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21 October 2019

Especially during October, when everything seems to be painted pink, it’s easy to overlook the fact that breast cancer is a disease of women and men. Male breast cancer accounts for 0.6 – 1.0% of all breast cancer cases. In the US, approximately 2600 men will be diagnosed with breast cancer each year. The lifetime risk is about 1 in 1000, versus 1 in 8 for women. Male breast cancer accounts for approximately 500 deaths in the US per year. Risk factors include increasing age, family history including BRCA gene mutations, obesity, alcohol intake, prior chest wall radiation, and low androgen hormone levels.

Male breast cancer tends to be diagnosed in later stages compared with breast cancer in women, and previous studies have come to conflicting conclusions about whether the poorer outcomes are due to higher stage at diagnosis or other factors. A study recently published in JAMA Oncology* looked at mortality rates among men and women diagnosed with breast cancer. The researchers used the National Cancer Database (NCDB) and compared men and women who were diagnosed with breast cancer between January 2004 – December 2014. Their data analysis included approximately 16,000 men and 1.8 million women. Some of the key findings:

  • Mean age at diagnosis was 63.3 for men and 59.9 for women
  • 3-year survival was 86.4% for men and 91.7% for women
  • 5-year survival was 77.6% for men and 86.4% for women
  • Overall survival was 45.8% for men and 60.4% for women

Men diagnosed with breast cancer were older, were more likely to be diagnosed at advanced stages, and were less likely to receive conventional therapy. However, differences in survival persisted even after controlling for clinical characteristics of the disease, age, race and ethnicity, and access to care. Limitations of this study are that cause of death could not be determined (so it is not clear if all of the deaths are related to breast cancer) and the NCDB does not contain information on recurrence, BRCA gene status, adherence to treatment recommendations, and other medical conditions. However, the researchers concluded that male sex remained a significant risk factor for poorer outcomes, which suggests that there are biological differences in male versus female breast cancer. 

Another study recently published in the journal Cancer* also used NCDB information to look at treatment trends for men treated for breast cancer from a similar time period. The authors evaluated approximately 10,000 cases and noted that:

  • 24% underwent breast conserving surgery (lumpectomy)
  • 70% of those undergoing lumpectomy received radiation
  • 44% of patients received chemotherapy
  • 62% of those with estrogen receptor positive (ER+) breast cancer received endocrine therapy
  • 35% of those with ER+ / lymph node negative breast cancer had Oncotype Dx testing on their tumor to help determine need for chemotherapy

These findings are consistent with a point made in the JAMA Oncology study noting that men were less likely to receive conventional therapy – for example only 62% with ER+ breast cancer received endocrine therapy and only 70% of those undergoing breast conserving surgery were treated with postoperative radiation therapy. Some of the same limitations apply to this study, in that reasons for differences in therapy could not be determined, and there was no information on disease recurrence.

A few other important points to make about male breast cancer:

  • Most male breast cancer presents as a lump, but as in women, most lumps are not cancerous. It is important that a proper evaluation (usually including a mammogram and ultrasound, and possibly biopsy) be performed for any change
  • As in women, male breast cancer may present with nipple discharge (especially blood), “puckering” or “pulling in” of the skin, or severe redness of the skin which can be mistaken for infection – the latter may indicate a more aggressive type of breast cancer known as inflammatory breast cancer
  • ALL men with breast cancer, and anyone with a family history of male breast cancer, should undergo genetic counseling and testing. As in women, most cases of male breast cancer are “sporadic” (not related to an inherited mutation), but men with breast cancer are more likely to carry deleterious BRCA (especially BRCA 2) mutations
  • Men who carry a deleterious BRCA mutation have an approximately 8% lifetime risk (to age 80) of developing breast cancer. So while that is considered “high risk” for men, they are still more likely to NOT develop breast cancer. We do not currently recommend prophylactic mastectomy in men who carry a deleterious BRCA mutation but who have not been diagnosed with breast cancer
  • Men who carry a deleterious BRCA mutation are also at higher risk for prostate cancer, melanoma, and pancreatic cancer

Men with breast cancer are usually treated using the same protocols that are used for women. Unfortunately there is limited data to support this. Male breast cancer is not common, so it is challenging to enroll large numbers of patients in clinical trials. However, men have historically been excluded from many breast cancer clinical trials, so how can we even make progress? The US FDA has recently issued draft guidelines encouraging the inclusion of male breast cancer patients in clinical trials – this is certainly a step in the right direction.

*If you are not able to access the full study and would like a copy, please email me: contact at drattai dot com

Additional Information:

2 October 2016

October is National Breast Cancer Awareness Month (NBCAM), which means pink is everywhere. Stores start setting out pink merchandise towards the end of September, and the displays often rival Christmas merchandising. How did this happen?

The original pink ribbon was actually peach. A woman by the name of Charlotte Haley made them in her home, and handed them out with cards stating: “The National Cancer Institute annual budget is $1.8 billion, only 5 percent goes for cancer prevention. Help us wake up our legislators and America by wearing this ribbon.” Ms. Haley was then approached by SELF magazine and breast cancer survivor Estee Lauder, who wanted to use the ribbon as part of a breast cancer awareness issue. Ms. Haley turned them down as she didn’t want her efforts to become overly commercialized. As the magazine and Ms. Lauder needed a symbol, the pink ribbon was born. The Susan G. Komen Foundation handed them out at their 1991 race, and in 1992 it officially became the symbol of NBCAM.

Many women who have been treated for breast cancer wear pink to signify their struggles with the disease. Family members and friends often wear pink to show their support of a loved one. For some, wearing pink is an important show of strength and solidarity. However, not everyone feels comfortable with being “branded” in such a way – a patient once asked me “I don’t HAVE to wear pink, do I?” Men with breast cancer have traditionally been left out from such movements, although the pink and blue ribbon now is used for male breast cancer awareness campaigns.

We all want do do something to help end a disease that impacts so many. Many organizations host  “save the *** (boobies, tatas, etc)” campaigns, all in the name of breast cancer awareness. Awareness is important – increased awareness is one reason that many women no longer feel embarrassed about going to a physician when they feel a lump in their breast. Not everyone is aware – there are still women and men diagnosed at later stages, especially in minority and underserved populations. But awareness and early detection do not equal cure. Awareness is not enough. Research is needed. Why do some women and men develop breast cancer? Why do some breast cancers spread? Why do some patients respond to treatment and some do not? Why do 40,000 women in the US alone still die due to metastatic breast cancer? We do not have prevention, and we do not have a cure.

Money is needed to fund worthy research projects, initiatives aimed at improving access to care as well as support programs. However, pink merchandise is not necessarily the answer – we can’t shop our way out of breast cancer. It is important in October and all year to “think before you pink“. The term “pink washing” has been applied to the practice of some organizations using pink for the sole purpose of raising their own brand awareness. A tag noting “in support of breast cancer awareness” sometimes means just that – no dollars donated, just “awareness”. Some of the marketing campaigns even promote products that may actually increase breast cancer risk, such as alcohol .

Directly donating to organizations that perform or fund cancer research is one way to help. Patients with breast cancer also need support services. There are many organizations ranging from large national ones to local community nonprofits that provide a variety of free services such as transportation, counseling, financial aid to cover insurance gaps, and even childcare. Before you donate to a nonprofit organization, first confirm that they are legitimate – Charity Navigator, GuideStar, or a similar site can help. In addition, do some basic research – make sure that the organization’s mission is aligned with your preferences. Do you want to help fund education or awareness campaigns, support services, research on metastatic disease, or research on prevention? A quick review of an organization’s mission statement can ensure that you are donating to a cause that you support.

So this fall, think twice about buying those pink breath mints. If you want to make a purchase to honor a loved one, make sure you know whether or not any money will be donated for breast cancer research, education, or support. If you are donating to an organization, make sure that organization is funding programs that you support.

Also realize that you also don’t need to spend a lot of (or any) money to make a difference. Nonprofit organizations and cancer centers are usually happy to have volunteers. If you want to make it more personal, offer to cook meals, do a few loads of laundry or clean the house for someone you know who is being treated for breast cancer. Provide transportation (and company) for appointments. Offer to take someone’s kids for the afternoon so the patient can get some rest. The possibilities are endless.

This October, you can make a difference, and it doesn’t have to involve purchasing a pink kitchen appliance.

Updated 1 October 2019