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EDITORIALS: George H Perkins and Lavinia P Middleton Breast cancer in men BMJ 2003; 327: 239-240 [Full text]

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Male breast cancer: Exploring the issues for men diagnosed with this condition across the UK

Rachel T Iredale, Peter Barrett-Lee, Kate Brain, Liz France, Jonathon Gray and Buddug Williams   (2 August 2003)

Breast cancer in men: evidence for suboptimal preoperative work-up.

Pieter J Westenend   (2 October 2003)

Breast cancer in men: Gynecomastia and breast cancer during finasteride therapy

Ferdinand Frauscher, Andreas P. Berger, Andrea Klauser   (24 October 2003)

Male breast cancer: Exploring the issues for men diagnosed with this condition across the UK 2 August 2003
Rachel T Iredale, Senior Research Fellow Institute of Medical Genetics, Heath Park, Cardiff, CF4 4XN, Peter Barrett-Lee, Kate Brain, Liz France, Jonathon Gray and Buddug Williams Send response to journal: Re: Male breast cancer: Exploring the issues for men diagnosed with this condition across the UK	It was heartening to see the editorial by Perkins and Middleton on male breast cancer in the US.1 We know that breast cancer in men is a rare condition - the median incidence in over 100 cancer registries world-wide is 0.5/100,000/ year2 and it accounts for less than 1% of all cases of breast cancer.3 Although the precise incidence of male breast cancer remains speculative, it is estimated that there may be up to 3,000 men across the UK with this diagnosis. We know that every year between 200 to 300 men in the UK are newly diagnosed with breast cancer. While the relatively common nature of female breast cancer has resulted in a high level of general awareness about the condition, male breast cancer is still a comparatively unknown entity, both by the general public and by health and social care professionals. Furthermore, despite government initiatives for modernising cancer services and raising standards of care, there is a paucity of information concerning the social and psychological impact of breast cancer in men. In 1999 we conducted a small pilot study using in-depth interviews with men with breast cancer.4 Our findings showed that major issues for men with this condition include delay in diagnosis, shock, stigma, altered body image, lack of emotional support and the provision of inappropriate information. All of the men in our pilot study had been given literature designed for women, and many were seen by ill-informed professionals. We concluded that male breast cancer is a neglected area and that there may be a need for gender-specific information and guidelines. In order to take forward our earlier research we began the MATCH Project (Men's Attitudes Towards Cancer and Health). Our main objective is to explore patient needs, treatment and management, and information provision with as many men as possible living with breast cancer across the UK. Our working hypotheses are: *That men react differently to women when given a diagnosis of breast cancer *That men with breast cancer require a different approach to treatment and care than women. *That men's ability to cope with their breast cancer diagnosis is affected by the treatment and care they receive from healthcare professionals. *That there are a number of organisational, cultural, professional and other factors which militate against the optimal management of men with breast cancer which can be identified and addressed. *That it is feasible to develop gender-specific guidelines for healthcare professionals dealing with male breast cancer. This research project uses a mixed method approach that includes, inter alia, a series of focus groups with men and women with breast cancer, and with healthcare professionals; sending out questionnaires to men diagnosed with breast cancer across the UK, and following up with semi-structured in-depth interviews. Although this study is on-going, some preliminary analysis of the data reveals that any literature received by men covers a wide-range of topics relating to cancer, but that all are written specifically for women. The men in our study have suggested that a section within existing leaflets and booklets incorporates information about male breast cancer, rather than having gender specific material. In addition, photographs of a male mastectomy are perceived to be extremely useful for patients. Most male participants in this study receive support from their partners and families and are unlikely to use formal sources of support. They appreciate the opportunity to discuss issues with a breast care nurse, but are more focused on problem-based coping i.e. getting to grips with the practicalities of their condition, than with emotion based coping. The prospect of attending a support group or talking to other men with breast cancer is not very appealing to men who see themselves as clear of cancer. However, for men just beginning their treatment matching patients on a one-to-one basis for support and after-care is perceived to be an important aspect of service provision. Further analysis will focus on the psychological and social consequences of a diagnosis of male breast cancer; sources of information and support; current management practice, and how different healthcare professionals can best provide for men at different stages of their illness. If you know of a man who has had breast cancer and would be willing to participate in our study please contact us at the address below. References 1. Perkins GH, Middleton LP. Breast cancer in men. British Medical Journal 2003; 327:239-240. 2. Sasco AJ. Epidemiology of male breast cancer. International Journal of Cancer 1993; 53: 538-549. 3. Young IE et al. The CAG repeat within the Androgen Receptor Gene in male breast cancer patients. Journal of Medical Genetics 2000; 37: 139- 140. 4. France L, Michie S, Barrett-Lee P, Brain K, Harper P, Gray J. Male cancer: a qualitative study of male breast cancer. Breast 2000; 9: 343- 348. Competing interests:   This study is funded by Breast Cancer Campaign
Breast cancer in men: evidence for suboptimal preoperative work-up. 2 October 2003
Pieter J Westenend, pathologist Pathologisch Laboratorium voor Dordrecht eo, Laan van Londen 1800, 3317 DA Dordrecht, Netherlands Send response to journal: Re: Breast cancer in men: evidence for suboptimal preoperative work-up.	In a recent editorial Perkins and Middleton point out that treatment of breast cancer in men is mainly based on extrapolating data derived from the treatment of women with breast cancer, since breast cancer in men is a rare disease and randomised trials are not available. They argue that for these and other reasons treatment of men with breast cancer may be suboptimal. In the Netherlands the situation is very similar with a low incidence rate of 0.8/100,000 men per year (Dutch cancer registry 1995) and a recent guideline from 2002 recommending treating breast cancer in men identical to women. In a response Iredale et al. draw attention to differences of social and psychological impact of a diagnosis of breast cancer in men compared to women. They conclude that too little is known and that there is a need to explore these issues further in order to improve the support for men with breast cancer. A side to the problem of breast cancer in men that was not mentioned by these authors is the diagnostic work-up of men with breast cancer. We recently performed two studies on the pathologic work-up of breast cancer in men. In the first study we evaluated the results of 153 fine needle aspiration cytology (FNAC) procedures in male breast lesions from 1985 until the end of 2000. We reported a sensitivity of 87% ( in the literature ranging from 87 to 100%), a specificity of 78% (in the literature ranging from 69 to 96%) and a positive predictive value of malignant of 100% (in the literature ranging from 89 to 100%). In the study period we received 31 malignancies from male breasts including 28 primary breast carcinomas, 2 melanoma metastases, and 1 malignant lymphoma. In 15 breast carcinomas a preoperative diagnosis was made by FNAC and in 4 carcinomas a preoperative diagnosis was made by core needle biopsy (CNB). This means that a preoperative diagnosis by FNAC or CNB was not available in 9 out of 28 breast carcinomas, a situation which would generally be regarded as unacceptable in women. A preoperative diagnosis was also not available for the 2 melanoma metastases and the malignant lymphoma. The latter was treated by modified radical mastectomy based on clinical findings suggesting breast cancer with extensive lymph node metastasis. In another study we evaluated the preliminary results of 26 CNB’s of male breast lesions from 1993 until the end of 2002. Although the number of procedures is too low to calculate sensitivity or specificity, we did not have a false positive diagnosis or a false negative diagnosis. This suggests that CNB is a reliable preoperative procedure. In this study period, overlapping the study period in the previous report, we diagnosed breast cancer in 19 men and 6 of them did not receive a preoperative diagnosis by either FNAC or CNB. In both studies we found evidence that a benign FNAC or CNB helps to avoid unnecessary operations. These data present evidence for suboptimal preoperative work-up of breast cancer in men, presumably because of a low level of suspicion of this diagnosis. I suspect that this situation is not unique for the hospitals that we are serving. As a consequence, too many men with breast cancer have to undergo a second operation. In addition, they are denied the benefits of a sentinel node biopsy procedure because of a previous breast operation. Therefore, CNB or FNAC should be used more often as a preoperative diagnostic procedure in men with a breast lesion. References 1. Perkins GH, Middleton LP. Breast cancer in men. BMJ 2003; 327: 239 -240 2. Iredale, R. T., Barret-Lee, P., Brain, K., France, L., Gray, J., and Williams, B. Male breast cancer: Exploring the issues for men diagnosed with this condition across the UK. BMJ . 2-8-2003. Rapid response. 3. Westenend PJ, Jobse C. Evaluation of fine needle aspiration cytology of breast masses in males. Cancer 2002; 96: 101-104 4. Westenend, P. J. Core needle biopsy in male breast lesions. J Clin Pathol . 2003. In Press. 5. Port ER, Fey JV, Cody HS, III, Borgen PI. Sentinel lymph node biopsy in patients with male breast carcinoma. Cancer 2001; 91: 319-323 Competing interests:   None declared
Breast cancer in men: Gynecomastia and breast cancer during finasteride therapy 24 October 2003
Ferdinand Frauscher, Associate Professor of Radiology University Hospital Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria, Andreas P. Berger, Andrea Klauser Send response to journal: Re: Breast cancer in men: Gynecomastia and breast cancer during finasteride therapy	We read with great interest the editorial of Perkins and Middleton on breast cancer in men (1). We would like to address another potential possibility for the development of breast cancer in men due to finasteride (Proscar) therapy. Finasteride is approved for the treatment of benign prostatic hyperplasia, and blocks the conversion of testosterone to dihydrotestosterone. In the Medical Therapy of Prostatic Symptoms trial finasteride, doxazosin, placebo, or a combination was given to 3000 patients with benign prostatic hyperplasia between 1997 and 2002. Breast cancer developed in one man in the finasteride-and-doxazosin group and in three men in the finasteride-and-placebo group (2). Green et al. reported a 4.5 percent rate of gynecomastia suggesting, that the ratio of estrogen to testosterone is definitely affected, and therefore finasteride could be a stimulator of breast cancer in men (3-5). References 1. Perkins GH, Middleton LP. Breast cancer in men. BMJ 2003;327: 239- 40. 2. Nyberg LM, Kusek JW. Letter to MTOPS principal investigators. Bethesda, Md.: Division of Kidney Urology and Hematologic Disease, National Institutes of Health, October 2, 2002. 3. Green L, Wysowski DK, Fourcroy JL. Gynecomastia and breast cancer during finasteride therapy. N Engl J Med 1996;335:823-823 4. Sasco AJ, Lowenfels AB, Pasker-de Jong P. Epidemiology of male breast cancer: a meta-analysis of published case-control studies and discussion of selected aetiological factors. Int J Cancer 1993;53:538-549. 5. Gradishar WJ. Male breast cancer. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the breast. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2000:661-7. Competing interests: None declared