Breast cancer in men

Breast cancer in men •

Updated 2012 Aug 01 02:54:00 PM: incidence of breast cancer about 1-1.2 per 100,000 men per year in United States (American Cancer Society Breast Cancer Facts & Figures 2011-2012) view updateShow more updates

Related Summaries: • Breast cancer (list of topics) • Breast cancer in women • Physician Quality Reporting System Quality Measures General Information Description: • male breast cancer Types: • 85% infiltrating ductal carcinomas • review of juvenile secretory carcinoma of breast (rare breast cancer with mean age of presentation 10 years) can be found in Pediatric Surgery Update 2006 Jun;26(6):3 Who is most affected: • mean age 59 years Incidence/Prevalence: • incidence of breast cancer about 1-1.2 per 100,000 men per year in United States o based on US data 1975-2008 o about 2,140 cases of breast cancer per year expected to occur in men (accounting for about 1% of all breast cancer) o about 450 men will die from breast cancer each year o Reference - American Cancer Society Breast Cancer Facts & Figures 20112012 PDF • global standardized incidence rate 0.4 per 100,000 person-years o based on cohort of 2,665 men diagnosed with breast cancer followed up to 30 years o Reference - J Clin Oncol 2011 Nov 20;29(33):4381 Causes and Risk Factors Causes: • occurs after exposure to high radiation levels or estrogenic hormones (for example, prostate cancer treatment) Likely risk factors: • risk factors include o advanced age o positive family history o Jewish origin o black race

excess exposure to female hormones (Klinefelter's syndrome) o environmental exposure (irradiation) o alcohol o obesity o higher socioeconomic or higher educational status o childlessness o Reference - literature review (Can J Surg 2002 Aug;45(4):296 PDF) Possible risk factors: • gynecomastia as risk factor is controversial, the term is used for both histologic findings and physical findings Factors not associated with increased risk: • occupational exposure to magnetic fields not associated with increased risk of breast cancer in cohort of 28,224 electric utility workers (Occup Environ Med 2007 Nov;64(11):782 full-text) Complications and Associated Conditions Associated conditions: • male breast cancer patients at increased risk for second primary cancer o based on cohort of 1,926 men < 85 years old with first primary breast cancer in California Cancer Registry 1988-2003 o 221 (11.5%) developed second primary cancer (standardized incidence ratio [SIR] 1.16, 95% CI 1.01-1.32) o specific cancers with significantly increased risk were second primary breast cancer (SIR 52.1, 95% CI 31.8-80.5), cutaneous melanoma (SIR 2.98, 95% CI 1.63-5) and stomach cancer (SIR 2.11, 95% CI 1.01-3.88) o Reference - Breast Cancer Res 2007;9(1):R10 full-text History and Physical History: o

Chief concern (CC): • unilateral painless

breast mass

• pain or bloody discharge suggests advanced disease History of present illness (HPI): • breast cancer should be suspected in a man > 40 years

old presenting with a unilateral breast mass, particularly if painless and nontender

Medication history: • thorough history of

drug and hormone intake; however, similar percentage of men with breast cancer and gynecomastia are taking drugs that may cause gynecomastia Physical: Skin: •

skin ulceration suggests advanced disease Diagnosis Making the diagnosis: • histology Rule out: • gynecomastia

Testing overview: • no definitive diagnostic algorithm • physical exam and fine-needle aspiration by experienced physicians is diagnostically accurate and can reduce need of open biopsies (Am J Surg 1998 May;175(5):383 in Am Fam Physician 1998 Sep 15;58(4):983) Imaging studies: • mammography shows spiculated or circumscribed mass, but data limited, less informative for patients < 50 years old • mammography does not appear useful for diagnosis of male breast cancer o mammography appears unnecessary for routine evaluation of men with suspected breast cancer  220 men referred to breast clinic with history of breast lump  134 had mammography, 96% of which was done by protocol prior to exam by breast clinician  4 cases of breast cancer diagnosed, all of which were suspected on clinical exam and confirmed by biopsy  Reference - Breast 2006 Feb;15(1):123 o mammography does not appear to improve breast cancer detection over clinical exam  based on retrospective chart review of 198 men presenting for mammography  212 mammograms performed  9 (4%) mammograms had suspicious findings  8 biopsies performed (remaining mammogram clinically consistent with lipoma)  2 (1%) cases diagnosed as breast cancer after biopsy  203 mammograms had benign findings  110 of 132 cases of gynecomastia due to predisposing medical condition or taking predisposing medication  1 mammogram appeared benign but later diagnosed as breast cancer  all diagnosed cases of breast cancer were suspected at clinical exam  Reference - Mayo Clin Proc 2007 Mar;82(3):297 Biopsy and pathology: • fine-needle aspiration tends to overestimate rate of malignancy • most common histologic finding is infiltrating ductal adenocarcinoma Staging • American Joint Committee on Cancer (AJCC) staging for breast cancer Clinical Staging: Stage T N M Stage 0 Tis N0 M0 Stage IA T1* N0 M0 Stage IB T0 N1mi M0

Stage

Stage IIA Stage IIB

Stage IIIA Stage IIIB Stage IIIC Stage IV * T1 includes T1mi.

Clinical Staging: T T1* N1mi T0 N1** T1* N1** T2 N0 T2 N1 T3 N0 T0 N2 T1* N2 T2 N2 T3 N1-N2 T4 N0-N2 Any T N3 Any T Any N

N

M M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1

** T0 and T1 tumors with nodal micrometastases only are excluded from Stage IIA and are classified Stage 1B. M0 includes M0(i+) If a patient presents with M1 prior to neoadjuvant systemic therapy, the stage is considered stage IV and remains stage IV regardless of response to neoadjuvant therapy.

Stage designation may be changed if postsurgical imaging studies reveal the presence of distant metastases, provided that the studies are carried out within 4 months of diagnosis in the absence of disease progression and provided that the patient has not received neoadjuvant therapy.

Postneoadjuvant therapy is designated with "yc" or "yp" prefix. Of note, no stage group is assigned if there is a complete pathologic response (CR) to neoadjuvant therapy, for example, ypT0ypN0cM0.

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definitions of staging abbreviations o primary tumor (T)  TX - primary tumor cannot be assessed  T0 - no evidence of primary tumor  Tis - carcinoma in situ  Tis (DCIS) - ductal carcinoma in situ  Tis (LCIS) - lobular carcinoma in situ

Tis (Paget's) - Paget’s disease of nipple NOT associated with invasive carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in underlying breast parenchyma  T1 - tumor ≤ 20 mm in greatest dimension  T1mi - tumor ≤ 1 mm in greatest dimension  T1a - tumor > 1 mm but ≤ 5 mm in greatest dimension  T1b - tumor > 5 mm but ≤ 10 mm in greatest dimension  T1c - tumor > 10 mm but ≤ 20 mm in greatest dimension  T2 - tumor > 20 mm but ≤ 50 mm in greatest dimension  T3 - tumor > 50 mm in greatest dimension  T4 - tumor of any size with direct extension to chest wall and/or to skin (ulceration or skin nodules), but invasion of dermis alone does not qualify as T4  T4a - extension to chest wall, not including only pectoralis muscle adherence/invasion  T4b - ulceration and/or ipsilateral satellite nodules and/or edema (including peau d'orange) of skin which do not meet criteria for inflammatory carcinoma  T4c - both T4a and T4b  T4d - inflammatory carcinoma  restricted to cases with typical skin changes involving at least one-third of skin of breast  histologic presence of invasive carcinoma invading dermal lymphatics supportive of diagnosis, but not required  dermal lymphatic invasion without typical clinical findings not sufficient for diagnosis of inflammatory breast cancer regional lymph nodes (N)  NX - regional lymph nodes cannot be assessed (for example, previously removed)  N0 - no regional lymph node metastases  N1 - metastases to movable ipsilateral level I, II axillary lymph node(s)  N2 - metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted; or in clinically detected ipsilateral internal mammary nodes in absence of clinically evident axillary lymph node metastases  clinical detection classification based on axillary lymph node dissection with or without sentinel lymph node biopsy  classification based solely on sentinel lymph node biopsy without subsequent axillary lymph node dissection designated (sn) for "sentinel node", for example, pN0(sn) 

o

N3 - metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement; or in clinically detected ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement  clinical detection classification based on axillary lymph node dissection with or without sentinel lymph node biopsy  classification based solely on sentinel lymph node biopsy without subsequent axillary lymph node dissection designated (sn) for "sentinel node", for example, pN0(sn) o distant metastasis (M)  M0 - no clinical or radiographic evidence of distant metastases (no pathologic M0; use clinical M to complete stage group)  cM0(i+) - no clinical or radiographic evidence of distant metastases, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal tissue that are ≤ 0.2 mm in patient without symptoms or signs of metastases  M1 - distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven > 0.2 mm • information, including clinical staging form and information on pathologic classification, can be found at AJCC PDF • Used with the permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer SBM, LLC. Treatment Treatment overview: • if stage II disease or greater - modified radical mastectomy followed by chemotherapy • radiotherapy does not seem to add any benefit Medications: • chemotherapy regimens o cyclophosphamide-methotrexate-5-fluorouracil o 5-fluorouracil-Adriamycin-cyclophosphamide • tamoxifen o disease is highly receptor-positive o many patients discontinue tamoxifen due to side effects Surgery and procedures: • radical mastectomy • modified radical mastectomy considered if pectoralis major not involved • occasionally lumpectomy and axillary dissection and postoperative RT if small primary tumor and not invading nipple-areola • castration is principal means of endocrine control 

breast conserving surgery with nipple-areola complex preservation in case report (J Med Case Reports 2008 Apr 28;2:126 full-text) Prognosis • worse than female stage for stage, presents at later stage, men with breast cancer delay presentation for medical care o stage I - 38% 10-year survival o stage II - 10% 10-year survival o stages III and IV lethal • men may have longer breast cancer-specific survival than women (level 2 [midlevel] evidence) o based on 2 observational studies o retrospective study compared 53 men vs. 53 women with breast cancer matched on age, date of diagnosis, stage and primary histologic findings  no significant difference in overall survival at 5 years (77% vs. 77%) or 10 years (56% vs. 51%)  men had higher breast cancer-specific survival at 5 years (90% vs.

81%) and 10 years (90% vs. 70%) but were more likely to die from other causes  Reference - Arch Surg 2004 Oct;139(10):1079 full-text o international cohort study of 459,846 women and 2,665 men diagnosed with breast cancer between 1970 and 2007  breast cancer-specific survival longer in men than women after adjustment for age, year of diagnosis, stage, and treatment (relative excess risk 0.78, 95% CI 0.62-0.97)  Reference - J Clin Oncol 2011 Nov 20;29(33):4381 • skin thickening and ulceration indicate poor prognosis • most important prognostic factors are tumor size, lymphatic invasion and axillary node status • increased age at diagnosis and advanced tumor size associated with higher mortality in series of 75 cases of primary male breast cancer (World J Surg Oncol 2005 Mar 2;3(1):16 full-text) • male breast cancer patients at increased risk for second primary cancer o based on cohort of 1,926 men < 85 years old with first primary breast cancer in California Cancer Registry 1988-2003 o 221 (11.5%) developed second primary cancer (standardized incidence ratio [SIR] 1.16, 95% CI 1.01-1.32) o specific cancers with significantly increased risk were second primary breast cancer (SIR 52.1, 95% CI 31.8-80.5), cutaneous melanoma (SIR 2.98, 95% CI 1.63-5) and stomach cancer (SIR 2.11, 95% CI 1.01-3.88) o Reference - Breast Cancer Res 2007;9(1):R10 full-text Prevention and Screening • not applicable Quality Improvement Physician Quality Reporting System Quality Measures: •

99. Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade o Percentage of breast cancer resection pathology reports that include the pT category (primary tumor), the pN category (regional lymph nodes), and the histologic grade • 194. Oncology: Cancer Stage Documented o Percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are seen in the ambulatory setting who have a baseline American Joint Committee on Cancer (AJCC) cancer stage or documentation that the cancer is metastatic in the medical record at least once within 12 months • see Physician Quality Reporting System Quality Measures for additional information Guidelines and Resources Guidelines: •

United States guidelines: • National Academy of

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Clinical Biochemistry (NACB) guidelines on use of tumor markers in testicular, prostate, colorectal, breast, and ovarian cancers can be found in Clin Chem 2008 Dec;54(12):e11 full-text or at National Guideline Clearinghouse 2010 Sep 17:15553 National Comprehensive Cancer Network (NCCN) guideline on breast cancer can be found at NCCN website (free registration required)

United Kingdom guidelines: • Association of Breast

Surgery guideline on surgical management of breast cancer can be found in Eur J Surg Oncol 2009;35 Suppl 1:1

European guidelines: • Haute Autorité

de Santé (HAS) conseils sur cancer du sein se trouvent sur le site Haute Autorité de Santé 2010 Jan [French] Review articles: • review can be found in World J Surg Oncol 2008 Jun 16;6:58 full-text • review can be found in Lancet 2006 Feb 18;367(9510):595, correction can be found in Lancet 2006 Jun 3;367(9525):1818 • review can be found in Ann Intern Med 2002 Oct 15;137(8):678, summary can be found in Am Fam Physician 2003 Feb 1;67(3):643, commentary can be found in Ann Intern Med 2003 Aug 19;139(4):305 • review of consensus conference III on image-detected breast cancer; state-of-the-art diagnosis and treatment can be found in J Am Coll Surg 2009 Oct;209(4):504 • editorial review can be found in BMJ 2003 Mar 8;326(7388):539 full-text, commentary can be found in BMJ 2003 Oct 18;327(7420):930 and 930 • series of 229 cases can be found in Cancer 1999 Feb 1;85(3):629 (J Watch 1999 Mar 15;19(6):47) • case report of secretory carcinoma can be found in World Journal of Surgical Oncology 2005 Jun 17;3:35 MEDLINE search:

to search MEDLINE for (Breast cancer in men) with targeted search (Clinical Queries), click therapy, diagnosis, or prognosis Patient Information • multi-page handout from National Cancer Institute or in Spanish • multi-page handout from American Cancer Society • handout from Cancer Research UK • handout from MacMillan Cancer Support • information on breast cancer from MacMillan Cancer Support • information on secondary breast cancer from MacMillan Cancer Support ICD-9/ICD-10 Codes ICD-9 codes: • 175.0 malignant neoplasm of nipple and areola of male breast • 175.9 malignant neoplasm of other and unspecified sites of male breast ICD-10 codes: • C50 malignant neoplasm of breast o C50.0 nipple and areola o C50.1 central portion of breast o C50.2 upper-inner quadrant of breast o C50.3 lower-inner quadrant of breast o C50.4 upper-outer quadrant of breast o C50.5 lower-outer quadrant of breast o C50.6 axillary tail of breast o C50.8 overlapping lesion of breast o C50.9 breast, unspecified  ICD-10-CA modification in Canada: code range C50.0-C50.9 subdivided and fourth digit added to identify laterality  0 right  1 left  9 unspecified side • Z80.3 family history of malignant neoplasm of breast • Z85.3 personal history of malignant neoplasm of breast References General references used: • literature review of 50 articles (Can J Surg 2002 Aug;45(4):296) • AJR Am J Roentgenol 1995 Apr;164(4):853 PDF in QuickScan Reviews in Fam Pract 1995 Oct:33 • Am J Surg 1995 Jul;170(1):24 in QuickScan Reviews in Fam Pract 1996 Jan:13 DynaMed editorial process: • DynaMed topics are created and maintained by the DynaMed Editorial Team.

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