MD Anderson Cancer Center
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Lisa: Welcome to Cancer Newsline, a weekly podcast series from The University of Texas, M.D. Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing you family's cancer risk. I'm your host Lisa Garvin. Today our subject is male breast cancer. And our guest today is Doctor Sharon Giordano, [phonetic] she's an Associate Professor of Breast Medical Oncology at M.D. Anderson. So Doctor Giordano, usually less than 2,000 cases are diagnosed in men a year. Do we see quite a few male breast cancer patients at M.D. Anderson?
Dr. Giordano: We do. Since we're a major referral center we do get a fair number of referrals of male breast patients. So I typically see one or two newly diagnosed cases each month in my clinic.
Lisa: Let's talk about male breast cancer. I think it kind of rose to the floor several years ago when Montel Williams, a public figure, was diagnosed. Did you see a wave of awareness about breast cancer after that?
Dr. Giordano: I think every time there's a celebrity diagnosed with a particular cancer type we do see a surge in awareness. But one of the major struggles and issues of male breast cancer is a lack of awareness, and that people really don't believe that men can get breast cancer.
Lisa: So as a result most breast cancer cases are diagnosed in a later stage, is that correct?
Dr. Giordano: Yeah, that's correct. We did a study using the national sear [phonetic] data and compared the stage of diagnosis between male patients with breast cancer and female patients with breast cancer. And we did find that men were more likely to be diagnosed when the cancer had spread to the lymph nodes, and more likely, in general, to be diagnosed with advanced disease.
Lisa: I would think, and I'm just guessing based on anatomy, that a lump would be a lot more obvious in a male than a female.
Dr. Giordano: Yeah, it typically is. So usually we don't see the very large tumors in a male patient, because it does become obvious sooner, due to the smaller size of breast tissue.
Lisa: Now is there a particular type of breast cancer that males get more than females? Or are they subject to the same types of breast cancer?
Dr. Giordano: Generally they're subject to the same types. The most common type of breast cancer is invasive ductal. And that makes up about 85% of breast cancer in women, and probably it's more like 95% of breast cancer in men. That's almost all men have an invasive ductal.
Lisa: Are there estrogen or hormonal issues in men? Because men obviously do have estrogen in their bodies, not as much as women, but do hormones play as big a role in male breast cancer?
Dr. Giordano: They play at least as big a role. In fact, they may play a bigger role. And it's sort of counter intuitive. Because you think, I mean we know that women have estrogen. And for women about 70% of tumors have receptors for estrogen, which means the estrogen stimulates the cancer to grow. Men also have estrogen, if you noted, and actually more than 90% of breast tumors in men are sensitive to estrogen, and grow because of estrogen. So it's actually more common in men than women, which always surprises a lot of people.
Lisa: That is kind of counter intuitive. Let's talk about comparing the two, and we'll start with symptoms. Are the symptoms about the same in male breast cancer as in women?
Dr. Giordano: Yeah, generally, most men present with a painless lump under the nipple. And sometimes there may be an ulceration of the skin. Sometimes there may be nipple discharge or bleeding from the nipple. But these are all some of the same signs that can happen in male and female patients.
Lisa: And the risk factors sound to be about the same as well.
Dr. Giordano: Generally the same. You know, there's, a lot of the risk factors for women are based on, you know, the age that a girl first gets her period, the number of children they have, age of the first pregnancy. So obviously none of those apply to the male patients. We do know that there is a syndrome called Klinefelter's, which is a chromosomal abnormality. And men that have that do have a significantly increased risk of breast cancer.
Lisa: But also they may also carry the BRCA Gene.
Dr. Giordano: That's, yeah, that's an excellent point. So having a man with breast cancer, particularly in a family with other cases of breast cancer, can really be a red flag for a family that's carrying a BRCA mutation.
Lisa: So in families with a BRCA mutation would it be wise for men to seek out genetic counseling and testing?
Dr. Giordano: Yes, absolutely! And if we have a male patient diagnosed with breast cancer, we would routinely offer that patient genetic counseling and the possibility of testing.
Lisa: Now let's talk about similarities in treatment across, I mean can you do a radical mastectomy on a man? Or what does that look like even?
Dr. Giordano: It's a, the surgical options are generally similar. Most men do end up having a modified radical mastectomy with the whole, the breast tissue removed. And really they end up with a, you know, scar across the chest line and the nipple gone. Sometimes a little bit less tissue on one side than the other. We can; sometimes the surgeons can offer a lumpectomy to male patients. But often there's not so much tissue to save, so the cosmetic result isn't that different. I have had a few patients that have chosen, that are male patients that have chosen to undergo reconstructive surgery. Either to have, you know, additional tissue put on the side that they had surgery, or to have a nipple tattoo. So that when they go swimming or outside that it's, it's not as obvious.
Lisa: Well in a man if there is a mastectomy, is there, is that area concave, or does it look different other than the scar and lack of nipple, or?
Dr. Giordano: It depends a little bit person to person. But usually there's a slight asymmetry between the two sides of the chest where it is a little bit, not necessarily concave, but a little flatter than the other side of the chest.
Lisa: How many of your patients do seek breast reconstruction?
Dr. Giordano: Not many. I'd say it's definitely the minority. But I do have a handful that have chosen to do that.
Lisa: And as far as reconstruction goes, do they do like the TRAM Flap, or the Gluteal Flap? I mean, are, is reconstruction about the same in men?
Dr. Giordano: I say much more it's usually a much more limited basis, because they're not trying to recreate, you know, a breast mound as they are in a female patient. So typically it's a much less involved, smaller surgery. And some of the male patients have just opted to have, again, the nipple tattooed on or nipple reconstruction. Because, you know, men, for example, swimming, you know, often they don't wear their shirts. So it can be more obvious in some ways than a female patient.
Lisa: And what about survival? I think what I've read is that survival, you know, depending on stage at diagnosis, seems to be fairly similar across males and females.
Dr. Giordano: It is pretty similar. Initially the older reports we thought that men didn't do as well and actually had poorer survival. But it turns out that's really just a result of being diagnosed with more advanced disease, and I think a little bit older at diagnosis. So when you take all of those factors into account, the survival does seem to be similar between male and female patients.
Lisa: And among the men you've treated, do you find, are there any sort of stigma's attached with them having what seen as a female disease?
Dr. Giordano: You know, again, I think that varies person to person. But I think there can be a certain amount of awkwardness about it. A lot of my patients will tell me that they had no idea they were at risk for breast cancer, and so the diagnosis comes as a really big shock to them. I've also heard from many different patients, stories about trying to go for mammography. Because we do, we routinely do mammogram the breast mass in male patients. And so I've had multiple, too many, patients tell me that when they've gone to have their mammogram, not necessarily here, but just in general, that, you know, the person who calls them calls Mrs. Jones instead of Mr. Jones, even though they're John Jones, or won't really let them come back and tries to take their wife. They say, oh, no, no, it's not for you. Let me take your wife back. And so they kind of get stuck in a situation where they have to almost make a scene to get medical care. And then a lot of the breast centers are very geared towards women. Everything's pink. You know, it's pink ribbons for breast cancer awareness. One of my patients told a story about getting his biopsy. And he came out and they gave him a, he had a little ice pack. But the ice pack is, was pink, and floral, and the instructions on it were place this inside of your bra. So, I mean he had a good sense of humor and thought this was really funny, but he's like, what am I supposed to do with this? So, there's a real issue with all of the, the centers and everything being so structured around women, that I think it sometimes can make a male patient feel a little out of place.
Lisa: I'm trying to visualize giving a man a mammogram. I can't imagine how hard that would be without a breast mound. Are there different approaches for a male in mammograms?
Dr. Giordano: No, not really. They just have a smaller amount of tissue that gets x-rayed.
Lisa: Well, yikes! And of course anyone woman who's had a mammogram knows what that's like. You know, I've heard that the analogy is, you know, slam your breast in the refrigerator door a couple of times and that's about what it feels like. As far as research, is there any research into male breast cancer, because it's so similar to female? Are there any kind of paths you're looking down for treatment and diagnosis for men?
Dr. Giordano: There's; I mean there's a couple of different branches of research. Some of the research that we've done has been focused looking at large national registries. So looking at our National Cancer Registry database, looking at your Medicare database. So trying to track down on a national level what are the, what's the biology of male breast cancer? How are men with breast cancer treated? What are their survival rates? On a more molecular basis we're also working to understand the biology of male breast cancer better. And I'm currently involved in a collaboration; it's a project that's gonna be jointly run between the United States and Europe. And so we're, we're working on getting together a very large cohort of male breast cancer patients, getting clinical information, and also getting tumor specimens, so that we can do studies of the biology of the disease and really try to answer the questions about: Is it really different than breast cancer in women? How is it different? And ideally, I think, what we all want to know is whether or not the treatments should be just extrapolated from studies in women, or whether or not there could be any different treatments for men.
Lisa: And do men suffer kind of the same treatment side affects like lymphoedema?
Dr. Giordano: Yes, absolutely. The same, I mean, very similar complications from surgery, such as lymphoedema. Very similar side affects of chemotherapy as women go through. The side affects of the hormone treatments can be a little bit different, and you know, we don't know as much about how the hormone treatments that we use to treat breast cancer work in male patients.
Lisa: So in closing Dr. Giordano, is there anything you need to say to men who may suspect that they have breast cancer?
Dr. Giordano: Well I think it's just very important for men to realize that they can get breast cancer, even though it is rare. So if a man has a breast lump he needs to get that evaluated by his physician and not dismiss it as something that couldn't happen to him.
Lisa: All right. Great. Thank you very much.
Dr. Giordano: Thank you.
Lisa: If you have questions about anything you've heard today on Cancer Newsline, contact Ask M.D. Anderson at 1-877-MDA-6789, or online at www.MDAnderson.org/Ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.
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