November 25, 2022 Author : Sílvia Alexandre Silva On average, breast cancer in men occurs 5-10 years later than in women and has a peak incidence around age 65. Male breast cancer is rarely diagnosed in asymptomatic stages . In fact, men are almost never aware of this disease and there is no indication of screening tests for the general population. More than 40% of cases are diagnosed in stages III and IV, and therefore have a worse prognosis. Symptoms and diagnosis The most common symptom of breast cancer in men is a breast lump . In most cases, this lump is not painful, it is located behind the nipple (it is retroareolar), but it is not centered to it. This eccentric location in relation to the nipple is important in the differential diagnosis with gynecomastia, which is the most common benign breast condition in men. Other possible symptoms of breast cancer are nipple discharge with traces of blood (hematic), skin retraction, nipple retraction or even ulcerations (open sores). Similar to what is done in women, the diagnosis of breast cancer in men is based on: Clinical exam; Imaging exam results; Anatomopathological study. Imaging exams When breast alterations are detected in the clinical exam, a bilateral mammography study should be requested, complemented by an ultrasound evaluation . In the face of a suspicious breast lesion, the ultrasound should cover the axilla, as metastasis to the axillary lymph nodes occurs in more than 50% of cases of male breast cancer. Other imaging tests, namely to exclude distant disease metastasis, such as computed tomography or bone scintigraphy, can be performed depending on the particularities of each case. Anatomopathological study Breast biopsy allows carrying out the anatomopathological study, which is fundamental for the definitive diagnosis and, if it is confirmed that it is breast cancer, to carry out its biological characterization, which has implications for the definition of the treatment. Mammary gland cells are responsible for milk production. Thus, the male breast has much less glandular tissue than the female breast, it is made up of ducts without terminal lobules. This different constitution means that the location and relative importance of the types of breast cancer are also different. In man: 40%-50% of cases involve the areola-nipple; Invasive ductal carcinoma represents about 85% of cases; Invasive lobular carcinoma is rare, accounts for about 1%-2% and is most often associated with Klinefelter syndrome. In women, this type of carcinoma represents 15% of cases. When it comes to hormone receptors there are also differences: The expression of hormone receptors for estrogens and progesterone is higher in men than in women, with values of 80% and 60%, respectively; In men, p53 and Cerb-B2 positive breast cancers are less frequent (5%); Male breast cancer is often positive for androgen receptors, which implies a differential diagnosis between a primary breast tumor and metastasis of prostate cancer. Treatment of male breast cancer The treatment of breast cancer should ideally be carried out by several specialties, medical and surgical, with differentiation in this pathology , who work in an integrated manner in a dedicated functional unit. Surgery Surgery is the main therapy for breast cancer in men in the early stages , as it happens in women. However, unlike these, men are rarely candidates for conservative surgery. In a conservative surgery, the tumor is excised with a safety margin and the remaining breast is preserved. Usually, surgery is followed by radiotherapy. The more central location of male breast tumors and the lesser impact on body harmony means that surgical excision of the entire breast ( total mastectomy ) and an axillary procedure, which may be a sentinel node biopsy or axillary lymphadenectomy, are generally performed, the latter associated with greater morbidity. The adjuvant treatments of surgery by radiotherapy, chemotherapy and hormone therapy are decided mainly based on the guidelines for the treatment of breast cancer in women. In many cases radiotherapy after mastectomy is unnecessary. Hormone therapy Tamoxifen is the most used anti-estrogen therapy in hormone-sensitive breast cancer , both in men and women. Several studies have shown low adherence to this therapy by men, probably due to possible side effects, for example: Weight gain; Sexual dysfunction and decreased libido; Diaphoresis (excessive sweating); Emotional lability; Venous thrombosis. In men, aromatase inhibitors are not an alternative as good as in women because they only inhibit the formation of estrogens in peripheral fat (80%) and the remaining 20%, produced by the testicles, are not affected. In the few cases of HER2-positive male breast cancer, the recommendations for the female population are followed, with direct anti-HER2 therapy. Approach in advanced disease For locally advanced breast cancers, with skin ulceration, chest wall involvement or major lymph node involvement, the initial therapeutic approach is medical, with chemotherapy and hormone therapy depending on the biological characteristics of the tumor. In cancers with disseminated disease (incurable disease), there is generally no indication for surgical treatment. Patients undergo chemotherapy, radiotherapy and hormone therapy according to the biological characteristics of the tumor, its general condition and any comorbidities that may be present. Prognosis In general, in men with breast cancer, the prognosis is worse than in women , for which contribute: Diagnosis at more advanced stages and ages; The presence of comorbidities that limit treatment possibilities. The size of the tumor and the number of lymph nodes involved at the time of diagnosis are important factors for the prognosis. Triple-negative and HER2-positive subtypes have a worse prognosis. Overall survival at 5 and 10 years after breast cancer diagnosis in men is 60% and 40%, respectively. Read also about incidence and risk factors for male breast cancer . Meet the general surgery clinical teamf rom Hospital da Luz network and book your consultation The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
