy. Radiation is given twice a day for only one week using external-beam radiation, a temporary radiation catheter, or catheters implanted within the breast. Only some patients may be eligible for PBI. Although preliminary results have been promising, PBI is the subject of a large, nationwide clinical trial, and the results proving the safety and effectiveness compared with standard radiation therapy are pending.
Targeting the radiation to the tumor area more directly may shorten the amount of time that patients need to undergo radiation therapy. A large national clinical trial, which began in 2005, is being done to compare the standard treatment of six weeks of conventional external-beam radiation therapy with a one-week treatment of PBI.
Intensity-modulated radiation therapy
Intensity-modulated radiation therapy (IMRT) is a more advanced way to deliver external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to target the tumor more precisely, give a uniform distribution of radiation throughout the breast tissue, and avoid damaging healthy tissue than is possible with traditional radiation treatment. IMRT may reduce the dose to nearby important organs, such as the heart and lung, and reduce the risks of some immediate side effects, such as peeling of the skin during treatment. IMRT also may help to reduce long-term effects on the breast tissue that were common with older radiation techniques such as hardness, swelling, or discoloration.
Two prospective, randomized clinical trials have compared IMRT with conventional radiation therapy after lumpectomy for patients treated for breast cancer. Both studies showed an even distribution of radiation dose throughout the breast with IMRT. IMRT use also resulted in a decrease in areas of the breast that received a higher-than-desired dose of radiation, which led to a decrease in side effects. For example, in one clinical trial, there were fewer cases of moist peeling of the skin during IMRT. In the other clinical trial, there was an improvement in breast appearance and less fibrosis (hardness of the breast) five years after IMRT treatment. Additional research is being conducted to compare the long-term side effects, such as heart disease, between IMRT and conventional radiation therapy 10 years or more after treatment.
Hormone therapy is useful to manage a tumor that tests positive for either estrogen or progesterone receptors for both early-stage and metastatic cancer. Because more than 75% of breast cancers in men have estrogen receptors, hormone therapy is often part of the treatment plan. This type of tumor uses hormones to fuel its growth. Blocking the hormones usually limits the growth of the tumor.
If it is determined that the tumor is hormone receptor-positive (uses estrogen or progesterone to grow [see Diagnosis]), then adjuvant hormone treatment may be used alone or after chemotherapy. Hormone therapies for men include:
Megesterol (Megace). Megesterol is a progesterone-like drug used to treat a progesterone receptor-positive tumor.
Aromatase inhibitors. Aromatase inhibitors block the production of estrogen. These agents are effective in treating breast cancer in women, but there is not much information on their use in male breast cancer.
Anti-androgen therapy. Male breast cancers often have receptors for male hormones. By lowering the production of androgens in the man’s body, oncologists have been able to shrink a tumor that has metastasized.
Side effects of hormone therapy can include hot flashes, decreased sexual desire or ability, and mood swings.
Targeted therapy
Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development.
Trastuzumab is approved for both the treatment of advanced breast cancer and as an adjuvant therapy for early-stage breast cancer for tumors that have too much of the HER2 protein, called HER2 positive. Data presented at the 2005 American Society of Clinical Oncology Annual Meeting demonstrated an approximate 50% decrease in recurrence and an improvement in survival for patients with HER2-positive early breast cancer who received trastuzumab either with or after adjuvant chemotherapy. At this time, one year of trastuzumab is recommended. Patients receiving trastuzumab have a 4% risk of heart problems, and this risk is increased if a patient has other risk factors for heart disease. These heart problems do not always go away, but they are usually treatable with medication. Ongoing research is evaluating how much trastuzumab is enough (from nine weeks up to two years).
For patients with HER2-positive breast cancer that no longer responds to trastuzumab, a drug called lapatinib (Tykerb) may slow the growth of breast cancer when combined with capecitabine. The combination of lapatinib and capecitabine is approved for the treatment of patients with advanced or metastatic HER2-positive breast cancer who have previously been treated with chemotherapy and trastuzumab.
Bevacizumab (Avastin) is used to treat metastatic or recurrent breast cancer (see below). This drug blocks angiogenesis (the formation of new blood vessels), which is needed for tumor growth and metastasis. When combined with paclitaxel, bevacizumab appears to shrink the tumor and remain smaller for a longer time in patients whose breast cancer has spread compared with paclitaxel alone. This combination was approved by the U.S. Food and Drug Administration in 2008.
Recurrent and metastatic breast cancer
Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (a local recurrence); in the chest wall; or in another part of the body, including distant organs (such as the lungs, liver, and bones). Some patients live years after a recurrence of breast cancer.
Breast cancer may also spread to other organs such as the brain, the opposite breast, adrenal glands, and spleen and is called metastatic breast cancer. This type of cancer is treatable, but not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the growth of the tumor.
Generally, a recurrence is detected when a person has symptoms. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research shows that having such tests does not improve the response to treatments used for advanced disease, nor do they prolong life.
Signs and symptoms depend on the site of the recurrence and may include:
A lump under the arm or along the chest wall
Bone pain or fractures, which may signal bone metastases
Headaches or seizures, which may signal brain metastases
Chronic coughing or trouble breathing, which may signal lung metastases
Other symptoms may be related to the location of metastasis and may include changes in vision, changes in energy levels, feeling ill, or extreme fatigue. A biopsy of the recurrent site is often recommended to be certain of the diagnosis and to check for ER, PR, and HER2 status, because this may have changed from the time of the original diagnosis.
The treatment of metastatic or recurrent breast cancer depends on the previous treatment(s) and the characteristics of the tumor (such as ER, PR, and HER2 status). Once metastatic disease is detected, the treatment may involve surgery to remove the metastasis and/or chemotherapy, hormone therapy, targeted therapy, and radiation therapy (if it hasn’t been already given) to control it. In some circumstances, radiation therapy may also be given to relieve symptoms.
The National Comprehensive Cancer Network (NCCN) also has a series of treatment guidelines that have been translated into patient-friendly language. In accordance with Cancer.Net’s Linking Policy, please note that this link does not imply ASCO’s endorsement of the content, but rather it is an effort to provide additional information that may be helpful to people living with cancer and their families. The NCCN treatment guide for breast cancer can be found at www.nccn.org.
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, infection, fatigue, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.
Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health.
Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net’s section on Managing Side Effects, based on ASCO’s curriculum.
In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer.Net’s section on Caring for the Whole Patient.
For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.
After treatment for breast cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. The recommendations for breast cancer follow-up care usually include regular physical examinations and mammograms. Specific information can be found in the Follow-Up Care for Breast Cancer. In addition, ASCO offers forms to help keep track of the breast cancer treatment you received and develop a survivorship care plan once treatment ends. Read more about the ASCO Cancer Treatment Summaries.
Breast cancer can come back in the breast or other areas of the body. The symptoms of a cancer recurrence include a new lump in the breast, under the arm, or along the chest wall; bone pain or fractures; headaches or seizures; chronic coughing or trouble breathing; extreme fatigue; and/or feeling ill. Talk with your doctor if you have these or other symptoms. The possibility of recurrence is a common concern among cancer survivors; learn more about Coping With Fear of Recurrence.
After surgery to treat breast cancer, the breast may be scarred and may have a different shape or size than before surgery. If lymph nodes were removed as part of the surgery or affected during treatment, lymphedema (swelling of the hand and/or arm) may occur. Read the Cancer.Net Feature: After Treatment for Breast Cancer: Preventing Lymphedema and
Some patients experience breathlessness, a dry cough, and/or chest pain two to three months after finishing radiation therapy because the treatment can cause swelling and fibrosis (hardening or thickening) of the lungs. These symptoms are usually temporary. Talk with your doctor if you develop any new symptoms after radiation therapy or if the side effects are not going away.
Men recovering from breast cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level and lowers the risk of recurrence. Your doctor can help you create a safe exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.
Genetic testing is becoming available to offer information for people with strong family histories of cancer. For male breast cancer, even if there is no family history of breast cancer, it is a good idea to talk with a genetic counselor.
Late effects of treatment for breast cancer include secondary leukemia, which currently affects 1% of people with breast cancer. There has also been some data suggesting that osteoporosis (loss of bone mass that makes bones break easily) is emerging as a side effect of treatment.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
What type of breast cancer that I have?
Can you explain my pathology report (laboratory test results) to me?
What is the stage of my cancer? What does this mean for treatment options?
Should I see a genetic counselor?
What are my treatment options?
What clinical trials are open to me?
What treatment do you recommend? Why?
What are the possible side effects of this treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
What are the chances that the cancer will come back?
What is my prognosis?
How can I keep myself as healthy as possible during treatment?
What follow-up tests will be needed, and how often will I need them?
What support services are available to me? To my family?
Research about breast cancer in men is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.
New surgical methods that save tissue or prevent scarring are being tested in clinical trials. A skin-sparing mastectomy may result in less scarring than traditional surgery.
Improved radiation therapy, to lower the risk of side effects
New therapies and combinations of therapies, including chemotherapy, hormone therapy, and targeted therapy are being studied in clinical trials.
Doctors and scientists are always looking for better ways to treat men with breast cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments, such as new chemotherapy, before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that this is the only way to make progress in treating male breast cancer, such as finding new drugs. Even if they do not benefit directly from the clinical trial, their participation may benefit men who develop breast cancer in the future.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands the standard treatments, and how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
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