Male breast cancer: patient and doctor discuss experience and treatment

MD Anderson Cancer Center
Date: 03-04-13

 

Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas: MD 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 your family's cancer risk. I'm your host Lisa Garvin. And today, we have two guests in our studio. We have Dr. Sharon Giordano who is an associate professor in the Breast Medical Oncology Department and also chair of the newly formed Health Services Research Department, and Dr. Oliver Bogler, who is the senior vice president of Academic Affairs here at MD Anderson and a male breast cancer survivor which brings us to our subject today of male breast cancer. Dr. Giordano, obviously, males do not get strict and at the same rate as females, but it's a pretty rare disease, is it not?

Dr. Sharon Giordano: It is a rare disease. It makes up about one percent of all cases of breast cancer. And across the United States, there are just over 2,000 new cases diagnosed each year. So it is quite rare.

Lisa Garvin: Do you see them in early stages at all, or do you see them across all stages at diagnosis?

Dr. Sharon Giordano: We see them across all stages at diagnosis. Obviously, men aren't undergoing screening for breast cancer in the same way that women are, so they do tend to present with a slightly more advanced stage disease when compared to women.

Lisa Garvin: Is the pathology different in male breast cancer? I know that female breast cancer, some can be sensitive to hormones. Is that the same in men?

Dr. Sharon Giordano: It's actually even more common. More than 90 percent of breast cancers in men are more sensitive to a hormone treatment.

Lisa Garvin: So Dr. Bogler, as a doctor, you know, do you think doctors are more likely to realize that there is something wrong, or less likely to realize there is something wrong?

Dr. Oliver Bogler: That's kind of complicated question for me. So I think we are probably more aware of the possibility of having a cancer. At the same time, we are also aware of the statistics. So in my case, I just thought it was so unlikely that as a man, I would have breast cancer. That took me quite a while, longer than it should have to do the right thing, and I'm going to check out, so.

Lisa Garvin: What made you suspicious?

Dr. Oliver Bogler: Well, it's pretty much a cliche. I felt a lump in my right breast just behind my nipple and, you know, I watched it for probably three or four months. It seemed to that it sometimes was bigger and sometimes it's smaller. It was a little bit painful, not acutely painful, but it did cause me some discomfort when I, you know, press on it and that's also something that's not usual for breast cancer, so I did some reading, I did some looking around, and, you know, convinced myself for far too long that it probably wasn't until, eventually, you know, I came to the right conclusion and went to see a doctor, so.

Lisa Garvin: How long did you wait before you took action?

Dr. Oliver Bogler: Probably, at three or four months. The other thing to realize is that my wife is a breast cancer survivor, and she had actually was just at the time that I was undergoing this--and just--was just reaching her five-year mark, survival-mark, so she had come through treatment, active treatment here in MD Anderson five years ago, and that was part of the reason I sort of hesitated because it seemed very peculiar to me to go to her and say, "Hey, I think I have what you had." So it took me about three or four months, and then eventually, I went and saw my primary care physician and he quickly recommended that I follow up with a specialist, so.

Lisa Garvin: What did this do to your headspace? I mean, how did you react all of this?

Dr. Oliver Bogler: Well, it was just very strange. You know, having--as I said, having seen my wife go through it, it was just--seemed so unlikely that we would both have the same disease. As it turns out, we were diagnosed pretty much at the same age with pretty much the same stage of disease. And--So it took me a while to sort of get through. It's hard for me now that I'm an active treatment to really remember why I felt so sort of silly, if you will, about this whole issue. You know, I wish I had just been more aware and just, you know, taken the right steps earlier.

Lisa Garvin:And Dr. Giordano, are you his physician?

Dr. Sharon Giordano: I am.

Lisa Garvin: Okay. And so, did he come to you directly? How did you all hook up?

Dr. Sharon Giordano:He was already diagnosed when he came to see me as a new patient, because I do see most of the male patient with breast cancer at MD Anderson. And his story is pretty typical. I mean he--three to four months delay, I would say actually isn't particularly long, but we certainly do see that the majority of men that are diagnosed with breast cancer do have it delay in diagnosis. And for the very reasons that Dr. Bogler said that they just don't really expect to have breast cancer. Sometimes their doctors don't expect them to have breast cancer either and may not pursue a very aggressive workup. So that's--it's a very typical story, and I've certainly seen patients with much longer delays than that because they just--doesn't enter their consciousness that they could have breast cancer.

Lisa Garvin: Do you have any cases where maybe their wife or significant other may see the symptoms before they do?

Dr. Sharon Giordano: Maybe not see the symptoms before they do, but I certainly have a lot of situations where the wife or significant other pushes the patient to come in and get it check out. Perhaps, the patient doesn't really think he could have breast cancer and is more reluctant to come in and the wife will drag him in, and say, "No, no, no, you need to get this checked out," and kind of start the whole chain of events.

Lisa Garvin: But I, just thinking, you know, anatomically, I would think that a lump in a male would show up a heck of a lot faster due to the, you know, the smaller amount of breast tissue. So are the symptoms more obvious if there's a lump? Is it more obvious than perhaps a woman?

Dr. Sharon Giordano: Yeah, I think perhaps it is. For very small tumors or noninvasive cancers, perhaps not. The type of cancer that you'd pick up on a mammogram might not be easily felt in a man, but once you get to the size of a tumor that you could feel, so, you know, a couple of centimeters, then yes, I do think it's more obvious and more prominent in men. But even saying that, having a lump under the nipple in a man, still, breast cancer is not the most likely diagnosis. The vast majority of--in that situation are going to have a diagnosis called gynecomastia which is just a benign enlargement of tissue behind the nipple. So, you know, I think that men certainly need to have awareness and it's a possibility and get it check out. But luckily, in most situations, it still won't breast cancer.

Lisa Garvin: Are the treatment paths similar? I mean, obviously in--with women, there is chemotherapy, there is radiation surgery or a combination thereof. Are the care paths similar?

Dr. Sharon Giordano: They're very similar, and really is the same recommendation for the deciding the use of chemotherapy and the use of hormone therapy and use of radiation therapy. The exact drugs we use for hormone therapy, we use similar estrogen-blocker that we use in premenopausal women is the--called Tamoxifen. This is the drug that we typically use for men with breast cancer. I'd say the one other difference is often the surgical management. Although it's possible to do a lumpectomy, usually the cosmetic result after a lumpectomy is not that different in a man than after a mastectomy, so most men end up having mastectomies.

Lisa Garvin: And Dr. Bogler, what sort of treatment are you going through for your cancer?

Dr. Oliver Bogler: So I'm going through the chemotherapy phase. I did 11 weeks of Paclitaxel and I'm now doing a cocktail called FAC. That's a course of four treatments, three weeks apart, I've done two. I got two more ahead of me. We are monitoring the response of a tumor and that's, you know, one of the advantages of the way that we do chemotherapy at MD Anderson for this disease which is to do it, and the new regimen setting you need comes before the surgery. So we've been watching the response of the tumor. So we actually got a decision point coming up next week to see if the tumor is responding to these first two cycles of the FAC. If it is, then we'll keep going. And I think, if not, we may decide to move to surgery. So I'm following pretty much exactly the same path that my--that I watched my wife go through five years ago. So I'm happy to say that the management of the side effects has improved in the last five years, especially the nauseas. I'm having an easier time with this FAC than she did. But it's like see one, do one. [Laughter]

Lisa Garvin: Right, right. And I know FAC is a very aggressive. [Inaudible Remark] Yeah. And FAC is an aggressive regimen. I mean you're wearing a hat, so obviously, you know, you have--

Dr. Oliver Bogler: Yeah.

Lisa Garvin: --lost the hair and everything. How are you feeling?

Dr. Oliver Bogler: You know, right now, I feel pretty good. I have mostly fatigue, that's my main sort of side effect, I think persistent side effect, so I feel pretty tired. I go to bed before the kids these days. But at the moment, I'm okay. Next week when I get my treatment, those the few difficult days right after the treatment, it's just you kind of feel, you know, really tired, and I can't eat very much. So I feel--I managed, you know, to lose some weight. And it's just a general, you know, slowing down of things, so.

Lisa Garvin: Do you feel like--I'm not sure if you're involved in active patient care. I know you're more in the research side. But do you feel like it's given you a new level of empathy?

Dr. Oliver Bogler: For sure, it's a whole a new experience. So you know, having been the spouse of a patient, that's one step. But now that I'm seeing--first, I'm seeing parts of MD Anderson that I never saw before. I'm meeting new people, having new experiences. So it's definitely a totally different view of the institution. I'm a, you know, I'm a researcher and an administrator, so I spend my time, you know, meeting with a lot of people and I know a good number of our faculty, you know, and sort of that context, but now I'm--I get to see them as a patient. And it's actually been a great experience. I mean I've--I feel I'm receiving excellent care and also lot of caring, sort of expression of support from my colleagues and across the institution. So it's been a very positive experience and I feel, you know, void by it. It's not a great time in my life, of course, but given a circumstances, I'm very happy.

Lisa Garvin: And let's talk about awareness. I mean I think a lot of us remember when Montel Williams, the talk show host came out and said that he had male breast cancer, but you really don't hear male breast cancer survivor standing up and saying, "I've had it." Do you find that awareness is an issue?

Dr. Oliver Bogler: It's a huge issue. And as Dr. Giordano was saying earlier, you know, it--I hope that by raising awareness, we maybe able to shift the curve a little bit for when men are diagnosed with this disease. And certainly there, I've become very interested in. I--You know, you hear it all time, you know, people saying--me and my wife did some outreach for breast cancer and she was at the meeting recently and a couple approached the table that she was, you know, staffing and, you know, the man said to his significant other, "Well, I don't need to worry about this," and then, you know. Actually, but his significant other said, "Well, wait a minute, maybe you do." And so, yeah, definitely, awareness is huge. And I think some of the fantastic work that's been done for, you know, breast cancer hasn't yet reached, you know, the male part of it. Now, admittedly, there are not that many men with this disease, but there are still some. And so, I think we could do some good in that area.

Lisa Garvin: And you probably feel like you're a wash in the sea of the pink when you're trying to find--

Dr. Oliver Bogler: Yeah.

Lisa Garvin: --support or other resources in the community?

Dr. Oliver Bogler: Yes. So I have a little blog which I actually called Entering the World--you know, World of Pink because of that. It's true. Now, there is lot of talk about, you know, the pinkification of breast cancer at the moment. And, you know, a lot of people in the breast cancer community feel that maybe we've, you know, we've reached some extremes in the area. I would say that, you know, and I'm from Europe, I'm from Germany and [inaudible] UK, so my perspective is that the United States has done, you know, an enormous amount in this area that's for the good. And the awareness and lack of stigma around cancer in general in America is very heartening, plus it's been very beneficial for research and all kinds of things. So I agree there are some excesses, but I think we need, you know, we need to also consider all the positives. So I would love to see the, you know, the male disease become a little bit more part of the conversation of breast cancer, but in proportion to its prevalence and importance.

Lisa Garvin: And Dr. Giordano, we're talking about 2,000 men in America every year that are diagnosed with breast cancer. Obviously with just small patient population, it's hard to gather data. Is that--Has that been a problem with you?

Dr. Sharon Giordano: It is, it's an issue for doing a research on the disease because no single investigator really sees enough patients to do--certainly to do clinical trials or to do large enough studies to have meaningful impact on the disease. And we are a part of a consortium now working with a group of academic centers across the United States and also a group of center across Europe to try to change that. So we have a registry ongoing collecting information about all the men who've been diagnosed across these centers of the last ten years. And we expect to collect data and pathologic specimens for more than a thousand men with breast cancer. Then we're meeting this forward into a prospective study where we're opening it again through centers here in the US and Europe. And from that, we'll be able to collect some quality of life information, some fresh blood samples, and hopefully, really get at the biology of the disease and understand whether or not there are significant differences between breast cancer in men and breast cancer in women.

Lisa Garvin: Do you see any promising therapeutic avenues at this stage of the game?

Dr. Sharon Giordano: One thing we're interested in exploring is the use of androgen receptor blockers for men with breast cancer. As part of the idea setting up this consortium is too see how many patients come through the doors over, you know, two, three-year period. And once we get that information, I think we'll have a better idea as to whether or not it's realistic to do a clinical trial. If there are enough patients that are coming through, then we could pull all these international groups together and perhaps be able to launch a clinical trial of drugs.

Lisa Garvin: Have you been able to ascertain risk factors such as--like do genetics play a part? Do we see it more in certain ethnicities or age groups?

Dr. Sharon Giordano: It's definitely an age-related disease. So similar to women, the older you are, the higher your risk is. Men, on average, tend to be a little bit older at diagnosis than women. Women, I believe the average age is maybe 62 and then at 67, so a little bit of a shift for older age. Genetics also does play a role. BRCA2 which is a breast cancer causing mutation that can be passed in families has been linked to breast cancer in men. In fact one of patients that I saw just yesterday had been recently diagnosed with the BRCA2 mutation. One of the recommendations for men that are recently diagnosed with breast cancer is to refer them to genetics for discussion about whether or not testing would be appropriate.

Lisa Garvin: Where are they getting the BRCA2 gene? Are they getting it from their mother or?

Dr. Sharon Giordano: They can inherit it either from the mother or father.

Lisa Garvin: Or the father, okay. Is there any patient education or literature out there for men with breast cancer?

Dr. Sharon Giordano: There are some websites that have some general information about men with breast cancer. At the education center here in the past, we had put together a packet also of information and resources from men with breast cancer. But in general, there's a lot less information out there and available for male patients and female patients. And even all of the products are so gender-specific. For example, I have a patient who--luckily, he has a great sense of humor and thought this was funny, but he went in and to have original biopsy and was given an icepack that was in a pink floral pad and the peel off instructions were place this inside of your bra. So--I mean he--that what he was given and he laughed, it's like, "What am I to do with this? I can't use this." And so, I think that does speak to the--I think everything has become so feminized in pink that sometimes it's sort of exclusionary for the men that do have breast cancer.

Lisa Garvin: Well, men might have some sort of emotional effects too. I mean for men--I mean you're in a cancer setting Dr. Bogler, you're a doctor, your wife has gone through this already. But for some men, they might be embarrassed by that and that's a factor.

Dr. Oliver Bogler: I absolutely agree. You know, I don't deal that with that myself as you sort of indicated just now, because if you can't talk about this disease in working at a cancer center, where can you talk about it. And I've been, you know, very open about it. But absolutely right, I think there are lots of men who deal with that particular issue. And, you know, when you see guys talking about their cancer, you know, Lance Armstrong, you know, testicular cancer, you know, these are the manly cancers to have. This is breast cancer is not one of them. But, you know, I haven't encountered much of that myself, even around the neighborhood or so someone when I talk to people who aren't necessarily, you know, engaged in the fight against cancer themselves. People are pretty accepting and I think that brings me back to that point that we are talking about a few minutes ago about the fact that there is a lot of awareness and, you know, in America about cancer in general, and breast cancer specifically. So there is a little bit of a sort of "oh," you know, but then people kind of accept it pretty quickly, so.

Lisa Garvin: Do you feel the ownness of being perhaps an ambassador for the disease given your position?

Dr. Oliver Bogler: I do, I feel a certain calling. And, you know, Dr. Giordano just mentioned that there aren't really any great sort of comprehensive resources. I've got a little bit of feedback for my Facebook page and my blog around that area. So I'm trying to summarize some of the reason, literature in lay terms and I'm still working on that, and I will ask Dr. Giordano's help when it's ready to go. [Laughter]

Lisa Garvin: Okay.

Dr. Oliver Bogler: I'd like to just put a webpage with just some, you know, some of the general questions that people have, the typical questions that everybody has who faces a diagnosis of cancer, and specifically, you know, hear from men. So we're working on it, you know.

Lisa Garvin: Dr. Giordano, what--I mean a mammogram, obviously, any women who's had one knows that you're putting that breast tissue between two glass plates. How on earth do you do a mammogram on a man?

Dr. Sharon Giordano: Really, exactly the same way. There is obviously less tissue to evaluate, but the tissue that's there is compressed between the two plates and you take an X-ray.

Lisa Garvin: Do you get as good a reading or maybe even a better reading on a mammogram with a man as opposed to a woman?

Dr. Sharon Giordano: I think you can get good readings on a mammogram in men. Sometimes, it's used to help tell a cancer from the condition we mentioned earlier called gynecomastia.

Lisa Garvin: And obviously, because of the low numbers of men with breast cancer, mammogram would not be a viable screening tool at this time.

Dr. Sharon Giordano: No, it wouldn't make any sense.

Lisa Garvin: How many male patients do you see a year Dr. Giordano?

Dr. Sharon Giordano: It varies month by month, but on average, somewhere between 10 and 20 new patients a year.

Lisa Garvin: What should men do that are diagnosed with breast cancer? Should they be treated in the community or are they better off in a multidisciplinary setting?

Dr. Sharon Giordano: In general, I'm a big supporter of multidisciplinary setting. I might also think for patients with a disease that's rare, they often can be very well served by coming to a major academic center. So I think patients get really good care coming to a center like MD Anderson where there is multidisciplinary care.

Lisa Garvin: And what would be your advice to men with breast cancer who have been diagnosed or may suspect that they have it?

Dr. Sharon Giordano: Well, certainly if a man finds a lump or suspects that he may have it, he really should not delay and go see his primary care physician. That physician then can do an examination, do a mammogram if indicated, and perhaps biopsy. I think it's really important as Dr. Bogler mentioned that we get awareness out, so people don't delay in the diagnosis and do come and get this evaluated.

Lisa Garvin:And do their significant others or spouses play a role in this?

Dr. Sharon Giordano: Sometimes. I think often, the wife or significant other can help convince patients to come in and get evaluated.

Lisa Garvin: And Dr. Bogler, for male breast cancer survivors like yourself, what sort of words of wisdom or encouragement do you have for them?

Dr. Oliver Bogler: I would as Dr. Giordano says, tackle the problem as early as you can. Know that you're not alone with this diagnosis that there are lots of guys out there who are also dealing with it. Try and connect if you're interested. And, you know, seek the best treatment. So, you know, I find it very comforting that Dr. Giordano has seen more people with this disease than any other physician, and she has a wealth of knowledge that she brings to bare on every case including mine. So that's very comforting to me.

Lisa Garvin: And tell us about your blog so men can visit that and get words of encouragement.

Dr. Oliver Bogler: Well, you can find it through Facebook, through my name or through Entering a World of Pink, and I would--I just wrote about my personal experience and how I'm dealing with the treatment, how I--my feelings about, you know, how I got here. But I also try and write about some of the signs behind, you know, the treatments that I'm experiencing and why we do them and bring some information in there. So it's kind of a bit of a varied blog, but very happy also to engage in conversations with people who are interested.

Dr. Oliver Bogler: Thank you very much.

Lisa Garvin: If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789, [background music] or online at mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune-in for the next Podcast in our series.