Higher rates of male breast cancer in central and eastern Africa could be related to higher liver infectious diseases that lead to hypoestrogenism.
By Dr Kumardeep Dutta Choudhury
Breast cancer is rarely witnessed in men. It has many similarities with breast cancer in women, but there are some significant differences too. Male breast cancer represents between 0.5 to 1 percent of all breast cancers diagnosed every year. In central Africa, male breast cancer accounts for 6 percent of total breast cancers. Higher rates of male breast cancer in central and eastern Africa could be related to higher liver infectious diseases that lead to hypoestrogenism.
Male Breast Cancer: What are the risk factors to assess?
Genetics and family history — History of breast cancer in a first-degree relative increases the risk of breast cancer among men. Approximately 15 to 20 percent of men with breast cancer have a family history of the disease. The risk is also higher among the men with inherited BRCA2 mutation rather than BRCA1 mutations. Other genes which are associated with an increased risk of breast cancer in men are PTEN tumor suppressor gene (Cowden syndrome), tumor protein p53 (TP53; Li-Fraumeni syndrome), partner and localizer of BRCA2 (PALB2), and mismatch repair genes (Lynch syndrome).
Alterations in the estrogen to androgen ratio — Excessive estrogen stimulation may be due to hormonal therapies (e.g., estrogen-containing compounds or testosterone), hepatic dysfunction, obesity, marijuana use or thyroid disease.
Primary testicular conditions — Testicular conditions that may increase risk of breast cancer in men including orchitis, undescended testes (cryptorchidism), and testicular injury.
How to diagnose male breast cancer?
Male breast cancer is generally diagnosed at a more advanced stage than female breast cancer, due to lack of awareness. In most of the cases, there is presence of painless, firm mass that is usually subareolar, with nipple involvement in 40 to 50 percent of cases. The involvement of the left breast is slightly more often than the right breast, and less than 1 percent of cases are bilateral. Patients may experience skin changes, including nipple retraction, ulceration, and fixation of the mass to the skin or underlying tissues. Axillary nodes are typically palpable in advanced cases.
Most histologic subtypes of breast cancer observed in women are also present in men. Although, men with breast cancer are rarely diagnosed with lobular carcinomas due to lack of acini and lobules in the normal male breast, these can be induced in the context of estrogenic stimulation.
Male breast cancer treatment: What is the role of surgery?
Approach to treatment in men is the same as that for women. However, the role of breast conserving surgery is limited because of the small volume of breast tissue. In hormone receptor-positive disease, adjuvant tamoxifen is given rather than an aromatase inhibitor (AI), due to insufficient evidence to support AI monotherapy for men. If there are contraindications with tamoxifen (e.g., hypercoagulable state), an AI with GnRHa may be administered. As AIs do not reduce testicular production of estrogens, GnRHa is administered concurrently with AI. They are treated with mastectomy, radiotherapy, chemotherapy and hormone therapy.
Limited available data suggest that these patients are at an increased risk of contralateral breast cancer; however, absolute risk is low. They are also at a risk for secondary malignancies. 12.5 percent may develop a second primary cancer. The most common types are gastrointestinal, pancreas, non-melanoma skin, and prostate cancer.
Survival rates according to the data from last 10 years suggest disease-specific survival rates for histologically negative nodes between – 77 and 84 percent, one to three positive nodes – 50 and 44 percent and four or more histologically positive nodes – 24 and 14 percent.
The author is a Sr Consultant & Head of Department, Medical Oncology, Fortis Hospital, Noida. Views expressed are the physician’s own.