Living with Male Breast Cancer: A Qualitative Study of Men's Experiences and Care Needs

Stakeholders' experiences and perceptions of male breast cancer:A qualitative evidence synthesis

BACKGROUND

The experiences, physical and mental health and needs of women with breast cancer have been studied in some detail, but there is a lack of discussion of the experiences of stakeholder groups such as men with breast cancer, partners and carers and healthcare professionals. The aim of this study was to explore and understand the experiences and perceptions of male breast cancer stakeholders from diagnosis through to survivorship.

METHODS

We conducted a thematic review of qualitative studies included in a large published scoping review on male breast cancer (reported under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews extension). To be included in a qualitative evidence review, studies had to use qualitative methods for data collection and analysis to capture the perspectives of men with breast cancer, partners or caregivers, and healthcare workers. Key characteristics and findings were extracted and a conceptual coding framework was summarized using thematic analysis.

RESULTS

Out of a total of 310 studies in the research literature (published research articles and gray literature), 15 studies met the inclusion criteria. These studies reported on the experiences of men with breast cancer, partners or caregivers, and healthcare workers, with participant numbers ranging from 2 to 31. A total of 17 descriptive themes (study outcomes) were identified. From these, four high-level analytic themes emerged: (1) Predicament; (2) Emotion; (3) Support; (4) Coping.

CONCLUSIONS

The gender stigma that exists at the patient, healthcare system, and family-society levels largely influences the experiences of the male breast cancer stakeholder population. To address gender inequalities in breast cancer care, healthcare organizations and society at large should remain equally attentive to the needs of male and female breast cancer patients. These needs include reducing healthcare and social stigma, providing gender-specific information and emotional support, and access to support groups.

Experiences and perceptions of men following breast cancer diagnosis: a mixed method systematic review

BACKGROUND

Men with breast cancer experience unique physical and emotional challenges. However, a thorough understanding of these experiences including the psychosocial effects and supportive care needs have received less attention. In some settings, men with breast cancer experience stigma within the healthcare system and their care needs are not prioritised. This influences the level of professional support offered, consequently worsening their health and well-being outcomes. This review explored the variabilities in the experiences and treatment modalities of male breast cancer (MBC) across different contexts.

METHODS

All primary study designs including qualitative, quantitative, and mixed methods studies that reported on the experiences, treatment approaches and outcomes of MBC were included in this systematic review. Six databases (Embase, Medline, PsycINFO, Global Health, CINAHL and Web of Science) were searched for articles from January 2000 to September 2023. A results-based convergence synthesis was used for data analysis and reported using PRISMA guidelines.

RESULTS

Of the studies screened (n = 29,687), forty-four fulfilled the predetermined criteria and were included. Our findings relating to the experiences and treatment approaches of MBC are broadly themed into three parts. Theme 1-Navigating through a threat to masculinity: describes how males experienced the illness reflecting on detection, diagnosis, coming to terms with breast cancer, and disclosure. Theme 2- Navigating through treatment: captures the experiences of undergoing breast cancer treatment/ management following their diagnosis. Theme 3-Coping and support systems: describes how MBC patients coped with the disease, treatment process, aftercare/rehabilitative care, and the available support structures.

CONCLUSIONS

Men experience a myriad of issues following a breast cancer diagnosis, especially with their masculinity. Awareness creation efforts of MBC among the public and healthcare practitioners are urgently required, which could change the perception of men in promoting early diagnosis, adherence to treatments, post-treatment monitoring, oncological results and a better quality of life. Considerations for training, education and development of specialised guidelines for healthcare practitioners on MBC would provide the necessary knowledge and skills to enhance their practice through the adoption of person-centred and male-specific care strategies. Professional care intervention and support for MBC should not end after the diagnosis phase but should extend to the entire treatment continuum and aftercare including future research focusing on MBC specific clinical trials.

TRIAL REGISTRATION

PROSPERO Registration No. CRD42021228778.

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.

Patients' views and experiences on the supported self-management/patient-initiated follow up pathway for breast cancer

PURPOSE

To explore patients' expectations and experience of Supportive Self-Management (SSM)/ Patient Initiated Follow Up (PIFU) following breast cancer treatments over a 12-month period.

METHODS

In total, 32/110 (29%) patient participants in the PRAGMATIC (Patients' experiences of a suppoRted self-manAGeMent pAThway In breast Cancer) study were interviewed at baseline, 3, 6, 9 and 12 months. Interviews in this sub-study used a mix-methods approach to explore understanding of the pathway, confidence in self-management, triggers to seek help and/or re-engage with the clinical breast team and impact of the COVID-19 pandemic. Responses to pre-assigned categories were summarised as counts/ percentages and collated in tabular or graphic format. Free responses were recorded verbatim and reviewed using framework analysis.

RESULTS

Participants regarded the SSM/PIFU pathway as a way to save time and money for them and the National Health Service (NHS) (14/32; 44%) and as a means of assuming responsibility for their own follow-up (18/32; 56%). Most maintained (very/somewhat) confidence in managing their BC follow-up care (baseline 31/32, 97%; 12 months 29/31, 93%). During the year, 19% (5/26) stopped endocrine therapy altogether because of side effects. Qualitative analysis revealed general satisfaction with SSM/PIFU and described the breast care nurses as reassuring and empathic. However, there was a lingering anxiety about identifying signs and symptoms correctly, particularly for those with screen-detected cancers. There was also uncertainty about who to contact for psychological support. The COVID-19 pandemic discouraged some participants from contacting the helpline as they did not want to overburden the NHS.

CONCLUSIONS

The results show that during the first year on the SSM/PIFU pathway, most patients felt confident managing their own care. Clinical teams should benefit from understanding patients' expectations and experiences and potentially modify the service for men with BC and/or those with screen-detected breast cancers.

Men's Lived Experiences of Breast Cancer and Changes in Occupation

Introduction

Male breast cancer is rare and frequently diagnosed at later stages of disease with low survival rates. There is a lack of knowledge of how breast cancer impacts men's occupations.

Objectives

This study is aimed at understanding the lived experiences of men with breast cancer and their changes in occupation. Methodology. Twenty-four men with breast cancer participated in semistructured phone interviews. Data was open-coded and analyzed for themes. Findings. The six major themes are as follows: (1) death as a reality, (2) unique personal insights, (3) social environment, (4) interactions with the healthcare system, (5) decreased engagement in occupations, and (6) finding meaning in new occupations.

Conclusion

The healthcare team can improve the patient experience by discussing and responding to the client's experience throughout the diagnosis, intervention, and survival continuum. The scope of occupational therapy is well suited to address the needs of men with breast cancer to maintain optimal levels of functioning.

A systematic literature review of the management, oncological outcomes and psychosocial implications of male breast cancer

BACKGROUND

Although male breast cancer (MBC) is a rare disease, accounting for <1% of all breast cancers, it has significant oncological, survival and psychosocial implications for patients. The aim of this study is to assess the latest literature in the diagnosis, management, oncological outcomes, and psychosocial impact of MBC.

METHODS

A systematic literature review was conducted using the PRISMA guidelines (Moher et al., 2009) [1] to explore the management of MBC, with particular focus on investigative imaging, surgical management, oncological outcomes, survival, genetic screening and psychosocial effects. Electronic databases were searched for randomised control trials, cohort studies and case series involving more than 10 patients. Imaging and surgical techniques, local and distant disease recurrence, survival, genetic screening and psychosocial implications in the setting of MBC were assessed.

RESULTS

The search criteria identified 199 articles, of which 59 met the inclusion criteria. This included 39,529 patients, with a mean age of 64.5 years (55-71), and a mean follow-up of 66.3 months (26.2-115). Mastectomy remains the most frequently used surgical technique, with an average of 89.6%. Loco-regional and distant recurrence rate was 10.1% and 21.4% respectively. Disease-free survival (DFS) at 5 and 10 years was 66.8% and 54.5% respectively. Disease-specific survival (DSS) at 5 and 10 years was 87.1% and 67.1% respectively. Overall survival (OS) at 5 and 10 years was 72.7% and 50.7% respectively. Genetic screening was conducted in 38.6% of patients of which 4.8% and 15.8% were found to be BRCA1 and BRCA2 carriers respectively. Psychosocial studies were conducted mainly using questionnaire and interview-based methodology focusing primarily on awareness of breast cancer in men, support available and impact on gender identity.

CONCLUSIONS

This review demonstrates that men present with later stage disease with subsequent impact on survival outcomes. There remains a paucity of high-level evidence and prospective studies are required. There is a need for increasing awareness amongst the public and health care professionals in order to improve outcomes and reduce stigma associated with MBC.

Fear of cancer recurrence in males diagnosed with breast cancer

PURPOSE

Fear of cancer recurrence (FCR) is a significant problem for individuals diagnosed with a variety of different cancers. To date, FCR has not been studied in males with breast cancer. The objective of this study was to examine the severity of FCR in males with breast cancer.

METHODS

Males with breast cancer participated in an anonymous online survey and completed the Fear of Cancer Recurrence Inventory-Short Form scale (FCRI-SF). A frequency analysis was used to determine the percentage of participants that fell above or below the clinical cutoff for significant FCR. Regressions explored associations between FCR, age, cancer stage, time since diagnosis, and self-health rating.

RESULTS

Fifty-nine participants completed the FCRI-SF. The mean age of the sample was 63.5 and 93% reported their race as white. The mean FCR score was 23.9 and 61% reported clinically significant FCR. More than 80% of the sample experienced at least problematic levels of FCR. Increasing age was associated with decreased FCR.

CONCLUSION

Results of this study suggest that FCR is prevalent in men with breast cancer but larger studies with representative samples should be undertaken to better assess the prevalence of FCR in this population and compare it with other groups of patients. More attention is needed to understand the psychological distress experienced by men diagnosed and treated for breast cancer.

Which Domains of Social Support Better Predict Quality of Life of Women with Breast Cancer? A Cross-Sectional Study

Objectives:

The study aimed at investigating the specific role of social support types (SSTs) on quality of life (QoL) and its domains of women with breast cancer in Iran.

Methods:

In this cross-sectional study, a number of 223 women with breast cancer visiting three cancer centers of Tehran, Iran, participated from October 2014 to May 2015. Medical Outcome Study-Social Support Scale and Functional Assessment of Cancer Therapy-Breast Cancer were used for data gathering. Backward multiple regression was utilized, adjusted by age, education, and family size.

Results:

The study indicated positive correlations between all SSTs and QoL domains, whereas only positive social interaction (PSI) showed a significant association with physical well-being. PSI showed the only predictive performance in terms of all QoL outcomes, beyond the covariates.

Conclusions:

The study revealed the PSI as the most influential support type to enhance all domains of QoL of women with breast cancer.

Occupational rehabilitation of male breast cancer patients: Return patterns, motives, experiences, and implications-A qualitative study

OBJECTIVE

Knowledge regarding the occupational rehabilitation of male breast cancer patients (MBCPs) is currently scarce; however, there may exist unmet needs of men affected by this rare disease. Therefore, this exploratory study investigated the experiences of MBCPs in their return to work (RTW).

METHODS

Interview data from 14 men with a breast cancer diagnosis were used for qualitative content analysis. Data were collected within the mixed-methods N-MALE project (Male breast cancer: patients' needs in prevention, diagnosis, treatment, rehabilitation, and follow-up care), conducted in Germany from 2016 to 2018.

RESULTS

The eight identified motives for RTW were desire for normalcy, distraction, need for activity, social contacts, work as a source of pleasure, financial considerations, lack of self-perception of illness, and having a job requiring low physical effort. The participants reported positive experiences with their workplaces from diagnosis through RTW. However, stigmatisation occurred. The aftermath of the disease and treatment led to changes in the interviewees' productivity, for instance due to fatigue.

CONCLUSION

The findings of this study contribute to a better understanding of RTW processes, as new insights were gained about motives and experiences particular to MBCPs. Support needs after return were apparent and may help to reduce long-term effects that limit productivity.

Defense Mechanisms and Repressive Coping Among Male Breast Cancer Patients

Objectives: The concept of defense mechanisms has undergone extensive revision and expansion since Freud first described these processes. Initially formulated as an unconscious repression of unpleasant memories, with further development focusing on the role of defense mechanisms in the regulation of internal conflicts, the concept shifted and evolved to incorporate the adaptation to external demands, including intrapsychic and interpersonal handling of burden of illness. In addition to defense mechanisms, coping provides another perspective on human adjustment to difficult life events. While there is substantial research on both coping and defense mechanisms in various psychiatric and somatic diseases, including cancer, little is known about defensive regulation, coping, and their interaction in male breast cancer patients. Methods: The present study is part of the N-Male project conducted between 2016 and 2018 in Germany (Male breast cancer: patients' needs in prevention, diagnosis, treatment, rehabilitation, and follow-up care). Semi-standardized interviews with 27 male breast cancer patients were analyzed with regard to defense mechanisms. In addition, fear of progression and repressive coping was assessed by self-report. Results: There was considerable variety in levels of defensive functioning as well as repressive coping in our sample. We found no difference in overall levels of defensive functioning between men with vs. without repressive coping. However, patients with repressive coping demonstrated a decopupled association between fear of progression and defensive functioning as compared to patients without repressive coping. Discussion: The study provides the first evidence of disease processing in male breast cancer patients Knowledge of patients' defense patterns and repressive coping seems promising for better planning targeted intervention strategies.

[Are men and women with breast cancer treated equally in Germany?]

INTRODUCTION

Within the statutory health insurance system of the Federal Republic of Germany, a system of quality assurance has been implemented and operationalised through the measurement of quality indicators. For breast surgery, these quality indicators are mainly based on recommendations of the German clinical guideline for screening, diagnosis, therapy and follow-up of breast cancer. The 2018 update of this guideline includes a new chapter on breast cancer in men. The aim of this analysis is to examine whether male and female patients with breast cancer are treated equally where appropriate and recommended by the clinical guideline, as measured by the quality indicators.

METHOD

Data of ten quality assurance indicators were analysed, for each indicator separately, stratified by sex and pooled over a 5-year period to gain statistical power. This dataset constitutes the largest data pool of men with surgical interventions for breast neoplasm in Germany. Indicator results were then compared between male and female cases. Additional subgroup analyses were carried out for two quality indicators with substantial outcome difference between male and female cases in order to detect possible differences in the treatment of breast cancer between different medical departments.

RESULTS

The database of the ten quality assurance indicators comprised 551,221 patients (546,324 females and 4,897 males) between 2014 and 2018. Pooled data of nine quality indicators (QIs) showed statistically significant outcome differences between male and female cases. In spite of pooling, the male sample size of four QIs was too small to allow for statistically reliable comparisons between male and female patients. Outcome differences in the remaining five QIs may, on the one hand, be explained by anatomical differences and different extent of the surgery, and on the other hand they confirm international data for lower HER2-positivity rates in male breast cancer patients. However, two process indicators, aiming at pretherapeutic biopsy and sentinel lymph node biopsy in invasive breast cancer recommended by the clinical guideline, show substantial differences of more than 6 percentage points between the sexes: although recommended by the clinical guideline, both procedures are carried out less often in male cases. Further analysis regarding the medical departments that recorded the treatment revealed that risk for non-adherence to guideline recommendation was high if treatment took place in non-gynaecological departments. Compared to gynaecological departments, procedures such as pretherapeutic biopsy and sentinel lymph node biopsy were carried out less frequently if cases were documented to be handled by surgery or plastic surgery departments.

DISCUSSION AND CONCLUSION

Analysis of breast surgery quality indicators reveals a lower level of adherence to guideline recommendations for men with breast cancer compared to women in some aspects of the guideline, as measured by statutory quality indicators in breast surgery. Male breast cancer might be a rare disease, but nevertheless, awareness-rising is needed in diagnostics, treatment and interdisciplinarity in order to avoid inequality between the sexes.