The rising incidence of male breast cancer

Cost-effectiveness of adjuvant endocrine treatment with tamoxifen for male breast cancer

BACKGROUND

Tamoxifen (TAM) is recommended as the first-line strategy for men with estrogen receptor (ER)-positive early breast cancer who are candidates for adjuvant endocrine therapy in ASCO guideline. Our study aims to analyze the cost-effectiveness of receiving adjuvant endocrine therapy with TAM compared to no TAM, and to assess the cost-effectiveness of using TAM with high adherence over low adherence for ER-positive early male breast cancer in the USA.

METHODS

Two Markov models comprising three mutually exclusive health states were constructed: (1) the first Markov model compared the cost-effectiveness of adding TAM with not using TAM (TAM versus Not-TAM); (2) the second model compared the cost-effectiveness of receiving TAM with high adherence and low adherence (High-adherence-TAM versus Low-adherence-TAM). The simulation time horizon for both models was the lifetime of patients. The efficacy and safety data of two models were elicited from the real-world studies. Model inputs were derived from the US website and published literature. The main outcomes of two models both included the total cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).

RESULTS

In the first model, TAM yielded an ICER of $5707.29 per QALY compared to Not-TAM, which was substantially below the WTP threshold of $50,000.00 per QALY in the USA. Probabilistic sensitivity analysis results demonstrated a 100.00% probability of cost-effectiveness for this strategy. In the second model, High-adherence-TAM was dominated absolutely compared to Low-adherence-TAM. The High-adherence-TAM was cost-effective with a 99.70% probability over Low-adherence-TAM when WTP was set as $50,000.00/QALY. All of these parameters within their plausible ranges did not reversely change the results of our models.

CONCLUSIONS

Our study will offer valuable guidance for physicians or patients when making treatment decisions and provide an effective reference for decision-making to consider the appropriate allocation of funds to this special group.

Trends in incidence, prevalence, and survival of breast cancer in the United Kingdom from 2000 to 2021

Breast cancer is the most frequently diagnosed cancer in females globally. However, we know relatively little about trends in males. This study describes United Kingdom (UK) secular trends in breast cancer from 2000 to 2021 for both sexes. We describe a population-based cohort study using UK primary care Clinical Practice Research Datalink (CPRD) GOLD and Aurum databases. There were 5,848,436 eligible females and 5,539,681 males aged 18+ years, with ≥ one year of prior data availability in the study period. We estimated crude breast cancer incidence rates (IR), prevalence and survival probability at one-, five- and 10-years after diagnosis using the Kaplan-Meier method. Analyses were further stratified by age. Crude IR of breast cancer from 2000 to 2021 was 194.4 per 100,000 person-years for females and 1.16 for males. Crude prevalence in 2021 was 2.1% for females and 0.009% for males. Both sexes have seen around a 2.5-fold increase in prevalence across time. Incidence increased with age for both sexes, peaking in females aged 60-69 years and males 90+ . There was a drop in incidence for females aged 70-79 years. From 2003-2019, incidence increased > twofold in younger females (aged 18-29: IR 2.12 in 2003 vs. 4.58 in 2018); decreased in females aged 50-69 years; and further declined from 2015 onwards in females aged 70-89 years. Survival probability for females after one-, five-, and ten-years after diagnosis was 95.1%, 80.2%, and 68.4%, and for males 92.9%, 69.0%, and 51.3%. Survival probability at one-year increased by 2.08% points, and survival at five years increased by 5.39% from 2000-2004 to 2015-2019 for females, particularly those aged 50-70 years. For males, there were no clear time-trends for short-term and long-term survival probability. Changes in incidence of breast cancer in females largely reflect the success of screening programmes, as rates rise and fall in synchronicity with ages of eligibility for such programmes. Overall survival from breast cancer for females has improved from 2000 to 2021, again reflecting the success of screening programmes, early diagnosis, and improvements in treatments. Male breast cancer patients have worse survival outcomes compared to females, highlighting the need to develop male-specific diagnosis and treatment strategies to improve long-term survival in line with females.

An update on existing therapeutic options and status of novel anti-metastatic agents in breast cancer: Elucidating the molecular mechanisms underlying the pleiotropic action of Withania somnifera (Indian ginseng) in breast cancer attenuation

Major significant advancements in pharmacology and drug technology have been made to heighten the impact of cancer therapies, improving the life expectancy of subjects diagnosed with malignancy. Statistically, 99% of breast cancers occur in women while 0.5-1% occur in men, the female gender being the strongest breast cancer risk factor. Despite several breakthroughs, breast cancer continues to have a worldwide impact and is one of the leading causes of mortality. Additionally, resistance to therapy is a crucial factor enabling cancer cell persistence and resurgence. As a result, the search and discovery of novel modulatory agents and effective therapies capable of controlling tumor progression and cancer cell proliferation is critical. Withania somnifera (L.) Dunal (WS), commonly known as Indian ginseng, has long been used traditionally for the treatment of several ailments in the Indian context. Recently, WS and its phytoconstituents have shown promising anti-breast cancer properties and, as such, can be employed as prophylactic as well as therapeutic adjuncts to the main line of breast cancer treatment. The present review is an attempt to explore and provide experimental evidences in support of the prophylactic and therapeutic potential of WS in breast cancer, along with a deeper insight into the multiple molecular mechanisms and novel targets through which it acts against breast and other hormonally-induced cancers viz. ovarian, uterine and cervical. This exploration might prove crucial in providing better understanding of breast cancer progression and metastasis and its use as an adjunct in improving disease prognosis and therapeutic outcome.

Imaging the Male Breast: Gynecomastia, Male Breast Cancer, and Beyond

The number of men undergoing breast imaging has increased in recent years, according to some reports. Most male breast concerns are related to benign causes, most commonly gynecomastia. The range of abnormalities typically encountered in the male breast is less broad than that encountered in women, given that lobule formation rarely occurs in men. Other benign causes of male breast palpable abnormalities with characteristic imaging findings include lipomas, sebaceous or epidermal inclusion cysts, and intramammary lymph nodes. Male breast cancer (MBC) is rare, representing up to 1% of breast cancer cases, but some data indicate that its incidence is increasing. MBC demonstrates some clinical features that overlap with those of gynecomastia, including a propensity for the subareolar breast. Men with breast cancer tend to present at a later stage than do women. MBC typically has similar imaging features to those of female breast cancer, often characterized by an irregular mass that may have associated calcifications. Occasionally, however, MBC has a benign-appearing imaging phenotype, with an oval shape and circumscribed margins, and therefore most solid breast masses in men require tissue diagnosis. Histopathologic evaluation may alternatively reveal other benign breast masses found in men, including papillomas, myofibroblastomas, and hemangiomas. Radiologists must be familiar with the breadth of male breast abnormalities to meet the rising challenge of caring for these patients. ©RSNA, 2024 Supplemental material is available for this article.

Feasibility of targeted therapies in the adjuvant setting of early breast cancer in men: real-world data from a population-based registry

BACKGROUND

Following the positive iDFS and OS results of the phase III clinical trials monarchE, NATALEE and OlympiA, new oral anticancer agents (the CDK4/6 inhibitors abemaciclib, ribociclib as well as the PARP inhibitor olaparib) have recently been introduced into the treatment of high-risk early breast cancer (eBC). However, only few male patients were included in these trials (0.4%, 0.6% and 0.3%, respectively). The objective of this real-world analysis was to determine the proportion of male patients with eBC fulfilling the clinical high-risk criteria of above-mentioned trials.

PATIENTS AND METHODS

We conducted a data inquiry and analysis with the Cancer Registry of Baden-Württemberg of men with breast cancer diagnosed between January 1, 2015 and December 31, 2021. Men with eBC were identified and the number of patients at clinical high-risk according to the inclusion criteria of monarchE, NATALEE and OlympiA was assessed.

RESULTS

Of 397 men with eBC, 354 (89.1%) had a HR + /Her2- and 4 (1.0%) a triple-negative subtype. 84 patients (21.2%) met the clinical high-risk criteria according to the monarchE, 189 (47.6%) those according to the NATALEE and 50 (12.6%) those according to the OlympiA trial.

CONCLUSION

In a large real-world sample, more men with eBC are at clinical high risk according to the inclusion criteria of monarchE, NATALEE and OlympiA than would be expected in women. This is most likely due to more advanced stages at initial diagnosis in men. To evaluate whether CDK4/6 and PARP inhibitors improve prognosis also in men should be the topic of future real- world analyses.

Exploring the One Health Paradigm in Male Breast Cancer

How cancer patterns in humans compare to those of other species remains largely unknown and there is an even bigger knowledge gap for rare cancers like male breast cancer. One Health is a convergence of human and animal healthcare that encourages cross-pollination of medical research uniting human and veterinary medicine. Recognising that breast cancer occurs spontaneously in other male species (e.g. primates, canines, felines), and knowing that no laboratory models exist for male breast cancer, which limits our ability to perform functional studies, we explored the feasibility of applying One Health to breast cancer in men by conducting a narrative review of the topic. Spontaneous development of breast cancer was reported in captive male primates and in companion canines and felines. Some parallels in tumour biology of human male breast cancer with canines and primates were found. The age distribution, pattern of biomarker expression and metastasis were similar, with mammary tumours typically detected after two-thirds of average lifespan. However, instances of triple negative and inflammatory breast cancer, which are rarely observed in human male breast cancer, were found in canines and histological classification was inconsistent between species. These disparities need redressing to enable full exploration of the One Health paradigm in rare cancers.

Difficulties of gender affirming treatment in trans women with BRCA1+ mutation: A case report

Gender affirming treatment in transgender women is based on a combination of antiandrogens and estrogens, with the latter maintained over the long term. When prescribing these treatments, we must consider the possibility of developing estrogen-dependent breast cancer. In transgender women, a breast cancer incidence of 4.1 per 100,000 has been estimated, which would increase the risk by 46% in relation to cisgender men but decrease it by 70% in relation to cisgender women. It is known that certain gene mutations such as BRCA1 imply an increased risk of breast cancer, but at present the risk in transgender women with BRCA1 treated with estrogens is not well established. We present the case of a transgender woman with a family history of breast cancer and BRCA1 mutation and the therapeutic decisions made in a multidisciplinary team. Following this case, we review and discuss the published literature.

Time Trends in Male Breast Cancer Incidence, Mortality, and Survival in Austria (1983-2017)

Background

Male breast cancer (MBC) comprises less than 1% of all breast cancer cases globally and remains understudied with persisting sex-specific survival disadvantages. We aim to contribute to better understanding of MBC with a comprehensive analysis of time-trends over several decades in Austria.

Methods

We used Austrian National Cancer Registry data on 1648 cases of MBC cases diagnosed between 1983 and 2017 in Austria. Overall incidence, mortality, and survival rates, as well as age-, stage-, and period-specific incidence and survival rates were calculated. Joinpoint regression was performed to assess trends.

Results

MBC incidence rates increased throughout the whole observation period (1983-2017) with an annual percent change (APC) of 1.44% (95% confidence interval, CI: 0.77 to 2.11). During the same period, morality rates were stable (APC: -0.25, 95% CI: -0.53 to 0.60). Ten-year survival rates showed three phases of decreasing increases with an average APC of 2.45%, 1983-2009 (95% CI: 2.1 to 2.74). Five-year survival rates improved until 2000 (APC: 2.31, 95% CI: 1.34 to 3.30) and remained stable thereafter (APC: 0.10, 95% CI: -0.61 to 0.80). Stage-specific analyses showed a single trend of stable incidence rates of distant disease MBC (APC: -0.03, 95% CI: -1.67 to 1.65). Further, we observed increases in localised, regional, and unknown stage cancer incidence and increases in incidence rates across all age groups over the whole observation period. However, the estimates on these subgroup-specific trends (according to age- and stage) show wider 95% CIs and lower bounds closer to zero or negative in comparison to our findings on overall incidence, mortality, and survival.

Conclusion

Despite improvements in survival rates, MBC mortality rates remained largely stable between 1983 and 2017 in Austria, possibly resulting from a balance between increasing overall incidence and stable incidence rates of distant disease MBC.

A Single Centric Quantitative Assessment of Male Breast Cancer Knowledge, Perception, and Awareness: Breaking the Stigma in Indian Population

Most people throughout the world are still uninformed of the problem of breast cancer in men. Despite increasing awareness programs targeting women, most people are unaware that breast cancer can also affect men. Our purpose is to assess the knowledge, perception, and awareness of male breast cancer among the adult male population. A descriptive cross-sectional survey included 128 male employees who agreed to participate in our study. We distributed pre-validated questionnaires to participants and gathered data following the one-on-one interview. The mean age of the participants was 37.71 years with a standard deviation of 7.65. About 55.5% of the participants were unaware that changes in the nipple position could be a sign of breast cancer. Majority of the participants, i.e., 60.9% believe positive family history will not increase the risk of breast cancer and 93% of participants have no idea about self-breast examination to detect lumps. On the other hand, 33.6% of participants stated that diagnosis and treatment of male breast cancer is embarrassing. Majority of the participants have no idea about the screening methods, 59.4% of participants have not heard about mammography, which is considered a modality of choice for early detection of breast cancer. The male university staff were lacking in knowledge and awareness about male breast cancer. In Indian community, because of shyness, they feel very embarrassed when it comes to openly discussing breast cancer. Because of this, it needs to receive more attention and to educate the male population about male breast cancer.

Proton Therapy in the Treatment of Men with Breast Cancer

Purpose

Male breast cancer treatment involves multimodality therapy, including radiation therapy; nevertheless, few men have received proton therapy (PT) for it. Further, heart disease is an established leading cause of death in men, and radiation therapy heart dose correlates with cardiac toxicity, highlighting the need for cardiac-sparing radiation techniques. Thus, we provide a descriptive analysis of PT in a male breast cancer cohort.

Patients and Methods

Men who received PT for localized breast cancer between 2012 and 2022 were identified from a prospective database. Toxicities were prospectively recorded by using the Common Terminology Criteria for Adverse Events (CTCAE), version 4.0.

Results

Five male patients were identified. All had estrogen receptor (ER)-positive, Her2neu-negative disease and received adjuvant endocrine therapy. One had genetic testing positive for BRCA2, one had a variant of unknown significance (VUS) in the APC gene, and one had a VUS in MSH2. Median age was 73 years (range, 41-80). Baseline comorbidities included obesity (n = 1), diabetes (n = 1), hypertension (n = 4), history of deep vein thrombosis (n = 1), personal history of myocardial infarction (n = 3; 1 with a pacemaker), and a history of lung cancer (n = 1). All received PT to the left chest wall and comprehensive regional lymphatics. One received passive-scattering PT, and 4 received pencil beam scanning. One patient received a boost to the mastectomy incision via electrons. Median heart dose was 1 GyRBE (range, 0-1.0), median 0.1-cm3 dose to the left anterior descending artery was 7.5 GyRBE (range, 0-14.2), and median follow-up was 2 years (range, 0.75-6.5); no patient experienced a new cardiac event, and all remain free from breast cancer recurrence and progression.

Conclusion

In a small case series for a rare diagnosis, PT to the chest wall and regional lymphatics, including internal mammary nodes, resulted in low cardiac exposure, high local regional disease control rates, and minimal toxicity. Proton therapy should be considered for treating men with breast cancer to achieve cardiac sparing.

Quality of Life in Male Breast Cancer: Prospective Study of the International Male Breast Cancer Program (EORTC10085/TBCRC029/BIG2-07/NABCG)

INTRODUCTION

Prospective data about quality of life (QoL) in men with breast cancer (BC) are lacking. A prospective registry (EORTC10085) of men with all BC stages, including a QoL correlative study, was performed as part of the International Male Breast Cancer Program.

METHODS

Questionnaires at BC diagnosis included the EORTC QLQ-C30 and BR23 (BC specific module), adapted for men. High functioning and global health/QoL scores indicate high functioning levels/high QoL; high symptom-focused measures scores indicate high symptoms/problems levels. EORTC reference data for healthy men and women with BC were used for comparisons.

RESULTS

Of 422 men consenting to participate, 363 were evaluable. Median age was 67 years, and median time between diagnosis and survey was 1.1 months. A total of 114 men (45%) had node-positive early disease, and 28 (8%) had advanced disease. Baseline mean global health status score was 73 (SD: 21), better than in female BC reference data (62, SD: 25). Common symptoms in male BC were fatigue (22, SD: 24), insomnia (21, SD: 28), and pain (16, SD: 23), for which women's mean scores indicated more burdensome symptoms at 33 (SD: 26), 30 (SD: 32), and 29 (SD: 29). Men's mean sexual activity score was 31 (SD: 26), with less sexual activity in older patients or advanced disease.

CONCLUSIONS

QoL and symptom burden in male BC patients appears no worse (and possibly better) than that in female patients. Future analyses on impact of treatment on symptoms and QoL over time, may support tailoring of male BC management.

JAG-1/Notch signaling axis in the spinal cord contributes to bone cancer pain in rats

Notch signal plays an important role in regulating cell-cell interactions with the adjacent cells. However, it remains unknown whether Jagged1 (JAG-1) mediated Notch signaling regulates bone cancer pain (BCP) via the spinal cell interactions mechanism. Here, we showed that intramedullary injection of Walker 256 breast cancer cells increased the expression of JAG-1 in spinal astrocytes and knockdown of JAG-1 reduced BCP. The supplementation of exogenous JAG-1 to the spinal cord induced BCP-like behavior and promoted expression of c-Fos and hairy and enhancer of split homolog-1 (Hes-1) in the spinal cord of the naïve rats. These effects were reversed when the rats were administered intrathecal injections of N-[N-(3,5-difluorophenacetyl)-l-alanyl]-S-phenylglycine t-butyl ester (DAPT). The intrathecal injection of DAPT reduced BCP and inhibited Hes-1 and c-Fos expression in the spinal cord. Furthermore, our results showed that JAG-1 up-regulated Hes-1 expression by inducing the recruitment of Notch intracellular domain (NICD) to the RBP-J/CSL-binding site located within the Hes-1 promoter sequence. Finally, the intrathecal injection of c-Fos-antisense oligonucleotides (c-Fos-ASO) and administration of sh-Hes-1 to the spinal dorsal horn also alleviated BCP. The study indicates that inhibition of the JAG-1/Notch signaling axis may be a potential strategy for the treatment of BCP.

Profile of Male Breast Cancer in Makkah Region of Saudi Arabia: A 4-Year Retrospective Analysis of Radiology and Histopathology

Background

Mammography is a method widely used for the diagnosis of breast disorders in women and may help detect breast cancer in its early stages. Male breast cancer often remains undiagnosed or is poorly controlled until serious complications arise; therefore, the use of screening methods is needed to help with early diagnosis.

Methods

From a total of 1,667 registered mammography cases screened, 17 male breast disease cases were included in this study. Mammography and ultrasound data were analyzed by Statistical Package of Social Sciences v.22 (SPSS). Diagnosis was made following biopsy in suspicious cases, and histopathological and immunological findings of all such patients were obtained for final diagnosis.

Results

The mean age of the patients was 35 years (range, 14-70 years); 17.6% of the cases were aged 37 yrs, and 2 cases were aged 51 and 52 yrs. Of the 17 cases, 11 had breast lesions, and skin thickening was observed in only 1 case. The different patterns of lesions detected were asymmetry of the parenchyma, mastitis, and hamartoma (n = 1 each), malignant lesions (n = 2), and gynecomastia (n = 6). According to the BI-RADS categorization, 8 cases were benign, one case was probably benign, and 2 cases were likely malignant. In the 2 cases with malignant lesions, pathological diagnosis was made after hematoxylin and eosin and immunocytochemistry examination as invasive ductal carcinoma (IDC) of no special type (NST), grade II and grade III.

Conclusions

Most breast lesions in this study population were benign, while IDC was the most common malignancy encountered. Mammography is currently the most accurate and cost-effective method for detecting breast lesions. The findings of our study may help increase awareness of male breast cancer and encourage Saudi men at risk to perform self-breast exam and undergo routine breast screening.

Survival Analysis in Male Breast Cancer With Bone Metastasis Based on the SEER Database

Purpose

Breast cancer (BC) has been extensively and deeply studied as the number one malignant tumor in women, but its status in male patients, especially in male metastatic patients, is rarely reported. Thus, this study aimed to explore the prognosis and risk factors of male BC with bone metastasis.

Patients and Methods

We searched the Surveillance, Epidemiology, and End Results (SEER) database to identify all patients diagnosed with male BC with bone metastasis from 2010 to 2016. Risk factors of overall survival (OS) and cancer-specific survival (CSS) were analyzed by univariable and multivariable Cox analyses. We also drew Kaplan–Meier plots to show the correlation between independent risk factors and survival.

Results

A total of 207 male BC patients with bone metastasis were included for analysis. Approximately one-third of patients also had lung metastasis. Luminal A subtype comprised 58.5% of the overall patient population. These patients had a poor prognosis, with 3-year OS and CSS rates, 36.7% and 39.5%, respectively. Further analysis revealed that age ≤60 years old, luminal A or B, and surgery were independent predictors of prolonged OS and CSS. On Cox multivariable analysis, brain metastasis was associated with OS and not CSS.

Conclusion

We identified four independent factors associated with prognosis in male BC patients with bone metastasis, namely age, tumor subtype, surgery, and brain metastasis. Knowing these risk factors will help clinicians make more appropriate treatment plans.

High-throughput Proteomic Profiling of Male Breast Cancer Tissue

BACKGROUND/AIM

Until now, little emphasis has been placed on the protein expression profile of male breast cancer (MBC) tumors, due to the rarity of the disease. The present study aimed to identify a proteomic pattern that is characteristic for malignant male breast tissue epithelium.

MATERIALS AND METHODS

The protein content of four male breast tumors and corresponding adjacent healthy (control) tissues was analyzed by high-throughput nano-liquid chromatography-MS/MS technology.

RESULTS

A total of 2,352 proteins were identified, that correspond to 1,249 single gene products, with diverse biological roles. Of those, a panel of 119 differentially expressed tissue proteins was identified in MBC samples compared to controls; 90 were found to be over-expressed in MBC tissues, while 29 were down-regulated. Concurrently, 844 proteins were detected only in MBC tumors and 197 were expressed exclusively in control mammary samples.

CONCLUSION

Differential proteomic expression was found in MBC tissue, leading to improved understanding of MBC pathology and highlighting the need for personalized management of male patients.

Management of Male Breast Cancer: The Journey so Far and Future Directions

Male breast cancer is now shown to be a unique entity and should be considered as a distinct disease. Given the relatively smaller number of cases, randomized controlled trials for treatment are extremely limited and majority of practices are derived from female breast cancer studies. This paper reviews available literature on surgical, radiation, and systemic therapies for male breast cancer, and discusses current practice recommendations.

Male Breast Cancer Review. A Rare Case of Pure DCIS: Imaging Protocol, Radiomics and Management

Ductal carcinoma in situ (DCIS) of male breast is a rare lesion, often associated with invasive carcinoma. When the in situ component is present in pure form, histological grade is usually low or intermediate. Imaging is difficult as gynaecomastia is often present and can mask underlying findings. We report a rare case of pure high-grade DCIS in a young male patient, with associated intraductal papilloma and atypical ductal hyperplasia. Digital breast tomosynthesis (DBT) showed an area of architectural distortion at the union of outer quadrants of the left breast without gynaecomastia. Triple assessment suggested performing a nipple-sparing mastectomy, which revealed the presence of a focal area of high-grade DCIS of 2 mm. DCIS, even of high grade, is difficult to detect with mammography and even more rare, especially when associated with other proliferative lesions. DBT with 2D synthetic reconstruction is useful as the imaging step of a triple assessment and it should be performed in both symptomatic and asymptomatic high-risk men to differentiate between malignant and benign lesions. We propose a diagnostic model to early detect breast cancer in men, optimizing resources according to efficiency, effectiveness and economy, and look forward to radiomics as a powerful tool to help radiologists.

Gender Differences in Recommended Treatment Decisions among Breast Cancer Patients: A Study Using the National Cancer Database

BACKGROUND

Previous studies have explored surgery refusal among female breast cancer patients. However, little attention has been given to other therapies in both females and males. The goal of this study was to determine the potential role of gender on recommended hormone therapy, chemotherapy, radiation therapy, and surgery refusal and to describe other determinants of refusal.

MATERIALS AND METHODS

A retrospective study of the National Cancer Database (NCDB) between 2004 and 2016 was conducted. The outcome was whether patients accepted or refused the recommended treatment. We examined four different outcome variables (hormone therapy, chemotherapy, radiation therapy, and surgery) relation to gender and other factors.

RESULTS

A total of 906,342 breast cancer patients met the eligibility criteria for hormone therapy, 1,228,132 for surgery, 596,229 for chemotherapy, and 858,050 for radiation therapy. The odds of refusing hormone therapy and surgery in males were 17% (AOR = 0.83; 95% CI: 0.75-0.92) and 33% (AOR=0.67; 95% CI: 0.50-0.90) lower compared to female patients, respectively. The odds of refusing radiation therapy were 14% higher in males compared to females (AOR=1.14; 95% CI:1.03-1.30). Older age and lack of insurance were significantly associated with each treatment refusal.

CONCLUSION

Female patients tend to refuse hormone therapy and surgery compared to males. A marginally statistically significant gender differences was found for radiotherapy refusal. The providers and other stakeholders can utilize the current findings to identify the risk groups and barriers associated with refusal for each treatment and to develop interventions.

Male breast cancer: an update

Male breast cancer (MBC) is rare, accounting for less than 1% of all breast cancer but the incidence has increased worldwide. Risk factors include increased longevity, obesity, testicular diseases and tumours, and germline mutations of BRCA2. BRCA2 carriers have 80 times the risk of the general population. Men generally present with breast cancer at an older age compared with women. Histologically, MBC is often of grade 2, hormone receptor positive, HER2 negative, and no special type carcinoma although in situ and invasive papillary carcinomas are common. Reporting and staging are similar to female breast cancer. Metastatic lesions to the male breast do occur and should be differentiated from primary carcinomas. Until recently, MBC was thought to be similar to the usual ER positive post-menopausal female counterpart. However, advances in MBC research and trials have highlighted significant differences between the two. This review provides an up to date overview of the biology, genetics, and histology of MBC with comparison to female breast cancers and differential diagnosis from histological mimics.

Cardiovascular and Other Competing Causes of Death in Male Breast Cancer Patients: A Population-Based Epidemiologic Study

Purpose

Male breast cancer (MBC) is a rare disease that tends to occur in elderly men. Little is known about the causes of death in MBC because of the small sample size of most studies. This study aimed to investigate the causes of death in MBC patients.

Patients and Methods

MBC patient data were obtained from the Surveillance, Epidemiology, and End Results database (1975-2016). Time trends of MBC mortality in the US population were analyzed using Joinpoint software. We calculated the proportion of each cause of death in the overall cohort and in different patient subgroups. Competing risk models were used to calculate cumulative mortality at different follow-up times. The risk of cardiovascular death (CVD) in MBC patients was compared to that of the age-matched general population by calculating standardized mortality ratio (SMR).

Results

In total, 6426 patients were included in the analysis. MBC mortality rate increased between 2004 and 2019 (annual percentage change=1.16, 95% confidence interval [CI]: 0.50, 1.80). There were 1757 patients (27.3%) who died of non-breast cancer causes. CVD was the leading cause of death in patients who were elderly or had localized disease. MBC patients had a 6.58-fold higher risk of CVD than the general population (SMR=6.58, 95% CI: 6.14, 7.05).

Conclusion

Non-breast cancer death accounts for the majority of deaths in MBC patients who are elderly or have localized cancer. Compared to the general population, MBC patients have an increased risk of CVD. These results highlight the importance of monitoring cardiovascular comorbidities in MBC patients.

Genetic Landscape of Male Breast Cancer

Male breast cancer (MBC) is now considered molecularly different from female breast cancer (FBC). Evidence from studies indicates that common genetic and epigenetic features of FBC are not shared with those diagnosed in men. Genetic predisposition is likely to play a significant role in the tumorigenesis of this rare disease. Inherited germline variants in BRCA1 and BRCA2 account for around 2% and 10% of MBC cases, respectively, and the lifetime risk of breast cancer for men harboring BRCA1 and BRCA2 mutations is 1.2% and 6.8%. As for FBC, pathogenic mutations in other breast cancer genes have also been recently associated with an increased risk of MBC, such as PALB2 and CHEK2 mutations. However, while multigene germline panels have been extensively performed for BC female patients, the rarity of MBC has resulted in limited data to allow the understanding of the magnitude of risk and the contribution of recently identified moderate penetrance genes of FBC for MBC predisposition. This review gathers available data about the germline genetic landscape of men affected by breast cancer, estimated risk associated with these genetic variants, and current guidelines for clinical management.

A spontaneous unveiling of bilateral DCIS in an elderly male

The rarity of male breast cancer continues to limit its study despite increasing incidence rates, particularly within the past decade [Speirs V, Shaaban AM. The rising incidence of male breast cancer. Breast Cancer Res Treat 2009;115:429–30]. Although this trend appears to be substantially documented, male patients with breast cancer have been and continue to be excluded from landmark breast cancer trials. Currently, there are no standardized breast cancer screening protocols in place for men, including those with pathogenic BRCA mutations. As a result, men with breast cancer typically present at a later stage, and on average, 8–10 years later than females [Ruddy KJ, Winer EP. Male breast cancer: risk factors, biology, diagnosis, treatment, and survivorship. Ann Oncol 2013;24:1434–43]. As the incidence of disease continues to rise, the need for algorithmic standardization with regards to screening, diagnosing, treating and managing male breast cancer has become imperative. We report the case of a 71-year-old male who presented with spontaneous bloody nipple discharge and was found to have bilateral ductal carcinoma in situ.

Nutrition and Breast Cancer Research in Arab Countries: Gaps, Opportunities, and Recommendations

According to the WHO, Arab countries have the highest relative increase in Breast Cancer (BC) rates worldwide. Current shifts in dietary patterns in these countries are postulated as important modifiable risk factors of the disease. The objectives of this review were to examine the gaps and opportunities in the extent, range and nature of nutrition-related BC research in Arab countries. Studies (n = 286) were identified through searching 14 electronic databases. Among the gaps identified were limited international collaborations, preponderance of laboratory-based research at the expense of population-based research, focus on single supplement/nutrient/food research, limited use of dietary assessment tools, and studying nutrition in isolation of other environmental factors. Despite these gaps, several opportunities appeared. The distribution of papers among Arab countries suggested that collaboration between high and middle income countries could create a positive synergy between research expertise and wealth. In addition, the steady increase in the number of articles published during the last two decades reflected a promising momentum in nutrition and BC research in the Arab world. These gaps and opportunities constituted context-specific evidence to orient nutrition and BC research in Arab countries which could ultimately lead to development of effective interventions for prevention of BC in these countries.

Identification of novel candidate genes by exome sequencing in Tunisian familial male breast cancer patients

Male Breast Cancer (MBC) is a rare and aggressive disease that is associated with genetic factors. Mutations in BRCA1 and BRCA2 account for 10% of all MBC cases suggesting that other genetic factors are involved. The aim of the present study is to screen whole BRCA1 and BRCA2 exons using the Ampliseq BRCA panel in Tunisian MBC patients with family history. Furthermore, we performed exome sequencing using the TruSight One sequencing panel on an early onset BRCA negative patient. We showed that among the 6 MBC patients, only one (MBC-F1) harbored a novel frameshift mutation in exon 2 of the BRCA2 gene (c.17-20delAAGA, p.Lys6Xfs) resulting in a short BRCA2 protein of only 6 amino-acids. We selected 9 rare variants after applying several filter steps on the exome sequencing data. Among these variants, and based on their role in breast carcinogenesis, we retained 6 candidate genes (MSH5, DCC, ERBB3, NOTCH3, DIAPH1, and DNAH11). Further studies are needed to confirm the association of the selected genes with family MBC.

MARCKS protein overexpression is associated with poor prognosis in male breast cancer

BACKGROUND

Male breast cancer (MBC) is a rare and aggressive disease. Thus, identification of new therapeutic targets is crucial.

OBJECTIVE

Our objective was to evaluate the protein expression of MARCKS (Myristoylated Alanine-Rich C-Kinase Substrate) in MBC and to investigate its prognostic value.

MATERIALS AND METHODS

MARCKS protein expression in tumor and stromal cells was analyzed by immunohistochemistry (IHC) in a retrospective series of 96 pre-chemotherapy MBC samples and 80 normal breast samples, from Tunisian patients treated at Salah Azaiez Institute. Correlations were searched between MARCKS expression and clinicopathological features including overall survival (OS).

RESULTS

MARCKS was overexpressed in epithelial tumor cells in 66% of the MBC samples versus 26% of normal samples (p= 1.40 × 10-7). Such positive MARCKS expression in epithelial tumor cells was associated with positive HER2 status (p= 4.0 × 10-3). It was associated with shorter OS in uni-and multivariate analysis. By contrast, stromal IHC MARCKS expression was correlated only with tumor grade.

CONCLUSION

MARCKS tumor cell overexpression might in part explain the aggressiveness and the poor prognosis of MBC. MARCKS can represent a potential therapeutic target for MBC.

Pharmacological management of male breast cancer

INTRODUCTION

Despite its rarity, male breast cancer shows a steadily rising incidence. Given the absence of ad hoc prospective randomized clinical trials, treatment strategies are based on extrapolation from female breast cancer recommendations or solely on population-based data.

AREAS COVERED

This review discusses the current treatment landscape for male breast cancer in the adjuvant and in the metastatic setting. The authors also discuss the biology and genomic landscape of male breast cancer. Original research and review articles, relative to the period 2010-2019, were included in the review of the literature.

EXPERT OPINION

There is a major medical need to include male patients with breast cancer in prospective clinical trials. The call to equality in breast cancer care can be pursued via two divergent paths: (i) a gender-neutral delivery of breast cancer information and (ii) the creation of separate sections, for the more common female breast cancer and for the rare male ones. We propose to differentiate male breast cancer care, acknowledging unique onco-sexual and social needs that can be only partially shared.

Exclusion of Men from Randomized Phase III Breast Cancer Clinical Trials

Male breast cancer treatment regimens are often extrapolated from female-based studies because of a paucity of literature analyzing male breast cancer. Using ClinicalTrials.gov, we analyzed breast cancer randomized clinical trials (RCTs) to determine which factors were associated with male-gender inclusion. Of 131 breast cancer RCTs identified, male patients represented 0.087% of the total study population, which is significantly less than the proportion of male patients with breast cancer in the U.S. (0.95%; p < .001). Twenty-seven trials included male patients (20.6%). Lower rates of male inclusion were seen in trials that randomized or mandated hormone therapy as part of the trial protocol compared with trials that did not randomize or mandate endocrine therapy (2.5% vs. 28.6% male inclusion; p < .001). It is imperative for breast cancer clinical trials to include men when allowable in order to improve generalizability and treatment decisions in male patients with breast cancer.

Exposure to a Glyphosate-based Herbicide Alters the Expression of Key Regulators of Mammary Gland Development on Pre-pubertal Male Rats

We previously reported that exposure during gestation and lactation to a low dose of glyphosate-based herbicide (GBH) reduced the area and perimeter of male offspring mammary gland at postnatal day 60 (PND60), whereas a higher dose increased the longitudinal growth of the gland. Here, our aim was to assess whether perinatal exposure to GBH exhibits endocrine disruptive action in male mammary gland at an early time point (pre-puberty), which could be related to the changes observed after puberty. We also wanted to explore whether an early evaluation of the male rat mammary gland is appropriate to assess exposure to potential endocrine disrupting chemicals (EDCs). Pregnant rats were orally exposed, through the diet, to vehicle (saline solution), 3.5 or 350 mg/kg/day of GBH from gestational day 9 until weaning. At PND21, the male offspring were euthanized, and mammary gland samples were collected. The histology and proliferation index of the mammary glands were evaluated, and the mRNA expression of estrogen (ESR1) and androgen (AR) receptors, cyclin D1 (Ccnd1), amphiregulin (Areg), insulin-like growth factor 1 (IGF1), epidermal growth factor receptor (EGFR) and IGF1 receptor (IGF1R) were assessed. Moreover, the phosphorylated-Erk1/2 (p-ERK1/2) protein expression was determined. No differences were observed in mammary epithelial structures and AR expression between experimental groups; however, the proliferation index was reduced in GBH3.5-exposed males. This result was associated with decreased ESR1, Ccnd1, Areg, IGF1, EGFR and IGF1R mRNA expressions, as well as reduced p-Erk1/2 protein expression in these animals. ESR1, Ccnd1, IGF1R and EGFR expressions were also reduced in GBH350-exposed males. In conclusion, the mammary gland development of pre-pubertal male rats is affected by perinatal exposure to GBH. Although further studies are still needed to understand the molecular mechanisms involved in GBH350 exposure, the present results may explain the alterations observed in mammary gland growth of post-pubertal males exposed to low doses of GBH. Our results also suggest that early evaluation of the male rat mammary gland is useful in assessing exposure to potential EDCs. However, analysis of EDCs effects at later time points should not be excluded.

Utility of Oncotype DX in Male Breast Cancer Patients and Impact on Chemotherapy Administration: A Comparative Study with Female Patients

BACKGROUND

Use of the Oncotype DX recurrence score (RS) has been widely adopted in women with early-stage hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER-) breast cancer (BC). Validation studies on the use of RS in male BC (MBC) are lacking.

OBJECTIVE

The aim of this study was to identify the utilization of RS and association with chemotherapy recommendations in early-stage MBC compared with female BC (FBC).

METHODS

Using the National Cancer Database (NCDB), a retrospective review was performed for patients with T1/T2, node-negative, HR+/HER2- BC between 2010 and 2014. Patients were stratified by demographics, tumor characteristics, RS, and chemotherapy use comparing MBC with FBC over the allotted time period.

RESULTS

A total of 358,497 patients-3068 (0.8%) males and 355,429 (99.1%) females-met the inclusion criteria. A smaller proportion of MBC patients received RS testing compared with FBC patients (32% vs. 35%, p < 0.001). Male patients who had RS were younger, had T2 tumors, lymphovascular invasion, and private insurance. The distribution of RS was similar in both groups. Only 4% of MBC patients with low RS received adjuvant chemotherapy, compared with 4.9% of FBC patients. Overall chemotherapy rates were similar in MBC and FBC patients.

CONCLUSIONS

Our results showed that RS has not been completely embraced in the management of MBC, although when performed in MBC, chemotherapy recommendations vary based on RS. Whether the use of RS affects the clinical outcomes of MBC is unknown. A prospective registry would help clarify and evaluate the impact of RS on clinical outcomes in MBC.

Relationship between agrochemical compounds and mammary gland development and breast cancer

The exposure to agrochemical pesticides has been associated with several chronic diseases, including different types of cancer and reproductive disorders. In addition, because agrochemical pesticides may act as endocrine disrupting chemicals (EDCs) during different windows of susceptibility, they can increase the risk of impairing the normal development of the mammary gland and/or of developing mammary lesions. Therefore, the aim of this review is to summarize how exposure to different agrochemical pesticides suspected of being EDCs can interfere with the normal development of the mammary gland and the possible association with breast cancer. It has been shown that the mammary glands of male and female rats and mice are susceptible to exposure to non-organochlorine (vinclozolin, atrazine, glyphosate, chlorpyrifos) and organochlorine (endosulfan, methoxychlor, hexachlorobenzene) pesticides. Some of the effects of these compounds in experimental models include increased or decreased mammary development, impaired cell proliferation and steroid receptor expression and signaling, increased malignant cellular transformation and tumor development and angiogenesis. Contradictory findings have been found as to whether there is a causal link between the exposure or the pesticide body burden and breast cancer in humans. However, an association has been observed between pesticides (especially organochlorine compounds) and specific subtypes of breast cancer. Further studies are needed in both humans and experimental models to understand how agrochemical pesticides can induce or promote changes in the development, differentiation and/or malignant transformation of the mammary gland.

Image-based screening for men at high risk for breast cancer: Benefits and drawbacks

Male breast cancer is a rare malignancy. Due to low prevalence and limited data to support male breast cancer screening, there are currently no recommendations for image-based screening in asymptomatic men and few recommendations for men at high risk for breast cancer. However, symptomatically diagnosed cancers in men are typically advanced, suggesting that earlier detection may improve outcomes. In this article we briefly review the risk factors for male breast cancer, and discuss the potential benefits and possible drawbacks of routine image-based screening for men at high risk for breast cancer.

Male breast cancer: a closer look at patient and tumor characteristics and factors that affect survival using the National Cancer Database

OBJECTIVE

To comprehensively describe the tumor and clinical characteristics of breast cancer in a cohort of male patients and to assess the factors that affect survival.

BACKGROUND

Much of the standard care of male breast cancer is based on the diagnosis and treatment strategies of female breast cancer. However, important clinical differences between the two have been elucidated, which suggests the need for unique attention to male breast cancer.

METHODS

We evaluated the records of male patients who were diagnosed with breast cancer between 2004 and 2015 using the National Cancer Database (NCDB). Data obtained were demographic characteristics, clinical and tumor data, type of therapy, as well as survival data. We used descriptive statistics to characterize our study population. We then performed a survival and Cox proportional hazards analysis.

RESULTS

We identified 16,498 patients (median age: 63 years). Several treatment modalities were used, of which surgery was the most common (14,882 [90.4%]). The total follow-up time was 13 years (156 months). Five-year survival was 77.7% (95% CI 76.9-78.4) and 10-year survival was 60.7%. In a Cox proportional hazards model, mastectomy was associated with the greatest survival (hazard ratio [HR] 0.49; p < 0.001).

CONCLUSION

We report what is to our knowledge the largest national population-based cohort of male breast cancer patients. Importantly, our data suggests that similar to female patients, several treatment modalities are significantly associated with improved survival in male patients, particularly surgery. Increasing age, black race, government insurance, more comorbidities, and higher tumor stages are associated with decreased survival.

Incidence of male breast cancer in Scotland over a twenty-five-year period (1992-2017)

Male breast cancer (MBC) accounts for around 1% of all breast cancers diagnosed. There are inconsistent reports on the incidence of MBC which some propose may be rising. Here, for the first time, the incidence of MBC in Scotland over 25 years from 1992 to 2017 was examined through interrogating the Information Services Division Scotland database. Results showed MBC incidence rose with age, peaking in the 65-70 and 75-79 age groups. Both the total number and the age-adjusted incidence of MBC increased in Scotland since 1992. This rising trend was most clear in the North of Scotland. Interestingly a higher MBC incidence in some rural areas was also observed. Our findings emphasise the need for a better understanding of MBC risk factors so that improved prevention policies can be applied for patient benefit.

Male breast cancer in the United States: Treatment patterns and prognostic factors in the 21st century

BACKGROUND

Male breast cancer (MBC) is a rare disease for which there is limited understanding of treatment patterns and prognostic factors.

METHODS

Men with TNM stage I to stage III breast cancer diagnosed between 2004 and 2014 in the National Cancer Data Base were included. Trends in treatment modalities were described using the average annual percentage change (AAPC) and estimated using Joinpoint software for the analysis of trends. Kaplan-Meier curves and the multivariate Cox proportional hazards regression model were used to compare survival between subgroups and to identify prognostic factors.

RESULTS

A total of 10,873 MBC cases were included, with a median age at diagnosis of 64 years. Breast-conserving surgery was performed in 24% of patients, and 70% of patients undergoing breast conservation received radiotherapy. Approximately 44% of patients received chemotherapy, and 62% of patients with estrogen receptor-positive disease received endocrine therapy. Oncotype DX was ordered in 35% of patients with lymph node-negative, estrogen receptor-positive/human epidermal growth factor receptor 2 (HER2)-negative tumors. During the study period, there was a significant increase in the rates of total mastectomy, contralateral prophylactic mastectomy, radiotherapy after breast conservation, ordering of Oncotype DX, and the use of endocrine therapy (P < .05). On multivariate analysis, factors found to be associated with worse overall survival were older age, black race, higher Charlson Comorbidity Index, high tumor grade and stage of disease, and undergoing total mastectomy. Residing in a higher income area; having progesterone receptor-positive tumors; and receipt of chemotherapy, radiotherapy, and endocrine therapy were associated with better overall survival.

CONCLUSIONS

Despite the lack of prospective randomized trials in patients with MBC, the results of the current study demonstrated that the treatment of this disease has evolved over the years. These findings further the understanding of the modern treatment and prognosis of MBC, and identify several areas for further research.

Saving the Male Breast: A Systematic Literature Review of Breast-Conservation Surgery for Male Breast Cancer

BACKGROUND

Male breast cancer (MBC) management is extrapolated from female BC. Mastectomy remains the most frequently used surgical procedure for male breast cancer (MBC). We performed a literature review to assess the use of breast-conservation (BCS) in MBC as well as outcomes following BCS.

METHODS

A systematic literature was performed, and articles screened to identify studies that measured overall survival (OS), disease-free survival (DFS), or local recurrence (LR) in patients undergoing BCS. Weighted averages based on study size were performed for LR, DFS, and 5-year OS.

RESULTS

Eight studies met the inclusion criteria with male breast surgery cases, and 859 (14.7%) underwent BCS. The mean follow-up time was 53 months, and mean age was 62.6 years, with stage II as the most common presentation. Two studies reported that 50-71.4% of patients underwent sentinel lymph node biopsy, and four studies reported axillary lymph node dissection in 14.3-100%. Five studies reported on adjuvant radiation therapy in 12.0-100% of total patients undergoing BCS. Four studies reported use of hormonal therapy in 73.8-100% of patients. Four studies reported use of chemotherapy in 25-66.7% of patients. Seven studies reported LR among 116 patients, with a weighted average of 9.9%. Three studies reported on DFS in 14 patients, with a weighted average 85.6%. Two studies report OS in 143 patients with a weighted average of 84.4%.

CONCLUSIONS

Breast conservation may be considered a safe alternative in the surgical treatment of MBC. Future research should focus on better standardization of local therapy for MBC and improved reporting of outcomes.

Male breast cancer: Specific biological characteristics and survival in a Portuguese cohort

Male breast cancer (BC) represents an individual subtype of BC, with therapeutic procedures based on female BC therapy results. The present study evaluated the parameters currently used for the characterization and therapy of male BC, and their association with disease-free (DFS) and overall survival (OS), aiming to obtain a comprehensive basis to improve the personalized care of male BC. A total of 196 patients from March 1970 to March 2018 (mean follow-up, 84.9 months) were profiled, using clinicopathological review, molecular assessment [BRCA1/2, DNA repair associated (BRCA1/2) status, immunohistochemistry, fluorescence in situ hybridization and DNA flow cytometry] and Cox regression statistical analysis. The median age of patients was 66.5 years. At presentation, 39.2% of patients with invasive carcinomas were in anatomic stage (AS) I. Patients exhibited primarily invasive carcinomas of no special type, histological grade 2, estrogen receptor α-(ERα) and progesterone receptor (PR)-positive, receptor tyrosine kinase erbB-2-negative, high Ki-67, Luminal B-like and aneuploid tumors. A total of 13 of the 44 (29.5%) BRCA-evaluated patients exhibited BRCA2 mutations, significantly associated with family history (FH), bilaterality, high Ki-67 expression, absence of PR and Luminal B-like tumors. Bilaterality was associated with the occurrence of non-breast primary neoplasms (NBPN). The 5 and 10-year DFS rates, excluding patients with distant metastasis, NBPN and in situ carcinomas (n=145) were 65.9 and 58.2%, respectively, and the 5 and 10-year OS rates were 77.5 and 59.2%, respectively. In the univariate analysis, Luminal B-like subtype, BRCA2 mutations, high Ki-67 expression, and AS II and III were significantly associated with shorter DFS and OS. In addition, age >70 years was associated with low OS. In the multivariate analysis, FH, AS II and III, and Luminal B-like subtypes were associated with poorer OS. In conclusion, the data from the present study emphasize the high incidence of BRCA2 mutation in male BC, and its association with FH, bilaterality, high Ki-67 expression, negative PR expression and Luminal B-like subtypes, and with shorter DFS and OS in univariate analysis.

A Case of Locally Advanced Breast Cancer in a 59-Year-Old Man Requiring a Modified Approach to Management

Patient: Male, 59

Final Diagnosis: Invasive ductal carcinoma

Symptoms: Foul-smelling discharge • painful breast mass

Medication: —

Clinical Procedure: Modified radical mastectomy

Specialty: Surgery

Neoadjuvant concurrent chemoradiation in male breast cancer: Experience from a tertiary cancer center

BACKGROUND

Male breast cancers (MBC) account for 1% of all breast cancers. Neoadjuvant concurrent chemoradiation (CTRT) is not the standard of care for treating breast cancer. However, in our center, it has been routinely used in patients with locally advanced breast cancer to downsize the tumor and make it amenable to surgery.

AIM

This study was conducted to examine the clinical and pathological profile and outcomes of patients with MBC treated at our institute with neoadjuvant CTRT.

SETTINGS AND DESIGN

The study was conducted at a tertiary cancer center and was retrospective in nature.

MATERIALS AND METHODS

All MBC patients treated with neoadjuvant CTRT at our center between 2001 and 2016 were enrolled in the study. Data were retrospectively extracted from the patients' case records.

STATISTICAL ANALYSIS

Kaplan-Meier method was used for survival analysis and the outcome variables were compared using the log-rank test.

RESULTS

Thirty-one MBC patients who received neoadjuvant CTRT were analyzed in this study. The median age of the patients was 53 years. Stage IIB disease was observed in 8/31 (26%) patients, stage III in 20/31 (64%), and stage IV in 3/31 (10%) patients. There was no grade 3 or 4 toxicity due to CTRT. Surgery was performed in 29/31 (94%) patients and none of the patients had a pathological complete response. The median duration of follow-up was 95.3 months. The 8-year event-free survival and overall survival for stage IIB, III, and IV were 75%, 50%, and 0% and 87.5%, 69%, and 0%, respectively.

CONCLUSION

This is the first study to report on the use of neoadjuvant CTRT in MBC. Prospective evidence from phase-3 randomized controlled trials on the safety and efficacy of CTRT in breast cancer is required before its routine use can be recommended.

Characterization of male breast cancer: results of the EORTC 10085/TBCRC/BIG/NABCG International Male Breast Cancer Program

Background

Male breast cancer (BC) is rare, managed by extrapolation from female BC. The International Male BC Program aims to better characterize and manage this disease. We report the results of part I, a retrospective joint analysis of cases diagnosed during a 20-year period.

Methods

Patients with follow-up and tumor samples, treated between 1990 and 2010, in 93 centers/9 countries. Samples were centrally analyzed in three laboratories (the United Kingdom, the Netherlands and the United States).

Results

Of 1822 patients enrolled, 1483 were analyzed; 63.5% were diagnosed between 2001 and 2010, 57 (5.1%) had metastatic disease (M1). Median age at diagnosis: 68.4 years. Of 1054 M0 cases, 56.2% were node-negative (N0) and 48.5% had T1 tumors; 4% had breast conserving surgery (BCS), 18% sentinel lymph-node biopsy; half received adjuvant radiotherapy; 29.8% (neo)adjuvant chemotherapy and 76.8% adjuvant endocrine therapy (ET), mostly tamoxifen (88.4%). Per central pathology, for M0 tumors: 84.8% ductal invasive carcinomas, 51.5% grade 2; 99.3% estrogen receptor (ER)-positive; 81.9% progesterone receptor (PR)-positive; 96.9% androgen receptor (AR)-positive [ER, PR or AR Allred score ≥3]; 61.1% Ki67 expression low (<14% positive cells); using immunohistochemistry (IHC) surrogates, 41.9% were Luminal-A-like, 48.6% Luminal-B-like/HER-2-negative, 8.7% HER-2-positive, 0.3% triple negative. Median follow-up: 8.2 years (0.0-23.8) for all, 7.2 years (0.0-23.2), for M0, 2.6 years (0.0-12.7) for M1 patients. A significant improvement over time was observed in age-corrected BC mortality. BC-specific-mortality was higher for men younger than 50 years. Better overall (OS) and recurrence-free survival (RFS) were observed for highly ER+ (P = 0.001), highly PR+ (P = 0.002), highly AR+ disease (P = 0.019). There was no association between OS/RFS and HER-2 status, Ki67, IHC subtypes nor grade.

Conclusions

Male BC is usually ER, PR and AR-positive, Luminal B-like/HER2-negative. Of note, 56% patients had T1 tumors but only 4% had BCS. ER was highly positive in >90% of cases but only 77% received adjuvant ET. ER, PR and AR were associated with OS and RFS, whereas grade, Ki67 and IHC surrogates were not. Significant improvement in survival over time was observed.

Time trend of breast cancer mortality in BRAZILIAN men: 10-year data analysis from 2005 to 2015

Background

Male Breast Cancer (MBC) is rare, which makes its understanding and treatment be extrapolated from what is known about the occurrence in women, with few epidemiological studies, with few epidemiological studies. Therefore, the aim of the present paper was to study breast cancer mortality in adult males in Brazil and its administrative regions between 2005 and 2015.

Methods

Ecological study with data on MBC mortality in adults between 2005 and 2015. Data were obtained from the Mortality Information System of the Department of Informatics of SUS (the Unified Health System of the country). Descriptive statistics were used for MBC mortality and linear regression to analyze the relationship between mortality and the country’s administrative regions. Percentage Change (PC) and Annual Percentage Change (APC) were the trend measures used for MBC mortality for the period.

Results

Between 2005 and 2015, there were 1521 deaths due to MBC in adults in Brazil. Regarding mortality by region, there was great oscillation in the rates of the country as a whole (PC = 113,87; β = 0,009 (IC95% 0,000 – 0,018); r² = 0,381; P = 0,043). The highest increase in MBC mortality occurred in patients aged 80 years or older (PC = 161,04; β = 0,201 (IC95% 0,640 - 0,339); r² = 0,550; P = 0,009) and there was significant increase in deaths for the 50–54-year age group (PC = 224,01; β = 0,135 (CI95% 0,052; 0,218); r² = 0,601; P = 0,005).

Conclusion

Mortality in adults due to MBC increased in Brazil during the study period with the highest percentage increase occurring for individuals aged 80 years or older.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5261-1) contains supplementary material, which is available to authorized users.

Diagnostic and prognostic value of 18F-FDG PET/CT imaging in suspected recurrence of male breast cancer

Purpose

Male breast cancer (MBC) is a rare malignancy, with recurrence being one of the main adverse predictors for prognosis. The aim of the study was to evaluate the diagnostic and predictive value of fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) PET/CT in the setting of suspected recurrence of MBC.

Patients and methods

Retrospective analysis of PET/CT findings was performed in 23 previously treated, histologically proven patients with MBC (mean age: 59.3±10.9 years; range: 36–79 years) with suspected recurrence. Kaplan–Meier disease-specific survival analysis was made with respect to histological, hormonal profile as well as PET/CT findings.

Results

Of the 23 patients, 19 (82.6%) showed recurrence. Recurrence at primary site with/without regional/distant site recurrence was seen in 12 (52.2%) patients. Only metastatic recurrence without primary site was seen in seven (30.4%) patients. Bone was the most common site of distant metastasis (14/23) followed by lungs (9/23), liver (4/23), brain (2/23), and adrenal (1/23). No recurrence (regional/distant) was noted in 4/23 (17.3%) patients; however, three of them had ¹⁸F-FDG-avid soft tissue lesions in esophagus, rectum and tongue, correspondingly, confirmed as second primaries with histopathology. Disease-specific survival analysis yielded nodal (P=0.01) as well as distant metastases (P=0.02) as the main survival predictors on PET/CT. Lung (P=0.001), followed by liver (P=0.009), and skeletal (P=0.01) metastases were the most adverse survival predictive factors.

Conclusion

¹⁸F-FDG PET/CT showed good diagnostic and prognostic utility in recurrent MBC. It was better than bone scan in evaluation of skeletal metastases. Most importantly, ¹⁸F-FDG PET/CT helped in early detection of second malignancy and their clinical management in studied patients.

Hormone signaling via androgen receptor affects breast cancer and prostate cancer in a male patient: A case report

Background

Male breast cancer (MBC) is rare, accounting for only around 1% of all breast cancers. Most MBCs are hormone-driven. Not only the estrogen receptor (ER), but also other steroid hormone receptors, including the androgen receptor (AR) and progesterone receptor (PgR) are expressed in MBC. AR activation in breast cancer cells facilitates downstream gene expression that drives tumorigenesis in a similar manner to ER. AR-mediated signalling works paradoxically in breast cancer and prostate cancer, and cancer cells expressing the AR are endocrine-sensitive.

Case presentation

We describe a case of double cancer of MBC and prostate cancer. A 69-year-old man was referred to our hospital with a lump in his left breast in the 1990s. The patient had cT3N3M0, stage IIIC breast cancer, and underwent a mastectomy and axillary lymph node dissection. Though adjuvant chemotherapy was administered, he experienced pleural metastasis 2 months after the surgery. Two years after the recurrence during endocrine therapy with oral 5-fluorouracil, he complained of frequent urination. Radiological and histological examinations revealed that the patient had cT3N0M0, stage III primary prostate cancer with a prostate-specific antigen (PSA) level of 40.5 ng/mL. Germline mutations in the BRCA1 and BRCA2 genes were not tested. He received multidisciplinary, continuous therapy for both breast and prostate cancer; however, 5 and 3 years after each diagnosis, respectively, he experienced a deep vein thrombosis in his right leg related to the endocrine therapy. Liver metastasis progressed after he stopped breast cancer therapy. However, long-term disease control had been achieved with anti-estrogen therapy for breast cancer and estrogen replacement therapy for prostate cancer.

Conclusions

Several studies have shown that estrogen exposure after estrogen depletion likely causes apoptosis of ER-positive breast cancer cells. Our findings indicate that this also applies to the environment in male body. AR dominant signaling prevents breast cancer recurrence and metastasis, especially in MBC patients.

Clinical features of patients with male breast cancer in Shanxi province of China from 2007 to 2016

This study aims to understand the clinical features, treatment, and prognosis of patients with male breast cancer (MBC) in Shanxi province of China from 2007 to 2016. Data for 77 patients with MBC were collected for analysis. Immunohistochemistry, pathological results, and other data such as demographic characteristics (age, marital status, smoking history, drinking history, and family history of cancer) as well as clinical data were investigated by retrieving information from the patients' medical records. A total of 12,404 patients were diagnosed with breast cancer between 2007 and 2016, and 77 were patients with MBC among them. The median diagnosis age of patients with MBC was 62 years (range, 24-84 years). The most common complaint was a painless lump in the breast, accounting for 68.8% of the patients, and the main pathological type in MBC was infiltrating ductal carcinoma (66.2%). In terms of hormone receptors, 80.5% (62/77) of patients with MBC were estrogen receptor positive, 75.3% (58/77) of patients were progesterone receptor positive, and only 6.5% (5/77) of patients were HER2 overexpressing. The multivariant Cox proportional hazards regression analysis showed that M stage is an independent prognostic factor (p=0.018, HR=18.791, 95% CI 1.663 to 212.6). The epidemiological and clinical features of Chinese MBC are similar to that of other countries. As the Chinese public have limited knowledge of MBC, it is necessary to increase awareness among them about it. Further research with a large sample size is required for better understanding of the risks associated with MBC.

Influence of Age on the Clinical Outcome of Breast Cancer for Men and the Development of Second Primary Cancers

BACKGROUND

Low incidence of breast cancer in men (BCM) (< 1% of all breast cancers) has led to a paucity of outcome data. This study evaluated the impact of age on BCM outcomes.

METHODS

For this study, BCM patients treated between 2000 and 2011 were stratified by age (≤ 65 or > 65 years). Kaplan-Meier methods were used to compare overall survival (OS) and breast cancer-specific survival (BCSS). Competing-risk methods analyzed time to second primary cancers (SPCs), with any-cause death treated as a competing risk.

RESULTS

The study identified 152 BCM patients with a median age of 64 years (range 19-96 years). The median body mass index (BMI) was 28 kg/m². Men age 65 years or younger (n = 78, 51%) were more overweight/obese than men older than 65 years (n = 74, 49%) (89% vs 74%, respectively; P = 0.008). Both groups had similar nodal metastases rates (P = 0.4), estrogen receptor positivity (P = 1), and human epidermal growth factor receptor 2 (HER2)neu overexpression (P = 0.6). Men 65 years of age or younger were more likely to receive chemotherapy (P = 0.002). The median follow-up period was 5.8 years (range 0.1-14.4 years). The 5-year OS was 86% (95% confidence interval [CI] 80-93%), whereas the 5-year BCSS was 95% (95% CI 91-99%). The BCM patients 65 years of age and younger had better OS (P = 0.003) but not BCSS (P = 0.8). The 5-year cumulative incidence of SPC was 8.4% (95% CI 3.4-13.4%). The prior SPC rate was higher for men older than 65 years (n = 20, 31%) than for those age 65 years or younger (n = 7, 11%) (P = 0.008). This did not account for differences in life years at risk. No difference was observed in SPC cumulative incidence stratified by age (P = 0.3).

CONCLUSIONS

Men 65 years of age or younger received more chemotherapy and had improved OS, but not BCSS, compared with men older than 65 years. For all BCM, SPC is a risk, and appropriate screening may be warranted.

Young male breast cancer, a small crowd, the survival, and prognosis?: A population-based study

Women diagnosed with breast cancer at young age often have poorprognoses. Yet, few studies have focused on the prognoses of young men with breast cancer. We therefore used Surveillance, Epidemiology, and End Results (SEER) population-based data and identified 151 male patients with breast cancer aged <40 years between 1988 and 2012. Propensity score matching analysis was used to balance the clinical variables among different groups. Kaplan-Meier curves were applied to compare the survival differences. The subgroup variables on cancer-specific survival (CSS) and overall survival (OS) were analyzed by the Cox proportional hazard model. Results showed that male patients with breast cancer aged <40 had a significant OS benefit compared with those aged ≥40 years (P < .001). The significant difference of the CSS was not found (P > .05). Compared with the male patients with breast cancer aged ≥40, those aged <40 had significant OS benefit in most subgroups (P < .05). Compared with the female patients with breast cancer aged <40, the male patients with breast cancer aged <40 had worse OS and CSS benefit only in the subgroup with progesterone receptor and estrogen receptor positive (P < .05). In conclusion, we demonstrated that young male patients with breast cancer had better OS compared with elder male patients with breast cancer. However, the survival benefit was not found compared with young female patients with breast cancer.

Negative Lymph Node Count and Lymph Node Ratio Are Associated With Survival in Male Breast Cancer

BACKGROUND

Male breast cancer (MBC) is usually diagnosed at late stages and therefore has a worse prognosis than female breast cancer (FBC). MBC is also more likely to have lymph node (LN) involvement than FBC.

MATERIALS AND METHODS

We sought to determine the prognostic role of the examined lymph node (LN), negative LN (NLN), and positive LN counts and the LN ratio (LNR), defined as (positive LNs/ENLs), on the survival rate among MBC patients. We performed a large population-based study using the data from the Surveillance, Epidemiology, and End Results program.

RESULTS

Older age, black race, stage IV disease, ≤ 1 NLN, and a > 31.3% LNR were significantly associated with worse survival across all prediction models. Moreover, we demonstrated a decreased risk of mortality in MBC patients across the MBC-specific survival model (hazard ratio, 0.98; 95% confidence interval, 0.96-0.998; P = .03) and 10-year MBC-specific survival model (hazard ratio, 0.98; 95% confidence interval, 0.96-0.999; P = .04).

CONCLUSION

MBC has had an augmented incidence over the years. We found several independent predictors of MBC survival, including age, race, stage, NLNs, and the LNR. We strongly suggest adding the NLN count and/or LNR into the current staging system. Further studies are needed to provide information on the mechanisms underlying the association between the NLN count and MBC survival and the LNR and MBC survival.

Characterising the adipose-inflammatory microenvironment in male breast cancer

Male breast cancer (MBC) incidence seems to parallel global increases in obesity. The stromal microenvironment contributes to carcinogenesis; yet, the role of adipocytes in this is understudied in MBC. We identified four cohorts of male breast tissues diagnosed when obesity was rare (archival cohort) and more common (contemporary cohort). We examined the microenvironment of archival and contemporary cohorts of MBC, diagnosed 1940-1970 and 1998-2006, respectively, with two cohorts of, archival and contemporary gynaecomastia, diagnosed 1940-1979 and 1996-2011, respectively, serving as controls. We quantified adipocytes, crown-like structures (CLS) and the presence of CD8, α smooth muscle actin (αSMA) and CD68+ macrophages in both cohorts, and determined how these affected survival, in the contemporary MBC cohort. In both MBC cohorts, mean adipocyte diameter was larger in the distant stroma compared with stroma close to the invading tumour (92.2 µm vs 66.7 µm). This was not seen in gynaecomastia. CLS were more frequent in both MBC cohorts than gynaecomastia (44/55 (80%) vs 11/18 (61%), P < 0.001). No relationship was found between CLS number and adipocyte size, although there were greater numbers of CLS in contemporary MBC > archival MBC > gynaecomastia. CD8 and CD68 expression in the stroma was significantly associated with reduced survival, with no effects seen with αSMA. Changes in the adipose-inflammatory microenvironment may be a contributing factor to the increase seen in MBC diagnosis.

Distribution of 21-Gene Recurrence Scores in Male Breast Cancer in the United States

BACKGROUND

The 21-gene recurrence score (RS) is a RT-PCR assay estimating risk of distant recurrence in estrogen receptor positive (ER+), human epidermal growth factor receptor 2 negative (HER2) breast cancer (BC). Studies validating RS are limited to women. Our objective was to assess RS distribution and factors associated with high-risk RS in male BC.

METHODS

Using the Surveillance, Epidemiology, and End Results database, we identified men and women with ER+/HER2- BC from 2010 to 2013. Patients were categorized into risk groups using the traditional and the Trial Assigning Individualized Options for Treatment (TAILORx) cutoffs. Multivariable logistic regression determined factors associated with testing and high-risk TAILORx RS.

RESULTS

We identified 1388 men and 154,196 women with ER+/HER2- BC. Twenty-five percent of men and 30% of women had RS testing. Mean age of tested men was 63; most were white (81%), had grade I or II tumors (67%), and had stage I or II (95%) BC. Factors associated with increased RS testing were younger age, recent year of diagnosis, lymph node negativity, and lower-stage tumors (p ≤ 0.05). By TAILORx, 21% of men had high-risk RS compared with 14% of tested women. Men with grade III and PR negative tumors were more likely to have a high-risk RS (p ≤ 0.05). Chemotherapy utilization was correlated with RS.

CONCLUSIONS

Using a large population-based dataset, we found that compared with women, men were significantly more likely to have high-risk RS. Grade III and PR-negative BC were significantly associated with high-risk RS. Higher RS in men correlated with increased chemotherapy utilization.