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Most women diagnosed with breast cancer have a common type of breast cancer that’s still in its earlier stages. Some women, though, develop less common forms of breast cancer. Signs and symptoms of the cancer may not be the same, and — depending on the type of cancer or the situation in which it was diagnosed — the treatment may be different.

Some women also are at higher risk of a second breast cancer than are others, and their treatment recommendations may be different. Breast cancer during pregnancy poses yet another unique situation in which treatment may be altered because of the circumstances.

If you’re diagnosed with an uncommon type of breast cancer, are at high risk for a second cancer or are facing unique circumstances, it’s important that you see an experienced breast cancer specialist. Talking with someone who’s familiar with your condition helps to ensure that you receive an accurate diagnosis and appropriate treatment.

This chapter discusses special breast situations, outlining differences in treatment approaches, compared with those for more common forms of breast cancer.

Locally Advanced Breast Cancer

About 5 to 10 percent of breast cancers are diagnosed as locally advanced breast cancers. Locally advanced breast cancer, which generally falls under the category of stage III breast cancer, refers to larger breast tumors with one or more of the following characteristics:

However, with stage III breast cancer, there’s no evidence that the cancer has spread (metastasized) to other parts of the body.

Locally advanced breast cancers sometimes occur in women who may not get medical attention when they first notice a breast lump. This may be because they fear being diagnosed with cancer. Locally advanced breast tumors can also occur because the tumor didn’t show up clearly on a mammogram. This is most often the case with a type of breast cancer known as invasive lobular breast cancer. These breast tumors can be very large but not be apparent on breast self-exams, clinical examination or mammography. This may be because they tend to infiltrate into normal breast tissue in a diffuse pattern that can feel like normal breast tissue, rather than forming a large mass.

Prognosis is generally less favorable for a stage III breast cancer than it is for a stage I or II breast cancer. However, there’s still hope for a cure. Treatment regimens typically include drug treatments (chemotherapy, hormone therapy or both), surgery and radiation.

Instead of performing surgery first, as generally happens with stage I and II breast cancers, for stage III breast cancer, chemotherapy to shrink the tumor is often the first course of action. Usually, an anthracycline medication is recommended, such as doxorubicin or epirubicin (Ellence), and a taxane medication, such as paclitaxel (Abraxance, Onxol) or docetaxel (Taxotere). Chemotherapy is usually given for four to eight cycles over a period of three to six months. In case of a HER2-positive cancer, trastuzumab (Herceptin) may be recommended.

For some women who have strongly positive estrogen (plus or minus progesterone) receptors, hormone (anti-estrogen) therapy may be recommended in place of chemotherapy.

Assuming that the tumor shrinks after initial drug therapy, the next step is usually surgery. A mastectomy is most often performed to remove the tumor. Nearby lymph nodes are evaluated with a sentinel node biopsy and may be removed, depending on the biopsy results. In some instances of locally advanced cancer, a lumpectomy (breast-conserving surgery) may be performed instead of a mastectomy. Lumpectomy isn’t an option, though, for inflammatory breast cancer.

After surgery — depending on how much chemotherapy you received before surgery and the response of the cancer to the medication — your doctor may recommend more chemotherapy. He or she also may recommend radiation therapy to destroy any remaining cancer cells in the chest wall area and nearby lymph nodes. If laboratory reports indicate that you have a hormone receptor positive cancer, your doctor may also recommend hormone therapy.

For more information on these types of treatment, and how they’re performed, see Chapter 11.

Inflammatory Breast Cancer

Inflammatory breast cancer is a type of locally advanced cancer that occurs in a very small percentage of women with breast cancer. In addition to spreading to fibrous connective tissue inside your breast, the cancer spreads to lymphatic vessels located in breast skin, causing noticeable skin changes.

Typically, a lump in your breast is the classic sign of breast cancer, but with inflammatory breast cancer, the lump, or mass, may not be apparent. Common signs and symptoms of inflammatory breast cancer include:

In spite of its name, inflammatory breast cancer isn’t caused by an inflammation or an infection. It occurs as a result of lymphatic drainage channels in breast skin becoming plugged with cancer cells. Inflammatory breast cancer usually spreads rapidly, and skin changes can become apparent in a matter of days to weeks.

Although it’s not an infection, inflammatory breast cancer can easily be confused with a breast infection (acute mastitis). Breast infections tend to occur in women who are breast-feeding. They typically cause a fever, and they’re easily treated with antibiotics. Inflammatory breast cancers don’t cause a fever, and they don’t respond to antibiotics.

If you have signs and symptoms associated with inflammatory breast cancer, your doctor will likely want to do a breast biopsy. A biopsy can confirm the presence or absence of cancer. In some cases, redness, warmth and swelling of the breast are caused not by an infection or cancer but rather by a previous surgery or radiation therapy that involved the outer breast or underarm. These procedures can cause partial blockage of lymphatic channels. As fluid and debris accumulate in the channels, breast tissue may swell (edema) and turn pink in color.

Inflammatory breast cancer is generally characterized by redness of the breast skin and swelling. In this photo, inflammatory breast cancer is present in the woman’s right breast. The skin is red, and the breast is swollen (see color illustration).

Women at High Risk of a Second Cancer

In situations where breast cancer is identified in a woman at high risk of the disease, treatment decisions tend to be more complex than for a woman at normal risk. That’s because women at high risk of breast cancer are also at greater risk of additional new cancers in the same breast or in the other breast.

Groups of women considered at high risk are discussed in Chapter 6. Here we discuss two particular high-risk groups — BRCA carriers and Hodgkin disease survivors — and treatment approaches for them.

You should know that there’s no evidence a woman at high risk of developing breast cancer is at a higher risk of the current cancer recurring than is a woman at normal risk with similar cancer characteristics.

If you’ve been diagnosed with breast cancer and genetic tests indicate that you carry a mutation in BRCA1 or BRCA2, you may want to consider surgical removal (mastectomy) of the affected breast, or perhaps both breasts, to decrease the chances of new cancers developing in the same or opposite breast. A mastectomy, however, is not mandatory. If breast conservation is important to you, a lumpectomy with radiation therapy is an option.

If you’ve been diagnosed with breast cancer and your doctor suspects, but doesn’t yet know if you carry an altered BRCA1 or BRCA2 gene, decisions regarding your treatment are more complicated. This is because a formal evaluation of your genetic risk, which typically includes examination of your family history, genetic counseling and possible genetic testing, may take a few weeks.

Some women undergoing genetic testing choose to proceed with a lumpectomy to remove the tumor, along with sampling of the underarm (axillary) lymph nodes to check for cancer spread. They hold off on having more extensive surgery until they’ve received the results of the genetic tests. Other women choose to proceed with more extensive surgery, such as mastectomy, rather than being faced with the possibility of additional surgery in the future.

Once genetic test results are available, you and your doctor can make decisions regarding other possible treatments to help prevent the development of new breast tumors. Because the BRCA1 and BRCA2 genes also increase your risk of ovarian cancer, you and your doctor may also discuss strategies to prevent development of ovarian cancer.

For more information on the BRCA genes, see Chapter 5. For more information on cancer prevention strategies, including preventive (prophylactic) mastectomy, see Chapter 6. For more information on ovarian cancer, see Chapter 17.

Women who’ve had Hodgkin disease and received radiation therapy to lymph nodes in their chest as part of their treatment are at increased risk of developing breast cancer. This is especially true among women who received radiation therapy at younger ages.

Factors that play key roles in determining a woman’s risk of breast cancer after treatment for Hodgkin disease include:

For Hodgkin disease survivors who later develop breast cancer, a mastectomy has been the standard treatment. Radiation therapy often isn’t possible because normal breast tissues typically can’t tolerate additional radiation therapy. However, because lower doses of radiation are now used to treat Hodgkin disease, it may be possible for some women to have a lumpectomy followed by breast radiation therapy, as long as the total amount of radiation they receive is within acceptable limits.

Because there’s an increased risk that cancer may also develop in the other breast, some women choose to have prophylactic mastectomy in the other breast, along with mastectomy to the breast affected with the cancer.

Bilateral Breast Cancer

Only a small percentage of women with newly diagnosed breast cancer have cancer in both breasts at the time their cancer is diagnosed. Cancer in each breast is called synchronous bilateral breast cancer. Because breast cancer rarely spreads from one breast to the other in its early stages, the two tumors — one in each breast — are almost always two different breast cancers.

Bilateral breast cancers tend to be more common in women with a strong family history of breast cancer. Having bilateral breast cancer doesn’t mean your prognosis is doubly worse. Similar to breast cancer that’s confined to one breast, the prognosis for women with bilateral breast cancer depends on the characteristics of the individual tumors, including their size and whether the cancer has spread to the lymph nodes under the arm.

In this situation, prognosis is generally based on the tumor that has the least favorable characteristics.

Treatment of synchronous bilateral breast cancer depends on the characteristics — size, grade and lymph node status — of each tumor. Options include a lumpectomy in each breast followed by radiation therapy or a mastectomy of each breast. Sometimes, based on the results of a sentinel node biopsy of each breast, the lymph nodes under one of the arms need to be removed but those under the other arm don’t.

If you choose to have a lumpectomy, radiation therapy is also needed. Decisions regarding additional treatment (adjuvant therapy), such as chemotherapy or hormone therapy, are based on the characteristics of the tumors and whether one or both of them carries a high risk of recurrence.

Women who’ve had one breast cancer and later develop cancer in the other breast are said to have metachronous bilateral breast cancer. Treatment for metachronous bilateral breast cancer is based on the characteristics of the tumor being treated. When treating the second breast cancer, your doctor likely will take into account the type of therapy you received for your first breast cancer, as well as other factors, such as your family history.

Unknown Primary Cancers

Occasionally, a woman will develop an enlarged lymph node under her arm, yet doctors aren’t able to find a tumor in her breast. If a biopsy of the enlarged lymph node indicates the presence of cancer, the tissue sample is studied closely under a microscope to determine if the cancer looks like breast cancer. The pathologist needs to make certain — as much as is possible — the cancer in the lymph node isn’t something other than breast cancer, such as melanoma or lymphoma. If a different cancer isn’t identified, the cancer is considered to be breast cancer and it’s treated as such.

The breast located next to the affected lymph node is carefully examined to try and find a hidden tumor. This usually involves a complete physical examination, mammogram and ultrasound exam of the breast. If these aren’t helpful, other tests may be used, such as magnetic resonance imaging (MRI) or a positron emission tomography (PET) scan.

If a tumor is found in the breast, a treatment regimen is developed, based on the size and grade of the tumor and number of lymph nodes involved. If no tumor is found and the cancer cells in the lymph nodes appear to be breast cancer cells, both the lymph nodes and the adjacent breast are treated.

In the past, treatment usually consisted of a mastectomy. In approximately half the cases in which a tumor couldn’t be identified on diagnostic tests, the pathologist was able to locate cancer cells in the mastectomy specimen removed during surgery. However, even in women in whom no cancerous cells were found in the breast, their cancers generally behaved similarly to breast cancer. Today, an alternative to mastectomy is radiation of the breast with close follow-up screening for any developing tumors.

In virtually all cases, the lymph nodes in the affected underarm area are removed (axillary lymph node dissection). Treatment for such cancers also typically includes additional (adjuvant) therapy — chemotherapy, hormone therapy or both.

The prognosis for women with an unknown primary tumor is similar to that of other women with stage II or III breast cancer that has spread to the underarm lymph nodes.

Metaplastic Breast Cancer

Most breast cancers are classified as adenocarcinomas — a subset of carcinomas arising from glands or glandular tissue, such as that in your breasts.

Metaplastic breast cancer is a rare type of breast cancer that undergoes a process of transformation called metaplasia. The cells start out looking similar to adeno-carcinomas and then transform into cells that take on a nonglandular growth pattern. This transformation may affect all of the cells within a tumor or only a small portion of them. When viewed under a microscope, metaplastic tumors typically display a mixture of adenocarcinoma-type cells and nonadenocarcinoma-type cells.

As in other breast cancers, the predominant indication of cancer is a lump in the breast. Metaplastic breast cancer is most often seen in women who are older than age 50, although it can occur at a younger age. Generally, this type of breast cancer doesn’t spread to the lymph nodes under the arm, and its cells are hormone receptor negative.

In spite of the fact that the cancer generally doesn’t spread to the lymph nodes, metaplastic breast cancer is often more aggressive than are adenocarcinomas, and it carries a higher risk of recurrence than do adenocarcinomas.

This type of cancer is generally treated with a lumpectomy or mastectomy. Your doctor may also recommend radiation therapy. Because metaplastic breast cancer is often hormone receptor negative, hormone therapy generally isn’t effective. Chemotherapy to help prevent a recurrence would seem to be a logical choice, but experience has shown that this type of cancer often doesn’t respond well to chemotherapy. At present, there’s no drug therapy regimen that’s been shown to be very beneficial against this particular type of breast cancer.

Lymphoma and Sarcomas

As was just mentioned, most breast cancers start in the glandular tissue of the breast, such as the ducts and lobules. A very few breast tumors — about 1 percent — develop in the lymphatic or connective tissues of the breast.

Tumors that originate in the lymphatic tissue are called lymphomas. Those that develop in the connective tissue are called sarcomas. Lymphomas and sarcomas are more likely to develop in other parts of the body than in the breast.

Breast lymphoma is a rare condition. Like carcinomas of the breast, breast lymphoma typically develops into a mass, but its growth is usually more rapid than that of carcinomas of the breast. The lymphoma may also develop into multiple masses or it may occur in both breasts. Occasionally, this type of cancer is accompanied by night sweats, fever and weight loss. A biopsy is needed to confirm the diagnosis.

In general, breast lymphoma is treated with chemotherapy and radiation therapy. Surgery usually isn’t an option, other than to establish a diagnosis, if necessary. A combination chemotherapy regimen called R-CHOP (ritaximab, cyclophosphamide, hydroxydaunomycin, Oncovin and prednisone) is often used. A review of breast lymphoma cases at one medical institution found that 11 out of 20 women treated with R-CHOP were still disease-free an average of 80 months (just under seven years) after their diagnoses.

The most common type of breast sarcoma is called a phyllodes tumor. Phyllodes tumors are usually noncancerous (benign), but they can be cancerous. On a mammogram, the tumors appear similar to benign masses called fibroadenomas. Phyllodes tumors tend to occur in women earlier than the age at which most breast cancers tend to occur.

To make an accurate diagnosis, a biopsy is required. If the biopsy reveals a cancerous phyllodes tumor, prognosis is generally dependent on factors such as the grade and size of the tumor and the tissue margins.

The primary treatment for a breast sarcoma is to surgically remove the tumor along with a wide margin of healthy tissue. Depending on the size of the tumor and its relation to your breast size, your doctor may recommend either a lumpectomy or a mastectomy.

Because cancerous phyllodes tumors — if they do spread — tend to spread through the bloodstream, there’s generally no need to examine lymph nodes under the arm. Phyllodes tumors, if they recur, tend to do so locally in the breast or spread to the lungs.

In addition to surgery, chemotherapy and radiation therapy are sometimes considered. However, unlike for treatment of typical breast cancer, there’s much less proof that these therapies are effective in treating breast sarcomas.

RADIATION THERAPY AND SARCOMA RISK

Studies and reports of individual cases suggest that radiation therapy to treat breast adenocarcinomas, the most common type of breast cancer, carries an increased risk of development of a later sarcoma in the bone or tissue of the irradiated area.

To further investigate this issue, two groups of researchers reviewed data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program. SEER is a database that collects cancer-related information from nine areas in the United States. These areas collectively represent almost 10 percent of the population.

The investigators found that previous radiation therapy does increase a woman’s risk of developing a sarcoma. But the increase in risk is extremely small — approximately 1 in 1,000 women over a 15-year period — and it doesn’t outweigh the benefits that radiation therapy generally provides in treating breast adenocarcinomas.

Paget’s Disease

Paget’s disease of the breast is a rare form of breast cancer that starts in the breast ducts and spreads to the skin of the nipple and the areola, the dark circle of skin around the nipple. Paget’s disease of the breast isn’t related to Paget’s disease of the bone, a metabolic bone disease.

Paget’s disease of the breast is most common in middle-aged women. Signs and symptoms may include:

Early detection of Paget’s disease is important. If you have a lump or skin irritation in the nipple area that persists for more than one or two months, see your doctor. A doctor may be able to diagnose the cancer by testing nipple discharge for cancer cells or with a biopsy of the area.

Because of the underlying breast cancer associated with Paget’s disease, a mammogram should be performed to check for any masses or abnormalities in the breast. Paget’s disease can be associated with both noninvasive and invasive breast cancer.

Prognosis and treatment for Paget’s disease depend on the size of the tumor and whether the cancer has spread to surrounding tissues or lymph nodes. A small, noninvasive tumor may require removal of just the nipple area and some surrounding tissue, followed by radiation therapy. A larger, more aggressive tumor may require a mastectomy.

Breast Cancer and Pregnancy

It’s very difficult and emotionally trying when a woman is pregnant and is diagnosed with breast cancer. Fortunately, this is uncommon, occurring in about 1 in 3,000 pregnant women. Women who are told they have breast cancer while they are pregnant usually are in their 30s.

During pregnancy, the ducts and lobules in a woman’s breasts multiply, blood vessels swell to allow for increased blood flow and the weight of the breasts can double. This makes the breasts dense and lumpy. As a result, it’s difficult to examine the breasts, and mammography has an increased rate of false-negative results, meaning it doesn’t detect cancer when cancer is present.

A careful examination of your breasts by your doctor is recommended at your first prenatal visit so he or she can be alert to any abnormalities that might occur later.

If a lump is detected during pregnancy, your doctor may do an ultrasound of your breast to see if the mass is a cyst or solid lump. If mammography or other radiological procedures are necessary, they usually can be done safely by shielding your abdomen and pelvis from radiation. Even if a mammogram comes back normal, but a worrisome mass can be felt, the mass should be biopsied. A biopsy is the surest way to determine if the lump is cancerous or benign. A biopsy is usually done as a needle procedure (see Chapter 8 for a description of biopsies).

If you’re breast-feeding when the lump is detected, your doctor may advise that you stop before the biopsy is performed to reduce the risk of complications. Be assured, there’s no evidence that cancer can spread to your baby through your breast milk.

Pregnancy itself doesn’t appear to worsen your prognosis if you have breast cancer. Most studies indicate that the prognosis for women who are pregnant is similar to that for women at a similar age and with a similar stage of breast cancer who aren’t pregnant. But the diagnosis may be delayed because a pregnant woman’s breasts are changing, making a cancerous lump more difficult to detect. When detection is delayed, the cancer may be diagnosed at a later stage, decreasing the chances of successful treatment.

Termination of the pregnancy hasn’t been shown to improve prognosis and is generally unnecessary.

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Laura’s Story

Laura was 34 years old, and she and her husband were expecting their second child when she found out that she had breast cancer. Her local doctor suggested termination of the pregnancy, but he also mentioned that he had read some articles in which pregnant women were able to continue their pregnancies while undergoing cancer treatment. Laura and her husband wanted to continue the pregnancy if at all possible, and they sought a second opinion with a cancer specialist.

After much discussion, explanation and careful consideration of the options, Laura, her husband and her doctors decided to continue the pregnancy but to proceed right away with a mastectomy. At the time of her surgery, Laura was five and a half months pregnant.

Unfortunately, Laura’s prognosis was very poor. The surgery revealed a very large — 15-centimeter (about 6-inch) — tumor. The laboratory report also indicated cancer cells in 21 of 22 underarm (axillary) lymph nodes.

Knowing that chemotherapy was important to her survival chances, and with the assurance of her medical team that chemotherapy drugs probably wouldn’t harm the baby, Laura agreed to have a couple of cycles of chemotherapy while she was still pregnant.

Approximately 10 weeks after her cancer diagnosis, Laura gave birth to a healthy baby girl by way of cesarean delivery. After the baby was born, Laura received additional chemotherapy followed by radiation therapy.

Laura says that the happiness of the pregnancy and the promise of another child made it easier for her to deal with her cancer. “I knew I had to be there to raise my children,” Laura says.

After Laura completed her treatment, she met regularly with her doctor, who monitored Laura’s health. Laura’s doctor was concerned the cancer would recur, but at each checkup Laura reported feeling fine, and there were no indications of a cancer recurrence.

Laura’s doctor finally felt comfortable that Laura would be OK when Laura brought with her to one of her checkups, the baby whose life she was determined to save — now a 15-year-old teenager.

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Treatment for breast cancer in a pregnant woman is similar to that for a nonpregnant woman, and is based on such factors as the size of the lump, its grade and the extent of lymph node involvement. But modifications may be made to protect the fetus, depending on the trimester you’re in. The first trimester is when fetal organ development takes place and is the period of greatest risk. Most medication is avoided during this time, if possible.

If the cancer is stage I or II, surgery is usually recommended and is generally safe for both mother and fetus, especially after the first trimester. In the first trimester, anesthesia can be harmful. Traditionally, the procedure of choice has been a mastectomy along with evaluation of the underarm (axillary) lymph nodes with a sentinel node biopsy. The advantage of this option is that mastectomy may decrease the need for radiation therapy, which can be dangerous to a fetus.

Some women diagnosed in the late stages of their pregnancies choose to have a lumpectomy, followed by radiation after delivery of the baby. Even if you’re far from delivery, lumpectomy may be an option, followed by chemotherapy after the first trimester and then radiation after the birth of the baby.

Surgery carries a slight risk of miscarriage or preterm labor, but it doesn’t increase the risk of birth defects.

Radiation therapy generally isn’t recommended in pregnant women because of possible risks to the fetus, such as miscarriage, birth defects and childhood cancer. It may also result in poor cosmetic results because of breast changes that occur during pregnancy.

In the first trimester, chemotherapy can cause miscarriage and fetal abnormalities, but this risk decreases substantially in the second and third trimesters, making its use an option in later stages of pregnancy. The chemotherapy drug methotrexate should be avoided, though, because it can have toxic effects on the placenta.

The long-term effects of chemotherapy on the child are unknown, but existing data suggest that it doesn’t affect later growth and development. Because chemotherapy drugs can come through in your breast milk, breast-feeding isn’t recommended during chemotherapy.

Hormone therapy generally isn’t recommended for a woman who’s pregnant, primarily because hormones can influence the pregnancy and may cause side effects in the fetus. After delivery, though, hormone therapy may be used in a woman whose cancer is hormone receptor positive. See Chapter 11 for more information.

One of the questions related to breast cancer and pregnancy is whether it’s safe to become pregnant after being diagnosed with breast cancer. In the past, there was concern about a later pregnancy because during pregnancy levels of female hormones increase, and these hormones are known to influence breast cancer development. The current feeling among doctors is that pregnancy following a diagnosis of breast cancer is generally safe. However, because many breast cancer recurrences tend to happen within the first few years after treatment, most doctors recommend waiting at least five years after treatment to become pregnant.

Sometimes, though, waiting so long may not be an option because doing so may place a woman outside the childbearing age. Ultimately, the decision is a personal one. The most important consideration usually revolves around your own risk of relapse.

Breast Cancer in Men

Breast cancer in men is uncommon. Approximately 1 percent of all breast cancers occur in men, and male breast cancer accounts for less than 1 percent of all cancers that occur in men.

In general, male breast cancer is similar to female breast cancer with a few differences. While hormone levels appear to influence the development of breast cancer in men, just as they do in women, in men, the influence appears to be related, in part, to an imbalance in the hormones estrogen and androgen. Approximately 85 percent of male breast cancers are estrogen receptor positive, and 70 percent are progesterone receptor positive. Men also tend to be older when they’re diagnosed.

The estimated breast cancer risk, up to age 70, in a man with a BRCA1 mutation is 1.2 percent (about 1 in 100). For a man with a BRCA2 mutation, it’s 6.8 percent by age 70 (6 to 7 cancers per 100 men).

The predominant sign of male breast cancer is a painless breast mass. Other signs and symptoms include nipple retraction, pain or tenderness, an open sore on the nipple, nipple discharge and nipple bleeding. Sometimes, no signs or symptoms are present.

Because men don’t have much breast tissue, a mass can usually be easily felt. In some cases, mammography may be helpful in distinguishing between a benign mass and a malignant one. A biopsy is used to diagnose a mass that appears suspicious. If cancer is present, it’s staged in the same way as female breast cancer — according to the tumor’s size and spread.

The standard treatment for male breast cancer is surgical removal of the tumor, if possible. The procedure most often recommended is a mastectomy, which involves removal of the breast tissue and evaluation of underarm lymph nodes (see Chapter 11 for more information). Radiation therapy also may be recommended to reduce the risk of a recurrence in the chest wall or regional lymph nodes.

Because so many male breast cancers are hormone receptor positive, hormone therapy is often recommended. The success of tamoxifen in female breast cancer has led to its use in men. Although no randomized clinical trials have been done to study the benefits of tamoxifen in men, data suggest that it may increase survival. Side effects of tamoxifen may include hot flashes and impotence. For men at high risk of recurrence, chemotherapy may be recommended after surgery.

If the cancer has spread (metastasized) to a distant part of the body, hormone therapy, chemotherapy or both may be recommended. For hormone receptor positive breast cancers, hormone therapy is usually given first.

Before tamoxifen came into widespread use for treatment of male breast cancer, the recommended hormone therapy was androgen ablation, which is essentially the removal of testosterone from the body. This was routinely done by removal of the testicles. Today, men are more commonly given drugs, such as luteinizing hormone-releasing hormone (LH-RH) agonists, to suppress testosterone production. These are the same medications used to suppress ovarian estrogen production in premenopausal women.

If one type of hormone therapy doesn’t work, another may be used. If there’s no response to any hormone therapies, chemotherapy may be considered.

Survival rates for men with breast cancer are similar to those of women with the same stage of the disease. Unfortunately, in men, breast cancer tends to be diagnosed at a later stage than in women, in part, due to reduced awareness.

As with women, prognostic factors that influence survival in men include lymph node status, tumor size and grade. Whether the cancer has spread to the lymph nodes is usually the most important prognostic factor.

Chapter 13: Breast Cancer

Special Situations