Breast cancer in men is rare in daily practices. Treatment takes place in different hospitals throughout the Netherlands. The breast cancer guideline is used for the treatment of men with breast cancer, where much of the treatment is derived from the treatment of women with breast cancer. (NABON 2012): https://richtlijnendatabase.nl/richtlijn/borstkanker2017/borstkanker_bij_mannen.html
Men with breast cancer differ in a number of respects from women with breast cancer, but there are also similarities in, for example, the treatment that is given. The important points for attention for the breast cancer and treatment for men are listed in this overview.
Figures for invasive breast cancer versus DCIS
A comparison of figures from the Dutch Cancer Registry of men and women with invasive breast cancer or carcinoma in situ with a diagnosis in the past 5 years (2011-2015) shows differences on a number of points. There are around 100 new men with invasive breast cancer every year, which makes the disease rare in men, compared to more than 15,000 women. Percentually, men account for only 0.6% of the total population of breast cancer patients. Carcinoma in situ is less common in men than in women. Men have DCIS in about 5-10% of cases, compared to 90-95% of men with invasive carcinoma. No screening takes place for men, unlike women, for whom this is common practice. (Cancer registration)
Increase in incidence and prevalence
There has been an increase in the number of new breast cancer cases in men and women in recent decades. Increasing the incidence and improving the chances of survival means this will also lead to a further increase in prevalence. (NABON 2012):
Age at diagnosis
The average age of a man with breast cancer was 68 in the group of patients diagnosed with invasive breast cancer or carcinoma in situ in the period 2011-2015. The youngest man was 18 years old and the oldest was 100 years old. This shows men are, on average, older when they develop breast cancer or carcinoma in situ, but this disease can occur in men of all ages. The average age of a man with breast cancer is 7 years older than the average age of a woman, who is 61 years old, with a range of 18 to 103 years old. (Cancer registration) old.
Breast tissue is the same for both boys and girls until puberty. In puberty, breast tissue develops under the influence of hormones in women, while breast tissue remains underdeveloped in men. Breast tissue primarily consists of fatty tissue, few ducts/milk ducts and almost no lobules/milk glands in an adult male. (Lattin et al. 2013)
All histological subtypes can occur in men, as in women, but in most cases (90-95%) there is an invasive ductal carcinoma, just like in women. Lobular carcinoma is much less common (1-2%) in men than in women, because the lobules/mammary glands are often not, or much less, developed in a male breast. Mucinous and papillary subtypes are also rarer in men with breast cancer. However, an invasive papillary carcinoma is more common in men than in women. (I. Fentiman 2009; Cancer registration ; Vermeulen et al. 2017)
The hormone receptor positive luminal A and B subtypes are most common in men with breast cancer. This is also reported in women with breast cancer who are a bit older and post-menopausal. The occurrence of non-luminal HER2 positive, basal-like subtypes and triple negative breast cancers is much rarer among men with breast cancer when compared to women with breast cancer. (Kornegoor et al. 2012; Vermeulen et al. 2017)
The staging according to TNM is also identical for men and women with breast cancer. Involvement of lymph nodes and haematological spread is also possible in men with breast cancer, just as in women with breast cancer. (NABON 2012):
The relative survival (with use of Dutch data from diagnosis years 2003-2012, see explanation below the table on relative survival, which roughly corresponds to the cancer-specific survival) of men with breast cancer has improved in recent years, but does lag somewhat behind the relative survival of women with breast cancer (see figure 1). The 5-year relative survival for men is 81%, while for women it is 86%. The relative survival rate for men drops to 70% after 10 years, while this is even better for women, namely 77%. (Cancer registration ; Patten et al. 2013)
A population-based study from abroad found that although the overall survival of men with breast cancer is worse, after correction for life expectancy, age, year of diagnosis and treatment, men actually have survival advantages over women. (Miao et al. 2011)
Figure 1 relative survival of breast cancer patients
Explanation: Survival refers to the percentage of patients who are still alive a certain number of years after diagnosis. The presented survival is the relative survival which is an approximation for cancer-specific survival. This means the observed survival was corrected for the expected mortality based on the Dutch population comparable on the basis of gender, age and calendar year. The standard is also standardised by age group, as the survival can vary greatly per age group, the standard is. All patients have been followed until the date of death, or until 1 February 2016 or, in the case of emigration, until the emigration date (Cancer registration)
Compared to women, men are more likely to present themselves at an older age, possibly with increased comorbidity, but men are also more likely to have an advanced stage of breast cancer (stage 3 or 4) with a larger tumour size, metastatic lymph nodes in the armpit or elsewhere in the body. (Giordano et al. 2004; Cancer registration)
A population-based study of prognostic factors in men with breast cancer was conducted by Dr. José Pablo Leone (University of Iowa, Iowa City) and colleagues. The study included a total of 2992 patients who were diagnosed between 2003 and 2013. ER positivity is associated with better prognosis, especially during the first five years after diagnosis. Higher age at diagnosis, tumour grade III/IV and stage IV, no surgery, no radiotherapy, ER negative status and no spouse have a negative impact on overall survival in men with breast cancer. (Leone et al. 2016)
Dr Carolien van Deurzen (Erasmus MC) and colleagues examined pathological data from 1483 men with breast cancer, which was collected as part of the EORTC’s International Male Breast Cancer Programme. Mitotic activity index (MAI), presence of fibrotic focus and low tumour infiltrating lymphocytes (TIL) density are inversely correlated with overall survival. The researchers concluded that, in these men with breast cancer, contrary to what was seen in women with breast cancer, the grade was not significantly correlated with clinical outcome measures. (Vermeulen et al. 2017)
The risk factors for men with breast cancer have been less well researched and the low incidence often makes it difficult to draw definitive conclusions. On a number of points, the risk factors for breast cancer in men are similar to the risk factors for breast cancer in women, but there are also differences.
Similarities in risk factors between men and women
Similar risk factors for both men and women for breast cancer are: older age, obesity, family history of breast cancer and/or ovarian cancer, genetic mutations with an increased risk of breast cancer (BRCA1/2), increased oestrogen levels, and chest radiotherapy. (Brinton et al. 2015; I. S. Fentiman 2016; R. M. Ferzoco, Ruddy, K. J. 2016)
Differences in risk factors between men and women
Differences in risk factors between men and women for being diagnosed with breast cancer are race, risks of genetic mutations and androgens.
The incidence of breast cancer is higher in men with dark skin at all ages, while it’s only young dark women who have a higher incidence compared to white women. Darker men have a poorer prognosis, such as advanced stage, larger tumour size, more positive lymph nodes and a higher grade. (Korde et al. 2010)
Approximately 5-10% of all men and women with breast cancer have a hereditary form. The best known are the BRCA1 and BRCA2 mutations. (Korde et al. 2010)
The hereditary predisposition to breast cancer can therefore be passed on to both men and women. However, breast cancer is more common in female BRCA1/2 mutation carriers than in male carriers. The risk of developing breast cancer in women is estimated at 60-80%, in men with a BRCA2 mutation this is estimated at 7%, and with a BRCA1 mutation it is below 2%. (Korde et al. 2010)
More recently, other gene mutations have been identified which are associated with a (moderate to strong) increased risk of breast cancer in women: CHEK2, PALB2, ATM, NF1. (Easton et al. 2015) Mutations have also been found which are very rare, but which may present a greatly increased risk of breast cancer in women: PTEN, TP53, CDH1, STK11. (Easton et al. 2015) It is currently not clear whether men with these gene mutations have an increased risk of breast cancer and how high that risk is.
You will find more information about heredity here.
Elevated androgen levels
Higher levels of androgens is only a breast cancer risk factor for women and not for men. (Brinton et al. 2015)
Elevated oestrogen levels
Conditions which cause changes with elevated oestrogen levels, such as Klinefelter’s syndrome, gynecomastia, liver diseases and disorders of testis, may lead to an increased risk of breast cancer in men. (Brinton et al. 2014)
Lifestyle factors and environmental factors
Lifestyle factors such as smoking and drinking alcohol as well as various environmental factors such as ionising radiation, electromagnetic fields, heat and chemicals may play a role in the etiology of breast cancer in men, but this has not been sufficiently demonstrated. (Ruddy and Winer 2013)
A protective factor for men and women with breast cancer is maintaining a normal body weight. Exercise results in a lower risk of breast cancer in post-menopausal women, but there is insufficient evidence that physical activity alone will protect men from breast cancer. (Arem et al. 2015; Brinton et al. 2014)
A non-painful lump in the breast, which may be discovered later in men, is the most common symptom in both men and women with breast cancer. In men, the location is often behind or near the nipple/aureola complex and the nipple is more often involved than in women in the early stages of the disease. Other symptoms in men may include: nipple discharge, nipple retraction, non-healing wound, redness and/or orange peel skin. Rarely do patients present with axillary lymphadenopathy or Paget’s disease. (Javidiparsijani et al. 2017; Silva da 2016)
The diagnosis for breast cancer in a man is the same as in a woman. First a clinical breast examination where the tumour is often palpable, followed by a mammography and with unclear findings, supplemented with an ultrasound with a biopsy. On a mammography, micro-calcifications are less common in men than in women. (Korde et al. 2010; NABON 2012): https://richtlijnendatabase.nl/richtlijn/borstkanker2017/borstkanker_bij_mannen.html
We hope the results of Boog research group/EORTC’s national retrospective and prospective studies will allow us to gain even more insight into the optimal treatment for men with breast cancer in the future.
The first results of the retrospective study of 1483 men show that the majority received a mastectomy (96%), but about 50% of men with positive lymph nodes received no radiation. A third of the men received chemotherapy and more chemotherapy was given over time. 90% of the men had a hormone receptor positive disease and 77% received additional anti-hormonal therapy. In most cases this anti-hormonal therapy consisted only of tamoxifen and sometimes in combination with an aromatase inhibitor or only an aromatase inhibitor. (Cardoso 2014)
More information about the Breast Cancer Research Group (BOOG)’s retrospective and prospective studies can be found in current studies.
The treatment of breast cancer in men is currently largely based on retrospective observational studies and derived from knowledge of breast cancer in post-menopausal women. (Biganzoli et al. 2012; Korde et al. 2010; NABON 2012): https://richtlijnendatabase.nl/richtlijn/borstkanker2017/borstkanker_bij_mannen.html
Mastectomy or breast-conserving surgery
A mastectomy is performed more often in men than breast-conserving surgery. This mastectomy often includes the nipple, depending on the location of the tumour. Breast-conserving surgery is not possible in a man, as opposed to a woman, because the tumour in the smaller breast has already spread to the surrounding tissue, making removing all breast tissue the best option. (Ruddy and Winer 2013; Silva da 2016)
Side effects of surgery
Side effects may occur after surgery, such as recurrent bleeding, infection, keloid formation, (nerve) pain, feeling of numbness and local lymphedema. (Silva da 2016)
Some male BRCA mutation carriers with a history of breast cancer opt for preventive bilateral mastectomy to reduce the risk of breast cancer, but the incidence of new 2nd primary breast cancer in men has not been adequately investigated and as yet remains unclear. (R. M. Ferzoco and Ruddy 2015)
Photos before and after a mastectomy
You can find various photos of men with breast cancer in a photo collection here.
Sentinel gland procedure and axillary lymph node removal
For sentinel gland procedure and axillary lymph node removal, the indication and technique are exactly the same as for women. Instead of an axillary lymph node removal, the armpit can also be radiated. (NABON 2012): https://richtlijnendatabase.nl/richtlijn/borstkanker2017/borstkanker_bij_mannen.html
Side effects of the sentinel lymph node procedure
The sentinel lymph node procedure has a small risk of complications. For example, decreased feeling and lymphedema. The risk of lymphedema is greater with radiation and extensive surgery.
Side effects of axillary lymph node removal
An axillary lymph node removal is more invasive than a sentinel lymph node procedure and also has a higher risk of side effects, such as reduced feeling or nerve pain, a less mobile shoulder and lymphedema.
Choice of additional treatment
Research has shown that prognostic models (MPI Morphometric Prognostic Index), NPI (Nottingham Prognostic Index), Adjuvant! On-line: https://www.adjuvantonline.com/ and Predict: http://www.predict.nhs.uk/) developed and validated for women, can also be effectively applied in men with breast cancer. (van der Pol et al. 2016) Oncoguide, based on the national guideline for breast cancer developed by IKNL, can also be used to find out which additional treatment a patient is eligible for: https://www.oncoguide.nl.
Indications for radiation of armpit and chest wall
For the situation after mastectomy, the indication for radiation depends on the armpit node status. With positive lymph nodes (after the sentinel lymph node procedure) the armpit and chest wall are radiated. In principle, the indication for chest wall irradiation in N2 or N3 disease is pT3N +, pT3N0 in lobular carcinoma. For pT1N1, or pT2N1 only if additional risk factors are also present such as: grade III, lymphangio invasion, young age (very rare < 40 years in men) and if resection has not turned out to be radical, microscopic macroscopic. A small number of men who are treated for breast-conserving treatment, in particular with regard to maintaining the nipple complex, are also radiated on the chest / chest wall. In addition, there may be an indication for radiation of the armpit. (NABON 2012): https://richtlijnendatabase.nl/richtlijn/borstkanker2017/borstkanker_bij_mannen.html
Side effects of radiotherapy
Side effects of radiotherapy can be: fatigue, skin reactions, loss of breast/armpit hair, scarring, lymphedema after armpit surgery, pain, lung complaints and heart complaints.
There have been no randomised trials for the use of chemotherapy in men with breast cancer. The same indications apply to chemotherapy for men as for women. The decision to start chemotherapy, certainly in old age, must take into account the presence of co-morbidity. Chemotherapy can also be given as neo-adjuvant. (Biganzoli et al. 2012; NABON 2012):
Side effects of chemotherapy
Side effects of chemotherapy can depend on the type of drug, the most common side effects are: hair loss, neuropathy, nausea, tiredness, taste change, influence on bone marrow (anaemia, decreased immunity), reduced fertility or infertility and influence on sexuality.
There is no research into trastuzumab in men with a HER2 positive tumour, this is also very rare, but the use is based on the advantage that women with breast cancer have. Trastuzumab and possibly also pertuzumab should therefore also be offered to men with HER2 positive tumours, often in combination with chemotherapy. (Biganzoli et al. 2012; NABON 2012):
Side effects of immunotherapy
These drugs have almost no side effects. The most common side effect is an impaired heart pumping function, in about 15% of cases, which is almost always reversible when the drug is stopped. The heart pumping function is checked for this reason.
Tamoxifen is a form of first choice adjuvant therapy in men, just like in women, for oestrogen positive tumours for a period of 5 years. The use of aromatase inhibitors is not recommended as an adjuvant therapy, because its efficacy has not been sufficiently demonstrated and oestrogens (20%) produced by testicles are unlikely to be inhibited and, moreover, this medicine may cause more side effects (NABON 2012)
Side effects of anti-hormonal therapy
Side effects of anti-hormonal therapy tamoxifen are gender-specific: decreased libido, erection problems, hot flashes (less often than women), depression, weight gain, decrease in body hair, decrease in muscle strength, muscle cramps, joint complaints, headache, fatigue, cognitive impairment, thromboembolism, bone pain, visual complaints and skin rash. (Silva da 2016)
Possibilities of plastic surgery
Reconstructive surgery is performed less frequently in men than in women. There are, however, various options (Patten et al. 2013)
Men use the same technique for nipple reconstruction as women. The nipple tip is made under local anaesthesia after the position has been determined together with the patient.
Technique and material
The Caterpillar technique is used to loosen a strip of skin at the location where the nipple tip should be, rolled up and attached. This technique is also used in women. Nipple tattooing can take place 10 weeks after the procedure.
3 months after surgery or when the desired result is achieved.
Infection or recurrent bleeding.
Dermatography nipple (areola) and scars (medical tattoo)
Nipple, areola and scars can be treated with dermatography or a medical tattoo in men, just like in women.
Technique and material
Finer structure dye is introduced with very thin needles. This finer dye also causes skin colour scars and these thin needles results in less trauma. Local anaesthesia is required for dermatography of the nipples in 10% of the cases. Fading may occur in the years following treatment, whereby new treatment is possible.
Duration of treatment
Treatment per nipple: 45-60 minutes. Treatment of scars, depending on the size: 30-45 minutes. (several sessions depending on: scar thickness, stiffness and skin structure etc.)
Sometimes skin infections and disappointing results.
Lipofilling is a possibility if there is a dent in the breast after the mastectomy
Breast cancer can recur after it has been treated. The cancer can recur in the breast, chest wall or in other parts of the body. Treatment of a local recurrence usually consists of surgery in combination with radio and/or chemotherapy. Response to treatment is similar to women with breast cancer. (NCI Updated 05/25/2007)
Treatment of metastatic disease
Metastatic disease in men has mainly been evaluated in case reports and small studies and the policy is also derived from a woman. Aromatase inhibitors are prescribed as anti-hormonal treatment and it is always recommended to offer this in combination with an LHRH agonist or orchidectomy. (NABON 2012):
Men with breast cancer can develop a second tumour, just like women, after treatment for breast cancer. Men with breast cancer can get any type of second tumour, but have an increased risk of: a second primary breast cancer, colon cancer, pancreatic cancer, prostate cancer, skin cancer and myeloid leukaemia. A shared genetic risk sometimes plays a role in a second tumour. For example, men with a BRCA2 mutation have both an increased risk of prostate and pancreatic cancer and breast cancer. (Cutuli et al. 2010; Hemminki et al. 2005; Korde et al. 2010)
According to guidelines, men will have annual check-ups for 5 years after diagnosis, just like in women, with a clinical examination and (contralateral) mammography for detection of a locoregional recurrence and/or 2nd primary tumour. The value of an annual (contralateral) mammography for men is not completely clear and can also be omitted in close consultation with the patient. (NABON 2012):
Points for interest for men with breast cancer with a migration background
Men with a migration background
Breast cancer can also occur in men with a migration background. The disease may present itself to these patients at a later stage. This makes the prognosis less favourable. It is known that women with a migration background are not always referred for genetic testing (Baars et al. 2016.) It is not known whether this also applies to men. Access to care is often less effective for people with a migration background, because care does not always respond adequately to barriers in communication (language barrier) and to cultural differences between patients and care providers. In addition, migrants often have lower health skills, the skills needed to obtain, understand and use health information when making disease and treatment related decisions. Migrants also perceive illnesses differently. Cancer could possibly be considered as an infectious disease. It is sometimes also thought of as a curse. Having cancer is also quickly associated with death and it may be a taboo subject. (Suurmond 2017)
What is important in the provision of care?
The aim is to ensure care is aligned as closely as possible with religious standards and values and the patient’s culture. It’s important to be aware of your own frame of reference. The following suggestions can help when talking to someone with a migrant background:
1) Start with what is important for this individual patient, what his values and views are;
2) Approach the patient and the environment with respect;
3) Start the conversation invitingly, with open questions, so that important topics can be discussed;
4) Enter into a timely discussion about illness and treatment and then offer the patient room to gather information which is important to him;
5) Call in a professional interpreter if the patient does not speak the Dutch language, or has insufficient knowledge of it;
6) Call in a (Muslim) spiritual caregiver in the hospital;
7) Inform the patient and his family at the prayer room/silence centre in the hospital;
8) Appoint a contact person within the hospital and, if necessary, call in psychosocial support;
9) Advise home care agencies which specialise in helping people with a migration background;
10) Coordinate the hospital visit in consultation with the patient and the family;
11) Keep checking what information needs are arising throughout the disease process.
Information for nurses and nursing specialists
Guide for nurses and nursing specialists, Petra Duijveman: click here
You can find on-line patient information for men with breast cancer and their loved ones here:
Breast Cancer Society the Netherlands (BVN)
You can find more information about participation in scientific research here.
You can find information about the Dutch Male Breast Cancer Consortium here.
You can find an overview of published articles on pubmed here.
You can find a photo collection with photos and a video of men with breast cancer here.
You can find more information about heredity here.
You can find more information about psychosocial consequences and identifying the need for psychosocial care here.
You can find information about guidelines here.
Tools to support treatment choices
You can find patient information to be printed specifically for men with breast cancer and a flyer of the website which can be printed here.
You can find links to other websites with information about men with breast cancer here.
Biganzoli, L., et al. (2012), ‘Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA)’, Lancet Oncol, 13 (4), e148-60.
Cardoso, F., Bartlett, J., Giardano S. et al. (2014), ‘Characterization of male breast cancer: First results of the EORTC10085/TBCRC/BIG/NABCG International Male BC Program’, San Antonio Breast Cancer Symposium, 2014, European Organization for Research and Treatment of Cancer, San Antonio, TX.
Cancer registration, NL ‘managed by IKNL ©dec 2016’ www.cijfersoverkanker.nl.
NCI (Updated 05/25/2007), ‘The website of the National Cancer Institute, PDQ Male Breast Cancer Treatment’, https://www.cancer.gov/types/breast/hp/male-breast-treatment-pdq.