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.

General Considerations

Breast cancer in men is a rare disease; the incidence is only about 1% of that in women. The average age at occurrence is about 60—somewhat older than the commonest presenting age in women. The prognosis, even in stage I cases, is worse in men than in women. Blood-borne metastases are commonly present when the male patient appears for initial treatment. These metastases may be latent and may not become manifest for many years. 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 a damaged liver associated with vitamin B deficiency.

Clinical Findings

A painless lump, occasionally associated with nipple discharge, retraction, erosion, or ulceration, is the chief 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. Nipple discharge is an uncommon presentation for breast cancer in men, as it is in women. However, nipple discharge in a man is an ominous finding associated with carcinoma in nearly 75% of cases.

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 of a breast lesion in a man. Biopsy settles the issue.

Treatment

Treatment consists of modified radical mastectomy in operable patients, who should be chosen by the same criteria as women with the disease. 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 receptor proteins may prove to be of value in predicting response to endocrine ablation. Adjuvant chemotherapy is used for the same indications as in breast cancer in women.

Since breast cancer in men is frequently a disseminated disease, endocrine therapy is of considerable importance in its management. Castration in advanced breast cancer is the most successful palliative measure and more beneficial than the same procedure in women. Objective evidence of regression may be seen in 60–70% of men who are castrated—approximately twice the proportion in women. The average duration of tumor growth remission is about 30 months, and life is prolonged. Bone is the most frequent site of metastases from breast cancer in men (as in women), and castration relieves bone pain in most patients so treated. The longer the interval between mastectomy and recurrence, the longer the tumor growth remission following castration. As in women, there is no correlation between the histologic type of the tumor and the likelihood of remission following castration.

Tamoxifen (10 mg orally twice daily) is becoming increasingly popular and should replace castration as the initial therapy for metastatic disease. However, little clinical experience is available with tamoxifen in male breast cancers. aminoglutethimide (250 mg orally four times a day) should replace adrenalectomy in men as it has in women. Corticosteroid therapy alone has been considered to be efficacious but probably has no value when compared with major endocrine ablation.

Estrogen therapy—5 mg of diethylstilbestrol three times daily orally—may be effective as secondary hormonal manipulation after medical adrenalectomy (with aminoglutethimide). Androgen therapy may exacerbate bone pain. Castration and tamoxifen are the main therapeutic resources for advanced breast cancer in men at present. Chemotherapy should be administered for the same indications and using the same dosage schedules as for women with metastatic disease.

Prognosis

The prognosis of breast cancer is poorer in men than in women. The crude 5- and 10-year survival rates for clinical stage I breast cancer in men are about 58% and 38%, respectively. For clinical stage II disease, the 5- and 10-year survival rates are approximately 38% and 10%. The survival rates for all stages at 5 and 10 years are 36% and 17%.