Survival benefit of tamoxifen and aromatase inhibitor in male and female breast cancer

Prognostic Impact of HER2 Low Status in Male Breast Cancer: Prospective Cohort Analysis

BACKGROUND

Male breast cancer (MBC) is a rare disease, and the potential influence of low expression of human epidermal growth factor receptor 2 (HER2 low) remains unexplored.

METHODS

In this prospective cohort study, we evaluated 870 patients treated for MBC between May 2009 and June 2023 to assess HER2 low status and its prognostic implications.

RESULTS

With a median follow-up of 43 months (range 1-175 months), 659 eligible patients were categorized into three groups based on HER2 status: 501 (76%) HER2 low, 81 (12.3%) HER2 zero, and 77 (11.7%) HER2 positive. HER2 positivity correlated with younger age, higher proliferation index, non-specific type histology, lymphovascular invasion (LVSI), and low differentiation grade. Notably, all these parameters were equally distributed between the HER2 zero and HER2 low groups. Additionally, HER2 positivity was significantly associated with increased occurrences of regional and distant lymph nodes and pulmonary metastases. However, no statistically significant difference was observed between HER2 zero and HER2 low. Disease-free and overall survival showed no significant disparities between the groups.

CONCLUSIONS

Our findings suggest that HER2 low status is frequently detected in MBC. Despite this, HER2 low did not correlate with clinical and pathological parameters, nor did it impact patients' survival.

Male breast cancer differs from female breast cancer in molecular features that affect prognoses and drug responses

BACKGROUND

Male breast cancer (MBC) is a rare malignancy with a worse prognosis than female breast cancer (FBC). Current MBC treatment strategies are based on those for FBC. However, molecular differences between MBC and FBC with respect to prognosis and drug responses remain unclear.

METHODS

After controlling for confounding factors with propensity score matching (PSM), differences between MBC and FBC were comprehensively analyzed using many types of data: survival, immune microenvironments, sex hormone responses, drug sensitivity, transcriptomes, genomes, epigenomes, and proteomes.

RESULTS

Overall survival (OS) and cancer-specific survival (CSS) were both worse for MBC than for FBC. Differentially expressed mRNAs were enriched in numerous cancer-related functions and pathways, with SPAG16 and STOX1 being as the most important prognosis-related mRNAs for MBC. Competing endogenous RNA (ceRNA) and transcription factor (TF)-mRNA regulatory networks contain potential prognostic genes. Nine genes had higher mutation frequencies in MBC than in FBC. MBC shows a comparatively poor response to immunotherapy, with five proteins that promote breast cancer progression being highly expressed in MBC. MBC may be more responsive than FBC to estrogen. We detected six United States Food and Drug Administration (FDA)-approved therapeutic target genes as being differentially expressed between MBC and FBC.

CONCLUSION

The poor prognosis of MBC compared to FBC is due to numerous molecular differences and resulting drug responses.

Prolonged tamoxifen-enriched diet is associated with cardiomyopathy and nutritional frailty in mice

Tamoxifen (TAM) is required for gene recombination in the inducible Cre/lox system. The TAM-enriched diet is considered safe, with negligible impact on animal wellbeing. However, studies reporting the long-term effects of the TAM diet and its potential impact on experimental outcomes are scarce. We conducted a longitudinal study on mice exposed to a 4-week dietary TAM citrate supplementation. Several parameters were recorded, such as body weight, body composition, mortality, and cardiac function. The collagen1a2 (Col1a2) transgenic mouse was used to assess TAM-induced recombination in vivo in cardiac fibroblasts followed by myocardial infarction (MI). The impact of TAM on the MI outcome was also evaluated. The recombination efficiency and cytotoxic effect of the TAM active metabolite, 4-hydroxy-tamoxifen (4-OHT), were assessed in vitro. Mice exposed to a TAM diet showed body weight loss and a 10% increase in mortality (P = 0.045). The TAM diet decreased cardiac function and induced cardiac remodeling, indicated by decreased fractional shortening from 32.23% to 19.23% (P = 0.001) and left ventricular (LV) wall thinning. All measured parameters were reversed to normal when mice were returned to a normal diet. Infarcted Col1a2-CreER mice on the TAM regimen showed gene recombination in fibroblasts, but it was associated with a substantial increase in mortality post-surgery (2.5-fold) compared to the controls. In vitro, 4-OHT induced gene editing in fibroblasts; however, cell growth arrest and cytotoxicity were observed at high concentrations. In conclusion, prolonged exposure to the TAM diet can be detrimental and necessitates careful model selection and interpretation of the results.

Male Breast Cancer: Current Scenario and Future Perspectives

Male breast cancer (MBC), one of the rare types of cancer among men where the global incidence rate is 1.8% of all breast cancers cases with a yearly increase in a pace of 1.1%. Since the last 10 years, the incidence has been increased from 7.2% to 10.3% and the mortality rate was decreased from 11% to 3.8%. Nevertheless, the rate of diagnoses has been expected to be around 2.6% in the near future, still there is a great lack in studies to characterize the MBC including the developed countries. Based on our search, it is evidenced from the literature that the number of risk factors for the cause of MBC are significant, which includes the increase in age, family genetic history, mutations in specific genes due to various environmental impacts, hormonal imbalance and unregulated expression receptors for specific hormones of high levels of estrogen or androgen receptors compared to females. MBCs are broadly classified into ductal and lobular carcinomas with further sub-types, with some of the symptoms including a lump or swelling in the breast, redness of flaky skin in the breast, irritation and nipple discharge that is similar to the female breast cancer (FBC). The most common diagnostic tools currently in use are the ultrasound guided sonography, mammography, and biopsies. Treatment modalities for MBC include surgery, radiotherapy, chemotherapy, hormonal therapy, and targeted therapies. However, the guidelines followed for the diagnosis and treatment modalities of MBC are mostly based on FBC that is due to the lack of prospective studies related to MBC. However, there are distinct clinical and molecular features of MBC, it is a need to develop different clinical methods with more multinational approaches to help oncologist to improve care for MBC patients.

Male Breast Cancer: a Review on Diagnosis, Treatment, and Survivorship

PURPOSE OF REVIEW

Male breast cancer is a relatively uncommon and rare disease that is often managed based on evidence adopted from trials pertaining to female breast cancer due to low accrual rates or exclusion of males. This is despite the known differences in the biology and epidemiology of this condition. This review provides an update regarding the management and surveillance of male breast cancer.

RECENT FINDINGS

Men with breast cancer tend to undergo more extensive surgery in the breast and axilla. The outcomes of male breast cancer compared to a similar subtype of female breast cancer appear worse when matched for stage. Systemic therapies remain predominantly based on recommendations for female breast cancer, although tamoxifen is the more optimal endocrine therapy for men than women. Surveillance with mammograms is recommended for patients harboring a breast cancer susceptibility gene but is otherwise not advised for men who have undergone a mastectomy. Notably, the role of other imaging modalities, including ultrasound and magnetic resonance imaging, is minimal. Although the focus on survivorship care among men is low, it is abundantly clear that this is a stigmatizing diagnosis for men, and they suffer from long-term physical and psychological sequelae following a diagnosis and treatment of breast cancer. In summary, providing more gender-inclusive care and advocating for increased representation of men in prospective breast cancer studies and clinical trials may help improve outcomes and provide enhanced support for this population.

Role of Endorphins in Breast Cancer Pathogenesis and Recovery

Understanding the relationship between stress and breast cancer development is essential to preventing and alleviating the cancer. Recent research has shed light on the cognitive, physiological, cellular, and molecular underpinnings of how the endorphin pathway and stress pathway affect breast cancer. This chapter consists of two parts. Part 1 will discuss the role of endorphins in breast cancer development. This includes a discussion of three topics: (1) the neurophysiological effect of endorphins on breast tumor growth in vivo, along with further experiments that will deepen our knowledge of how β-endorphin affects breast cancer; (2) how both the opioid receptor and somatostatin receptor classes alter intracellular signaling in breast cancer cells; and (3) genetic alleles in the opioid signaling pathway that are correlated with increased breast cancer risk. Part 2 will discuss the role of endorphins in recovery from breast cancer. This includes a discussion of three topics: (1) the relationship between breast cancer diagnosis and depression; (2) the effectiveness of cognitive behavioral therapy in reducing stress in breast cancer patients; and (3) the effect of psychotherapy and exercise on preserving telomere length in breast cancer patients.

Effects of occupational therapy on quality of life in breast cancer patients: A systematic review and meta-analysis

BACKGROUND

The objective was to discuss the impact of occupational therapy on different domains of quality of life in breast cancer patients. We performed a literature search to identify articles published before June 27, 2023, using the following databases: PubMed, Embase, Web of Science, Cochrane Library, and Scopus.

OBJECTIVE

The objective was to discuss the impact of occupational therapy on different domains of quality of life in breast cancer patients.

DATA SOURCES

We performed a literature search to identify articles published before June 27, 2023, using the following databases: PubMed, Embase, Web of Science, Cochrane Library, and Scopus.

METHODS

This study was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Randomized controlled trials that reported the effects of occupational therapy on quality of life in breast cancer patients were identified. Two reviewers independently assessed eligibility, extracted data, and determined risks of bias. Pooled standardized mean differences (SMDs) with 95% confidence intervals (CIs) were estimated using random-effects meta-analyses. Galbraith plots, meta-regression analysis, subgroup analysis, and sensitivity analysis were used to identify heterogeneity in treatment effects.

RESULTS

Eight studies were included, with a total of 543 patients. The experimental group exhibited better global health (pooled SMD = 0.640, 95% CI = 0.251-1.028, P = .001), physical health (pooled SMD = 0.640, 95% CI = 0.251-1.028, P = .019), social health (pooled SMD = 0.251, 95% CI = 0.011-0.490, P = .040), and cognitive function (pooled SMD = 0.863, 95% CI = 0.266-1.460, P = .05) and improve fatigue (pooled SMD = -0.389, 95% CI = -0.586 to -0.192, P = .000), and role function (pooled SMD = 0.287, 95% CI = 0.029-0.546, P = .029) than the control group. The 2 groups exhibited comparable emotional health (pooled SMD = 0.243, 95% CI = -0.051 to 0.536, P = .105) and pain (pooled SMD = -0.312, 95% CI = -0.660 to 0.036, P = .079).

CONCLUSION

The current evidence shows that occupational therapy can improve the quality of life of breast cancer patients, especially their global health, physical health, social health, cognitive function, fatigue, and role function.

Male Breast Cancer: Three Case Reports and a Literature Review

INTRODUCTION

Male breast cancer (MBC) accounts for 0.5%-1% of all breast cancers diagnosed worldwide. However, its biological characteristics can be distinguished from that of female breast cancer (FBC).

CASE REPRESENTATION

The diagnostic and treatment approaches for MBC are mainly similar to that of FBC due to the lack of male breast cancer-related studies, clinical trials, and literature. An increasing number of retrospective and prospective studies have been conducted to clarify the individualized care for MBC. Herein, we report three cases of advanced MBC to describe the diagnostic approaches, treatment process, and survival prognosis.

CONCLUSION

MBC patients had older age, later stage at first diagnosis, higher expression of hormone receptors, and poor prognosis. A literature review was conducted to determine the incidence, risk factors, disease features, diagnosis, treatment, survival, and management of MBC.

An introduction to male breast cancer for urologists: epidemiology, diagnosis, principles of treatment, and special situations

Breast cancer (BC) is mainly considered a disease in women, but male BC (MaBC) accounts for approximately 1.0% of BC diagnoses and 0.5% of malignant neoplasms in the western population. The stigmatization of MaBC, the fact that men are less likely to undergo regular health screenings, and the limited knowledge of health professionals about MaBC contribute to men being diagnosed at more advanced stages. The aim of this article is to increase the visibility of MaBC among urologists, who have more contact with male patients. This review highlights key points about the disease, the risk factors associated with MaBC, and the options for treatment. Obesity and increased population longevity are among the important risk factors for MaBC, but published studies have identified family history as extremely relevant in these patients and associated with a high penetrance at any age. There is currently no screening for MaBC in the general population, but the possibility of screening in men at high risk for developing BC can be considered. The treatment of MaBC is multidisciplinary, and, because of its rarity, there are no robust clinical studies evaluating the role of systemic therapies in the management of both localized and metastatic disease. Therefore, in current clinical practice, treatment strategies for men with breast cancer are extrapolated from information arising from studies in female patients.

Male Breast Cancer: From Molecular Genetics to Clinical Management

MBC is a rare disease accounting for almost 1% of all cancers in men and less than 1% of breast cancer. Emerging data on the genetic drivers of predisposition for MBC are available and different risk factors have been associated with its pathogenesis. Genetic alterations, such as pathogenetic variants in BRCA1/2 and other moderate-/low-penetrance genes, along with non-genetic risk factors, have been recognized as pathogenic factors for MBC. Preventive and therapeutic implications could be related to the detection of alterations in predisposing genes, especially BRCA1/2, and to the identification of oncogenic drivers different from FBC. However, approved treatments for MBC remain the same as FBC. Cancer genetic counseling has to be considered in the diagnostic work-up of MBC with or without positive oncological family history. Here, we review the literature, reporting recent data about this malignancy with a specific focus on epidemiology, and genetic and non-genetic risk factors. We introduce the perspective of cancer genetic counseling for MBC patients and their healthy at-risk family members, with a focus on different hereditary cancer syndromes.

A practical guide to endocrine therapy in the management of estrogen receptor-positive male breast cancer

The majority (more than 90%) of male breast cancers (MaBCs) are estrogen receptor-positive, such that endocrine therapy is the mainstay of MaBC treatment. Endocrine therapy has been associated with improved overall survival in observational studies on MaBC, though large randomized clinical trials have never been completed to confirm this benefit in this population. Tamoxifen is currently the preferred drug for both metastatic and adjuvant treatment of MaBC. Known differences in treatment patterns and hormonal milieu between men and women may warrant a unique approach to the management of toxicities in men. This review provides a detailed discussion of endocrine therapy for MaBC.

Breast cancer

Breast cancer is still the most common cancer worldwide. But the way breast cancer is viewed has changed drastically since its molecular hallmarks were extensively characterised, now including immunohistochemical markers (eg, ER, PR, HER2 [ERBB2], and proliferation marker protein Ki-67 [MKI67]), genomic markers (eg, BRCA1, BRCA2, and PIK3CA), and immunomarkers (eg, tumour-infiltrating lymphocytes and PD-L1). New biomarker combinations are the basis for increasingly complex diagnostic algorithms. Neoadjuvant combination therapy, often including targeted agents, is a standard of care (especially in HER2-positive and triple-negative breast cancer), and the basis for de-escalation of surgery in the breast and axilla and for risk-adapted post-neoadjuvant strategies. Radiotherapy remains an important cornerstone of breast cancer therapy, but de-escalation schemes have become the standard of care. ER-positive tumours are treated with 5-10 years of endocrine therapy and chemotherapy, based on an individual risk assessment. For metastatic breast cancer, standard therapy options include targeted approaches such as CDK4 and CDK6 inhibitors, PI3K inhibitors, PARP inhibitors, and anti-PD-L1 immunotherapy, depending on tumour type and molecular profile. This range of treatment options reflects the complexity of breast cancer therapy today.

Poor prognosis of male triple-positive breast Cancer patients: a propensity score matched SEER analysis and molecular portraits

Background

The purpose of this study was to explore clinicalpathology features, molecular features and outcome of male breast cancer patients who expressed ER, PR as well as HER-2, namely triple-positive male breast cancer (TP-MBC), and compared them with triple-positive female breast cancer patients (TP-FBC).

Methods

TP-MBC and TP-FBC from 2010 to 2017 were selected from the Surveillance, Epidemiology, and End Results database (SEER). Kaplan-Meier plotter and multivariable Cox regression model were applied to analyse the difference between TP-MBC and TP-FBC on cancer-specific survival (CSS) and overall survival (OS). Propensity score matched (PSM) analysis was used to ensure well-balanced characteristics. 7 cases TP-MBC and 174 cases TP-FBC patients with the genomic and clinical information were identified from the cohort of The Cancer Genome Atlas (TCGA) and the Memorial Sloan Kettering (MSK).

Result

336 TP-MBC and 33,339 TP-FBC patients were taken into the study. The percentages of TP-MBC in MBC patients were higher than the rates of TP-FBC in FBC patients from 2010 to 2017 except 2012. Compared with TP-FBC, more TP-MBC were staged III (17.9% vs. 13.5%) or stage IV (11.0% vs. 6.9%). TP-MBC were more frequently to be older than 65-years-old (47.0% vs. 29.3%), Balck (15.2% vs. 10.8%), ductal carcinoma (91.7% vs. 84.4%) and metastases to lung (4.5% vs. 2.1%) or bone (8.6% vs. 4.7%). TP-MBC had worse OS and CSS than TP-FBC in all stages (P < 0.001). In multivariable prediction model of TPBC, male patients had a higher risk than female. Lastly, the worse OS (P < 0.001) and CSS (P = 0.013) were seen in the 1:3 PSM analysis between TP-MBC and TP-FBC. Genomic analysis revealed that TP-MBCs have some notable rare mutations, like ERBB2, ERBB3, RB1, CDK12, FGFR2, IDH1, AGO2, GATA3, and some of them are not discovered in TP-FBC.

Conclusion

TP-MBC had a worse survival than TP-FBC, and there were different genomic features between two groups. Current knowledge and treatment to TP-MBC maybe inadequate and remain to be explored.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08267-9.

Efficacy of Endocrine Therapy for the Treatment of Breast Cancer in Men: Results from the MALE Phase 2 Randomized Clinical Trial

Importance

The extent of changes in estradiol levels in male patients with hormone receptor-positive breast cancer receiving standard endocrine therapies is unknown. The sexual function and quality of life related to those changes have not been adequately evaluated.

Objective

To assess the changes in estradiol levels in male patients with breast cancer after 3 months of therapy.

Design, Setting, and Participants

This multicenter, phase 2 randomized clinical trial assessed 56 male patients with hormone receptor-positive breast cancer. Patients were recruited from 24 breast units across Germany between October 2012 and May 2017. The last patient completed 6 months of treatment in December 2017. The analysis data set was locked on August 24, 2018, and analysis was completed on December 19, 2018.

Interventions

Patients were randomized to 1 of 3 arms: tamoxifen alone or tamoxifen plus gonadotropin-releasing hormone analogue (GnRHa) or aromatase inhibitor (AI) plus GnRHa for 6 months.

Main Outcomes and Measures

The primary end point was the change in estradiol levels from baseline to 3 months. Secondary end points were changes of estradiol levels after 6 months, changes of additional hormonal parameters, adverse effects, sexual function, and quality of life after 3 and 6 months.

Results

In this phase 2 randomized clinical trial, a total of 52 of 56 male patients with a median (range) age of 61.5 (37-83) years started treatment. A total of 3 patients discontinued study treatment prematurely, 1 in each arm. A total of 50 patients were evaluable for the primary end point. After 3 months the patients' median estradiol levels increased by 67% (a change of +17.0 ng/L) with tamoxifen, decreased by 85% (-23.0 ng/L) with tamoxifen plus GnRHa, and decreased by 72% (-18.5 ng/L) with AI plus GnRHa (P < .001). After 6 months, median estradiol levels increased by 41% (a change of +12 ng/L) with tamoxifen, decreased by 61% (-19.5 ng/L) with tamoxifen plus GnRHa, and decreased by 64% (-17.0 ng/L) with AI plus GnRHa (P < .001). Sexual function and quality of life decreased when GnRHa was added but were unchanged with tamoxifen alone.

Conclusions and Relevance

This phase 2 randomized clinical trial found that AI or tamoxifen plus GnRHa vs tamoxifen alone led to a sustained decrease of estradiol levels. The decreased hormonal parameters were associated with impaired sexual function and quality of life.

Trial Registration

ClinicalTrials.gov Identifier: NCT01638247.

Breast cancer-related lymphedema and its treatment: how big is the financial impact?

PURPOSE

Decongestive lymphatic treatment (DLT) is still the gold standard for treatment of breast cancer-related lymphedema (BCRL). With up to 17% of the patients treated for breast cancer developing BCRL, this morbidity imposes a tremendous financial burden for patients and society. Knowledge about this economic burden related to BCRL and its conservative treatment in a European setting is lacking. The aim of this prospective, longitudinal cohort study was to estimate the direct healthcare costs related to BCRL and its treatment in a European setting.

METHODS

Patients with BCRL were treated with DLT consisting of an intensive treatment phase of 3 weeks, followed by a maintenance treatment phase of 6 months. Additionally, the follow-up period comprised 6 months. During these 3 weeks and 12 months, all direct costs associated with the treatment of BCRL and its sequelae were documented through billing prices and a self-developed questionnaire which was administered after the intensive treatment phase, and subsequently 3-monthly during the entire period.

RESULTS

A total of 194 patients were enrolled in this study. Of these, 17% (n = 32) showed lymphedema stage I, 56% (n = 109) had lymphedema stage IIa, and 27% (n = 53) had lymphedema stage IIb. Total direct healthcare costs per patient were €2248.93 on average during the entire period of 3 weeks of intensive treatments and 12 months of maintenance decongestive therapy. Within these mean direct costs, €1803.35 (80%) was accounted for statutory health insurances, and €445.58 (20%) was out-of-pocket expenses for patients.

CONCLUSION

This study is one of the first standardized high-quality health economic analyses of BRCL treatment in Europe. The present study indicates that the price tag of BCRL treatment in Belgium is high not only for the health insurance but also for the patients Clinical trial registration number The study makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Breast Cancer and Tamoxifen: A Nigerian Perspective to Effective Personalised Therapy

Estrogen-receptor positivity in tumour, often requiring long-term tamoxifen therapy, is thought to characterise between 43% and 65% of breast cancer cases in Nigeria. The patient population is further marked by late-stage diagnosis which significantly heightens the tendency for tumour relapse in the course of tamoxifen therapy. Despite tamoxifen being considered a reliable chemopreventive in high-risk individuals and an effective adjuvant therapy for hormone-sensitive tumours, mortality has remained high among breast cancer patients in the West African region where Nigeria belongs. The Nigerian breast cancer population, like other similar patient-populations in the West African region, provides a mix of intrinsic genome-diversity and perhaps unique tumour biology and evolution. These peculiarities suggest the need for a rational approach to tumour management and a personalised delivery of therapy in Nigeria's dominant estrogen-receptor-positive patient population. Herein, critical indices of tamoxifen-therapy success are discussed in the context of the Nigerian breast cancer population with emphasis on salient aspects of tamoxifen-biotransformation, host- and tumour-genomics, and epigenetics.

Adjuvant treatment of early male breast cancer

PURPOSE OF REVIEW

Male breast cancer (MaBC) is a rare disease, and some challenges exist in its management because current treatment recommendations are extrapolated from trials that mostly excluded men. This review will revise all available data that could improve the treatment of MaBC, with a special focus on adjuvant systemic treatments.

RECENT FINDINGS

To date, men with hormone receptor-positive breast cancer, who are candidates for adjuvant endocrine therapy, should be offered tamoxifen (TAM) for five years. Additional five years are possible, according to tolerance and recurrence risk. If TAM is contraindicated, a gonadotropin-releasing hormone (GnRH) agonist or antagonist and aromatase inhibitor should be proposed. Chemotherapy and targeted therapy in the other breast cancer subtypes should be used with the same indications offered to women with breast cancer. All men with breast cancer should be offered genetic counseling and germline genetic testing of cancer predisposition genes.

SUMMARY

For decades, men with breast cancer have been treated suboptimally and denied the participation in clinical trials. Recently, many clinical trials started enrolling both genders, as strongly endorsed by the Food and Drug Administration. Hopefully, this turnaround will help subdue the disparities in the quality of care.

Management of Male Breast Cancer: ASCO Guideline

PURPOSE

To develop recommendations concerning the management of male breast cancer.

METHODS

ASCO convened an Expert Panel to develop recommendations based on a systematic review and a formal consensus process.

RESULTS

Twenty-six descriptive reports or observational studies met eligibility criteria and formed the evidentiary basis for the recommendations.

RECOMMENDATIONS

Many of the management approaches used for men with breast cancer are like those used for women. Men with hormone receptor-positive breast cancer who are candidates for adjuvant endocrine therapy should be offered tamoxifen for an initial duration of five years; those with a contraindication to tamoxifen may be offered a gonadotropin-releasing hormone agonist/antagonist plus aromatase inhibitor. Men who have completed five years of tamoxifen, have tolerated therapy, and still have a high risk of recurrence may be offered an additional five years of therapy. Men with early-stage disease should not be treated with bone-modifying agents to prevent recurrence, but could still receive these agents to prevent or treat osteoporosis. Men with advanced or metastatic disease should be offered endocrine therapy as first-line therapy, except in cases of visceral crisis or rapidly progressive disease. Targeted systemic therapy may be used to treat advanced or metastatic cancer using the same indications and combinations offered to women. Ipsilateral annual mammogram should be offered to men with a history of breast cancer treated with lumpectomy regardless of genetic predisposition; contralateral annual mammogram may be offered to men with a history of breast cancer and a genetic predisposing mutation. Breast magnetic resonance imaging is not recommended routinely. Genetic counseling and germline genetic testing of cancer predisposition genes should be offered to all men with breast cancer.

Features, Outcomes, and Management Strategies of Male Breast Cancer: A Single Institution Comparison to Well-Matched Female Controls

Objective

The primary objective of this study was to delineate differences in management, overall and distant disease-free survival in males diagnosed with breast cancer and treated at The Ohio State University Comprehensive Cancer Center as compared to comprehensively matched female subjects. Secondary objectives included assessment of clinical and histopathologic features and recurrence score, as measured by Oncotype DX and the modified Magee equation #2.

Materials and Methods

This single institution retrospective study compared male and comprehensively matched female patients (1:2) with stage I-III breast cancer between 1994 and 2014. Recurrence risk was estimated using a modified Magee equation. Overall survival and distant disease-free survival were estimated and compared using Kaplan-Meier and Log-rank methods.

Results

Forty-five male breast cancer patients were included (stage I: 26.7%; stage II: 53.3%; stage III: 20.0%; hormone receptor positive: 97.8%; human epidermal growth factor receptor 2 negative: 84.4%) with a median age of 63.8 (43.0-79.4) years at diagnosis. Intermediate and low recurrence scores were most common in male and female patients respectively; mean score was similar between groups (20.3 vs. 19.8). The proportion of male breast cancer patients treated with adjuvant chemotherapy and post-mastectomy radiation was lower compared to female patients (42.2% vs. 65.3%, p=0.013; 22.7% vs. 44.4%, p=0.030, respectively). Overall survival and distant disease-free survival between male and female patients were similar.

Conclusion

Male breast cancer patient outcomes were similar compared to well-matched female patients suggesting that breast cancer specific factors are more prognostic than gender.

Survival benefit of tamoxifen in male breast cancer: prospective cohort analysis

Background

Due to the lack of prospective data, current treatment of male breast cancer (MBC) is based on information obtained from retrospective analysis or by extrapolation from studies on female patients. In this prospectively enrolled cohort study, we retrospectively examined the survival effect of tamoxifen in MBC patients.

Methods

In this prospectively enrolled cohort study, 448 patients with MBC were treated between May 2009 and June 2018. The primary endpoint was disease-free survival (DFS).

Results

Between May 2009 and June 2018, 448 men with breast cancer were identified, with a median age at diagnosis of 69 years (range 27–96 years). The median follow-up was 39 months (range 3–89 months). Most tumours were larger than 20 mm; invasive ductal carcinoma was of no special histological type and with an intermediate grade of differentiation. Almost half of the men were diagnosed with positive axillary lymph nodes (43.5%). Hormone receptor (HR) positivity was observed in 98.4% of the patients. Notably, DFS among men who did not receive tamoxifen was significantly reduced as compared with those who underwent tamoxifen therapy (P = 0.002). The recurrence rate and mortality in the group of patients without and with tamoxifen treatment were 18.2% and 11.2%, respectively. The most common localisation of metastases was the bone. After adjustment for prognostic factors, we found that tamoxifen was found to reduce the recurrence rate by 68% (hazard ratio HR = 0.32; 95% confidence interval, CI: 0.14–0.74).

Conclusions

Tamoxifen treatment was associated with improved DFS for MBC patients.

Clinical trial registration

DRKS00009536.

Tamoxifen is a candidate first-in-class inhibitor of acid ceramidase that reduces amitotic division in polyploid giant cancer cells-Unrecognized players in tumorigenesis

Polyploid giant cancer cells (PGCC) represent a poorly understood, small subpopulation of tumor cells that are increasingly being recognized for their critical role in therapy resistance, metastasis, and cancer recurrence. PGCC have the potential to generate progeny through primitive or cleavage-like division, which allows them to evade antimitotic insults. We recently demonstrated that the sphingolipid enzyme acid ceramidase (ASAH1) is required for this process. Since specific ASAH1 inhibitors are not clinically available, we investigated whether tamoxifen, which interferes with ASAH1 function via off-target effects, has a potential clinical benefit independent of estrogen signaling. Our results show that tamoxifen inhibits generation of PGCC offspring in prostate cancer, glioblastoma, and melanoma cells. Analysis of two state-level cancer registries revealed that tamoxifen improves survival outcomes for second, nonbreast cancers that develop in women with early stage breast cancer. Our results suggest that tamoxifen may have a clinical benefit in a variety of cancers that is independent of estrogen signaling and could be due to its inhibition of acid ceramidase. Thus the distinct application of tamoxifen as potentially a first-in-class therapeutic that inhibits the generation of PGCC offspring should be considered in future clinical trials.

Male breast cancer: a neglected disease

Male breast cancer (MBC) is rare, tending to afflict sedentary men, with adolescent obesity being a risk factor. Men fare worse compared with matched females with breast cancer. The preponderance of ER+ve disease affects the molecular profile: most cases have luminal A tumors. Through male ignorance and risk-taking, delay is frequent and this lacuna needs addressing with health education. The major gene mutation responsible for MBC is BRCA2. Five single nucleotide polymorphisms (SNPs) are significantly and uniquely associated with MBC risk with two located in the 8q24.21 regions. Mastectomy is being gradually replaced by nipple-preserving surgery and radiotherapy but this trend could be expedited with neoadjuvant endocrine therapy. Significant advances will occur only after expansion of collaborative groups and this is a matter of pressing importance.

What are the economic burden and costs associated with the treatment of breast cancer-related lymphoedema? A systematic review

OBJECTIVES

To provide an overview of costs associated with the treatment of breast cancer-related lymphoedema (BCRL) and its possible sequelae, borne by patients or by society.

DATA SOURCES

According to the PRISMA guideline, a systematic literature search was carried out in four electronic databases: PubMed, Web of Science, Cochrane Clinical Trials and EMBASE. Searches were performed on October 1, 2018.

STUDY SELECTION

Eligibility criteria: (1) expenses of adults (age > 18 years), (2) concerning patients with BCRL, (3) overview of (in)direct costs associated with BCRL, (4) expenses in which at least one type of conservative treatment modality for lymphoedema is included and/or costs for hospital admissions due to infections. Reviews and meta-analyses were excluded.

DATA EXTRACTION

After assessing the risk of bias and level of evidence, quantitative data on (in)direct costs for BCRL treatment during a well-mentioned timeframe were extracted.

DATA SYNTHESIS

Eight studies were included. Three studies reported on patient-borne costs related to BCRL. Mean direct costs per year borne by patients ranged between USD$2306 and USD$2574. Indirect costs borne by patients ranged between USD$3325 and USD$5545 per year. Five studies estimated society-borne costs related to BCRL from claims data, billing prices and providers' services during 12 to 24 months of follow-up. Mean direct treatment costs after 1 year of decongestive lymphatic therapy (DLT) ranged between €799 (= USD$1126.60) and USD$3165.

CONCLUSION

This systematic review revealed that BCRL imposes a substantial economic burden on patients and society. However, more standardized high-quality health economic analyses among this field are required. Recent economic analyses related to BCRL treatment in Europe, Asia, Africa and South America are lacking. Worldwide, further scrutiny of the economic impact of DLT for BCRL in clinical settings is needed.

CLINICAL TRIAL REGISTRATION NUMBER

The review makes part of a double-blind, multi-center, randomized controlled trial (EFforT-BCRL trial), which is registered in clinicaltrials.gov (NCT02609724). CME reference S58689, EudraCT Number 2015-004822-33.

Incidence and survival outcomes of early male breast cancer: a population-based comparison with early female breast cancer

Background

Male breast cancer (MBC) is a rare malignancy. We aimed to analyze the incidence trends, clinicopathological characteristics, and survival outcomes in early MBC comparison with early female breast cancer (FBC).

Methods

We included eligible MBC and FBC patients with stage I-II disease in the Surveillance, Epidemiology, and End Results (SEER) database from 2000-2015. Joinpoint regression was used to evaluate the trends in age-adjusted incidence. A one-to-four propensity score matching (PSM) analysis was performed to reduce bias in a retrospective study. Survival outcomes were evaluated using Kaplan-Meier analyses with the log-rank test and Cox proportional hazards regression analysis.

Results

Trends in the age-adjusted incidence rates of early MBC were stable [2000-2015, annual percentage change (APC) =0.50, 95% confidence interval (CI): -0.1 to 1.1, P=0.102]; however, the incidence of early FBC changed significantly over the time period (2000-2015, APC = 0.30, 95% CI: 0.0 to 0.6, P=0.045). In the matched cohort, unmarried status, higher grade, larger tumor size, and advanced lymph node (LN) status were associated with a higher risk of breast cancer death and death of any causes both in early MBC and FBC patients. The hormone receptor (HR) status was as a prognostic factor in FBC patients, but not in MBC. Early MBC had worse breast cancer-specific survival (BCSS) and overall survival (OS) than early FBC in stage I, stage II and HR-positive subgroup of patients.

Conclusions

The biological behavior, clinicopathological features, and clinical outcomes of early MBC are different from that of FBC. Further studies on individualized treatment approaches in MBC are needed.

The use of selective estrogen receptor modulators on bone health in men

Selective estrogen receptor modulators (SERMs) represent a class of drugs that act as agonist or antagonist for estrogen receptor in a tissue-specific manner. The SERMs drugs are initially used for the prevention and treatment of osteoporosis in postmenopausal women. Bone health in prostate cancer patients has become a significant concern, whereby patients undergo androgen deprivation therapy is often associated with deleterious effects on bone. Previous preclinical and epidemiological findings showed that estrogens play a dominant role in improving bone health as compared to testosterone in men. Therefore, this evidence-based review aims to assess the available evidence derived from animal and human studies on the effects of SERMs on the male skeletal system. The effects of SERMs on bone mineral density (BMD)/content (BMC), bone histomorphometry, bone turnover, bone strength and fracture risk have been summarized in this review.

Tamoxifen treatment for male breast cancer and risk of thromboembolism: prospective cohort analysis

Purpose

Thromboembolism is a common adverse event in women treated with tamoxifen (TAM) for breast cancer. The risk in male breast cancer patients is poorly investigated. We aimed to examine the risk of thrombotic events after TAM in male breast cancer patients.

Patients and methods

In this prospective cohort study, 448 patients treated between May 2009 and July 2017 for male breast cancer (BC) were assessed for eligibility. Patients with follow-up shorter than 6 months were excluded. The cumulative risk of thromboembolism was evaluated.

Results

The median follow-up was 47 months (range 6–101 months) with a median age of 69.4 years (range 27–89 years). Oestrogen receptor and progesterone receptor expression levels were observed in 98.3 and 94.9% of cases, respectively. During the follow-up period, thrombotic events were documented in 21 (11.9%) of 177 patients receiving TAM and in 1 (2.5%) of 41 patients who did not receive tamoxifen. The estimated incidence was 51.9 per 1000 person-years and 21.5 per 1000 person-years, respectively. Notably, the highest risk was identified in the first 18 months, where 81% of the observed thrombotic events occurred. Patients aged older than 71 years had a significantly increased risk of thrombotic event under TAM treatment than their younger counterparts (p = 0.033). History of thrombotic event, cardiovascular and liver disease, as well as additional adjuvant treatment were not associated with increased thrombotic risk.

Conclusion

The risk of thrombotic event in men treated with TAM for breast cancer is markedly increased in the first 18 months of treatment, and should be considered during treatment decisions.

Surgical options for male breast cancer

BACKGROUND

Male breast cancer (MBC) is a rare disease for which no randomised controlled trials (RCT) have been conducted to determine optimal surgical management. The available data have been reviewed to identify reasonable options and reveal areas in need of investigation.

METHODS

All published series on the surgical management of MBC have been reviewed to determine approaches to treatment of the primary, the breast and the axilla together with the psychological sequelae of surgery.

FINDINGS

Mastectomy is still the major surgical offer but a convincing case can be made for the use of neoadjuvant endocrine treatment in order to facilitate breast conserving surgery. Sentinel node biopsy has been successfully used for staging MBC although nomograms for prediction of nodal status are inadequately calibrated. There are psychological sequelae of mastectomy in males and as yet no evidence that the needs of those with MBC are being met.

CONCLUSIONS

Collaborative studies are required so that men can participate in meaningful RCTs to provide an evidence-based rational foundation for the surgery of MBC.

The effect of training interventions on physical performance, quality of life, and fatigue in patients receiving breast cancer treatment: a systematic review

OBJECTIVES

The primary purpose of this systematic review is to structure the available evidence concerning physical exercise programs and their effects on (1) physical performance outcomes, (2) experienced fatigue, and (3) quality of life (QoL) in patients during the initial treatment for breast cancer.

DATA SOURCES

A systematic literature search, based upon the PRISMA guideline, up to January 1, 2018, was performed using four databases (Web of Science, Cochrane Library for Clinical Trials, PubMed, and Medline).

STUDY SELECTION

Inclusion criteria were as follows: (1) adults > 18 years; (2) patients with breast cancer undergoing initial treatment; (3) interventions with the aim to influence the patient's physical activity, QoL, or fatigue; (4) randomized controlled trials (RCTs) of all ages. The selected studies were scored for methodological quality, and data concerning physical performance, QoL, and fatigue were extracted. Twenty-eight RCTs were included.

DATA EXTRACTION

Different treatment modalities during initial treatment were identified (radiation therapy, chemotherapy, and combination therapy), as well as different types of physical training interventions (cardiovascular endurance exercise, strengthening programs, or a combination of both). Therefore, the results were clustered with regard to the above-mentioned grouping; extracting every relevant outcome related to physical performance (6 MWT or VO_2peak; grip/muscle strength), QoL (questionnaires), and fatigue (questionnaires).

DATA SYNTHESIS

Different training programs (endurance, resistance, or a combination of both) were found. These programs were applied during different phases of initial treatment. Some programs were supervised while others were home based. Overall, most training interventions provided an improvement in physical performance and a decrease in perceived fatigue. QoL was the outcome variable least susceptible to improvement.

CONCLUSION

Different types of exercise programs are available for rehabilitation purposes of breast cancer patients during adjuvant therapy. Overall resistance training or resistance training in combination with CV endurance training provides the best results, especially on physical performance and perceived fatigue.