The majority of men with localized breast cancer undergo mastectomy, rather than breast-conserving therapy, despite comparable cause-specific survival between these treatments, according to a new database analysis (Int J Radiat Oncol Biol Phys 2013;87:747-752). Moreover, when compared with the situation in women, men with locally advanced disease are less likely to receive postmastectomy radiation.
“That men aren't routinely treated with breast-conservation therapy certainly is not surprising,” said the study's lead researcher, Rachel Rabinovitch, MD, an investigator at the University of Colorado (CU) Cancer Center and Professor of Radiation Oncology at the CU School of Medicine. However, because data are difficult to collect, “identifying a population of men who did get breast conservation and who had equivalent outcomes to men who had undergone mastectomy was unexpected,” she said.
Gender bias and assumptions about men are being made when they aren't given the option of breast-conserving treatment, said Rabinovitch, adding that this study comparing male and female cancer patients “opens the box on the whole discussion of what treatment should be offered to men.”
Asked for her opinion for this article, Sharon H. Giordano, MD, MPH, Professor of Medicine and Internist in the Department of Breast Medical Oncology at the University of Texas MD Anderson Cancer Center, agreed and said that the finding that men have breast-conserving treatment less often than women isn't surprising due to the physical differences between the sexes. “Men just don't have as much breast tissue,” she said.
Moreover, cosmetic differences resulting from mastectomy compared with lumpectomy may be less noticeable in men than in women. “Just because men are having more mastectomies doesn't mean that they're all being treated inappropriately.”
Still, one finding of concern in the study was the lower use of postmastectomy radiation in men: “This could maybe indicate a gap in treatment in men versus women,” Giordano said.
Overall, “this paper gets us to think about breast conservation more often than we probably do,” said Beth Siegel, MD, FACS, Director of the Breast Center at New York Hospital Queens. “It's reasonable to talk to men about their treatment options instead of automatically having a knee jerk reaction and proceeding to mastectomy.”
Using data from the Surveillance, Epidemiology and End Results (SEER) registry, the researchers identified 4,276 men and 718,587 females diagnosed with primary invasive breast cancer from 1973 to 2008. Overall, 0.6 percent of the breast cancer cases occurred in men. Breast cancer in women was diagnosed at a median age of 60 to 64 versus age 65 to 69 in men.
Forty-two percent of men presented with regional disease compared with 31 percent of the women. Additionally, eight percent of males presented with distant disease versus six percent of females. Between the years of 1998 and 2008, a total of 77.1 percent of men and 67.1 percent of women were estrogen-receptor positive, while 65.5 percent of men and 55.8 percent of women were progesterone-receptor positive.
Overall, 67.3 percent of men with breast cancer versus 38.3 percent of women with the disease received mastectomy, while 9.7 percent of men versus 42.6 percent of women had breast-conserving surgery. When the investigators excluded patients with non-curative surgery from the analysis, 12.6 percent of men and 52.6 percent of women received breast-conserving treatment.
In males with localized disease, cause-specific survival was not significantly different for the 4.6 percent who received lumpectomy with radiation compared with the 70 percent treated only with mastectomy (hazard ratio 1.3).
The investigators also found that 33.6 percent of men with regional breast cancer received postmastectomy radiation, compared with 44.8 percent of women. This was “a disappointing finding,” said Rabinovitch. “We should be treating the disease the same way as in women.”
However, the researchers did not observe a cause-specific survival benefit for male patients who received this treatment.
Overall, cause-specific survival for breast cancer in men improved over time, with the largest significant change occurring in those diagnosed between 1998-2008 compared with 1973-1987 (HR 0.73). The improvements identified in the survival of male breast cancer patients are interesting because this population isn't screened as with women, Rabinovitch noted, so any improvements in male survival are likely due to better treatments, she said.
Challenges with Surgery and Radiation in Men
The standard of care in appropriately selected female patients is usually breast-conserving surgery with radiation, Siegel said. In men, breast cancer is usually centrally located—i.e., adjacent to the nipple, behind it, or growing into it, often dictating the need for a mastectomy, she said.
Men generally present with larger tumors and have less breast tissue, so using breast-conserving therapy to spare the nipple-areola complex may not be possible, said Julia White, MD, Director of Breast Radiation Oncology at the Ohio State University Comprehensive Cancer Center and Breast Cancer Working Group Chair of the Radiation Therapy Oncology Group.
Furthermore, said Richard J. Bleicher, MD, FACS, Associate Professor in the Department of Surgical Oncology at Fox Chase Cancer Center, based on the study data, “we can't definitively make the determination of whether breast conservation is safe in men.”
The researchers evaluated cancer-specific survival but did not assess overall survival. The risks associated with surgery and radiation, including cardiac and pulmonary complications and related deaths, need to be considered, he said, adding that because men have a smaller breast size, tumors may develop closer to the chest wall and heart.
He pointed to another recent study (Ann Surg Oncol 2012;19:3199-3204?) evaluating overall survival and gender differences in breast cancer treatment using the National Cancer Data Base, which found that men were more likely to undergo mastectomy and less likely to receive radiation. Women had a better five-year overall survival rate than men for Stages 0, I, and II disease, while there were no differences for Stages III and IV, he noted.
“I believe that breast conservation in men is probably safe, although we don't typically do it because, right now, we don't quite have the data to support the approach.”
Another consideration is that the cosmetic difference between lumpectomy and mastectomy is small, Siegel said. In addition, mastectomy provides better margins and usually doesn't require postoperative radiation for local control as does lumpectomy.
If male patients are candidates for both types of surgery and the cancer is behind the nipple-areola complex, they may likely choose to have a mastectomy because a lumpectomy will still require removing the nipple and undergoing radiation, Giordano explained.
One concern the study raised is that men who undergo mastectomy for lymph node positive cancer may not receive postoperative radiation when it would be appropriate, noted White. Postmastectomy radiation in men with positive lymph nodes is likely a critical component to preventing distant metastases and improving this population's overall cure rate as it has been documented to do in women, she said.
Also asked for his opinion, Rahul Tendulkar, MD, a radiation oncologist at Cleveland Clinic, said that in the absence of definitive data in the literature about which men should receive radiation, oncologists are left to use their clinical judgment and to extrapolate from indications for radiation in women. Overall, relatively fewer men receive radiation because “we may not always have as clear an indication for when radiation should be utilized in these patients as we do with women.”
How Male Breast Cancer May Differ
Whether male and female breast cancer is the same disease has been a topic of speculation over the years, and it is still difficult to say for sure due to lack of data, White said. However, the new study found that breast cancer in males tends to be diagnosed at an older age, is more frequently ER-positive, and is more often larger and node positive when compared with the disease in women.
“This makes you think they are similar diseases biologically but not exactly the same,” she said.
Oncologists often assume that breast cancer is similar in men and women, but certain observations do suggest otherwise, said Bleicher. For example, researchers have noticed clusterings of male breast cancer cases for unknown reasons, and male breast cancer also presents with different margins and grades.
In addition to higher rates of ER-positive tumors and more invasive breast cancer, men tend to have less triple-negative breast cancer than women do, Giordano said.
Overall, male patients don't fare as well because they are generally diagnosed at a later stage, but stage for stage, men and women tend to have similar outcomes, Siegel said.
Talking About Breast Conservation with Men
Men who are diagnosed with breast cancer should be encouraged to talk with their doctors about all available treatment options, including breast-conservation therapy, Tendulkar said. Patients who are truly motivated to maintain their cosmetic appearance should discuss whether they are candidates for this approach.
He said he has seen one male patient with breast cancer who opted for a lumpectomy because he was concerned about cosmetic appearance due to his areola being removed. Most men, however, don't seem to be particularly concerned about the cosmetic impact of having a mastectomy, Tendulkar said.
“In comparison, although there are physical, psychosocial, cosmetic, and functional reasons women decide to preserve their native breast, in men, a lot of those issues don't come under consideration.”
Despite potential psychosocial differences, oncologists should address what a mastectomy scar looks like and consider that there are men who do care about their appearance, Rabinovitch said. “They may spend time with their shirts off at the beach and the deformity of a mastectomy may have a negative impact on their sex lives.”
And, concluded Bleicher, while having a conversation about breast conservation in men is reasonable, there also needs to be an extensive informed-consent discussion.