Male Breast Cancer: Temporal Trends and Treatment

Male Breast Cancer: Temporal Trends and Treatment

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Description: Male breast cancer is a rare disease in Lithuania, comprising less than 0.2% of malignancies among men. During the last decade, there has been no change in the frequency of the disease, with 10–15 cases registered every year during 1988–2006, and only 16 of the more than 8000 new cases in 2006 presented male breast carcinoma. Data published in the Cancer Incidence in Five Continents during 1978–2002 show no changes in the variability of the rate of incidence of male breast carcinoma either.

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Author: Algirdas Jackevičius, Leonarda Šarakauskienė, Valerijus Ostapenko, Saulius Bružas, and Alg (Fellow) | Visits: 2132 | Page Views: 2190
Domain:  Medicine Category: Therapy Subcategory: Cancer 
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Contents:
ACTA MEDICA LITUANICA. 2009. Vol. 16. No. 3�4. P. 119�123
DOI: 10.2478/v10140-009-0017-5 � Lietuvos moksl akademija, 2009 � Lietuvos moksl akademijos leidykla, 2009 � Vilniaus universitetas, 2009

Male breast cancer: temporal trends and treatment in Lithuania
Algirdas Jackevicius1, Leonarda Sarakauskien , Valerijus Ostapenko1, Juozas Kurtinaitis1 , Saulius Bruzas1, Algimantas Mudnas1
1 Institute of Oncology, Vilnius University, Vilnius, Lithuania 2 Hospital of Oncology, Kaunas University of Medicine, Vilnius, Lithuania

Male breast cancer is a rare disease in Lithuania, comprising less than 0.2% of malignancies among men. During the last decade, there has been no change in the frequency of the disease, with 10�15 cases registered every year during 1988�2006, and only 16 of the more than 8000 new cases in 2006 presented male breast carcinoma. Data published in the Cancer Incidence in Five Continents during 1978�2002 show no changes in the variability of the rate of incidence of male breast carcinoma either. Materials and methods. is investigation analyzed 100 male patients with breast carcinoma treated during the period 1988�2006 in two clinics: Institute of Oncology at Vilnius University and Hospital of Oncology at Kaunas University of Medicine. e average age of the patients was 67.5 years (range, 31�90 years). e patients were grouped according to the progression of the disease: 13 patients in stage I, 41 patients in stage II, 31 patients in stage III, and 15 patients in stage IV. e type of cancer was as follows: invasive ductal carcinoma was the most frequent (68 cases), lobular carcinoma in 9 cases, and adenocarcinoma in 6 cases. e most common method of treatment was modified mastectomy by Madden (75 cases). Furthermore, 53 patients received a combined treatment: 23 patients were treated with radiotherapy, 9 patients with chemotherapy, 14 patients received radiotherapy and chemotherapy, and 14 patients were treated with tamoxifen. Results. e status of the patients was validated up to December 31, 2007 by checking the active follow-up examinations as well as utilizing the assistance and results of primary health care centers and the population registry. e overall survival rates were calculated using mortality issues as primary endpoints. e overall 5-year survival rate of all male patients with breast carcinoma was estimated to be 42.7%. e 5-year survival rate of the patients in stages I and IIA was 71.9% and 79.5%, respectively, and in stage IIB 53.5%. Lower survival rates (15.8% and 11.2%) were observed in stage IIIA and stage IIIB, respectively. None of the patients in stage IV survived beyond 5 years. A 2-year survival rate of 6.7% was the best estimate of this group. Conclusion. e overall survival rate of male breast cancer patients treated at two major medical centers of Lithuania was estimated to be below 50%. es low survival rate can be explained by late detection of advanced cases and the lack of innovation during cancer treatment. Key words: male breast cancer, treatment, survival

INTRODUCTION Male breast cancer is a rare disease in Lithuania, comprising less than 0.2% of malignancies among men (1). During the last decade, there was no change in the frequency of the
Correspondence to: Algirdas Jackevicius, Department of Breast Diseases, Institute of Oncology, Vilnius University, Santariski 1, LT-08660 Vilnius, Lithuania. E-mail: algirdasj@is.lt

disease: usually 10�15 cases were registered every year, and only 16 of more than 8000 new cancer cases in 2006 were diagnosed as male breast carcinoma. Data published in the Cancer Incidence in Five Continents (1978�2002) show no variability in the incidence rate during the previous decades, either (Table 1). e worldwide variation in the rate of incidence of male breast cancer markedly lags behind that of breast cancer in women, with higher rates in North America and Europe and lower rates in Asia (2).

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Algirdas Jackevicius, Leonarda Sarakauskien, Valerijus Ostapenko, Juozas Kurtinaitis et al.

Ta b l e 1 . The number of new cases, crude and age standardized rates (ASR), of male breast cancer in Lithuania 1978�2002
Period
1978�1982 1983�1987 1988�1992 1993�1997 1998�2002

MATERIALS AND METHODS During 1989�2006, 201 males were diagnosed with breast cancer in Lithuania. e average age of these patients was 64.6 years (range, 20�98 years). e present study analyzes 100 male patients treated in 1988�2006 at the Institute of Oncology Vilnius University and the Hospital of Oncology, Kaunas University of Medicine. e mean age of patients was 67.5 years (range, 31�90 years). e distribution of patients according to cancer stages in the population and in the present study is given in Table 2. e distribution of patients according to TNM classification was the following: 13 patients had T1N0M0, 24 patients T2N0M0, 2 patients T1N1M0, 14 patients T2N1M0, 1 patient T1N2M0, 3 patients T2N2M0, 1 patient T3N0M0, 9 patients T3N1M0, 2 patients T3N2M0, 2 patients T4N0M0, 8 patients T4N1M0, 6 patients T4N2M0, and 15 patients had distant metastases (Table 3). e majority of patients (65 cases) had a tumour in the region of the nipple. In 19 of these patients, the tumour manifested as a large ulceration spread to the whole breast. Table 4 also includes a listing of the histological types of male breast cancer, with invasive ductal carcinoma as the most common type (68 patients), lobular carcinoma
Table 2. Male breast cancer distribution during 1989�2006 in the population and the hospital samples*
Stage
I II III IV unknown Total

Number of new cases
30 39 43 32 60

Incidence rates Crude rate ASR, world
0.4 0.5 0.5 0.4 0.7 0.4 0.4 0.4 1.3 0.5

Breast irradiation, other environmental exposures, and genetic inheritance are among the main male breast cancer risk factors (3�7). e ageing of the male population cannot be excluded, as the majority of cases occur at age of 60�65 years � five years later than in female patients (8, 9). Based on the EUROCARE data, 5-year standardized relative survival rates vary in Europe from below 60% (Slovakia 40%, Estonia 52%, Austria 57%) to above 70% (Finland 70.4%, Sweden 72.1%). e survival rates in Europe for males (observed in 57% cases, relatively 72%) are lower as compared to those of females (observed in 65% cases, relatively 73%). According to the research literature as well as our own clinical experience, the interval between the onset of symptoms of the disease and the initiation of therapy was longer in males as compared to females. During the month a er the onset of symptoms of the disease, only one third of male patients came for treatment (8). Male breast cancer is a rare disease, although the incidence has increased slightly over the past 25 years. As many other rare diseases, male breast cancer has not been studied enough. In addition, a paucity of researchers and minimal funding has hindered work on breast cancer in men, and further work is clearly needed to better investigate this disease. In this paper, we analyzed 100 male patients treated at two clinics: Institute of Oncology at Vilnius University and Hospital of Oncology at Kaunas University.

Population Cases %
26 82 53 26 14 201 12.9 40.8 26.4 12.9 7.0 100.0

Study group Cases %
13 41 31 15 100 13.0 41.0 31.0 15.0 0.0 100.0

Note. * P > 0.05 (Kruskal�Wallis equality of populations rank test).

Ta b l e 3 . The distribution of patients according to pTNM and the histological type of tumour
pTNM
T1N0M0 T2N0M0 T1N1M0 T2N1M0 T1N2M0 T2N2M0 T3N0M0 T3N1M0 T3N2M0 T4N0M0 T4N1M0 T4N2M0 T2N1,2M1 T3N1,2M1 T4N1M1 T4N2M1 Total

Adenocarcinoma
1 2

Solidum
1

Ductal
11 20 2 9 1 2 1 6 1 5 4 4

Lobular
2 2 1 1 1 1

Carcinoma NOS
1 1

Ductal & lobular

Total
13 24 2 14 1 3 1 9 2 2 8 6 4 2 4 5 100

1

2 2 1 1

1 1

1 1 6 1 3 2 68

9

1 4 1 13

1

Male breast cancer: temporal trends and treatment in Lithuania

121

Ta b l e 4 . The distribution of patients according to disease stage and method of treatment
Method of treatment
Mastectomy simplex Mastectomy simplex + rad* Quadrantectomy Mastectomy Mastectomy + tam** Mastectomy + rad Mastectomy + che*** Mastectomy + rad + che Radiotherapy Chemotherapy Radiotherapy + che Palliative treatment Total

Stage I
1 1 7 1 2

IIA
1 4 5 2 9 1 2

IIB
1 3 1 3 4 5

IIIA

IIIB

IV

Total
2 5 1 19 7 23 9 14 6 3 2 9 100

1

5 1 5 2

3 3 2 1 2 2 1 2 16

1 2 2 1 3 1 5 15

13

24

17

2 15

Note. Rad � radiotherapy, tam � tamoxifen, che � chemotherapy.

(9 patients), adenocarcinoma (6 patients), and other rarer histological types (17 patients). Hormone receptors were recorded in as many as 78% of male breast carcinomas. Five patients worked under unfavourable environmental conditions, three were electricians, and 24 were agricultural workers. Ten patients had a strong family history of breast cancer. Modified mastectomy by Madden was the most common method of treatment; it was applied in 75 cases. Simple mastectomy (mastectomy simplex) was performed in 7 cases, one patient was treated with quadrantectomy, 6 patients received radiotherapy, while 3 patients received only chemotherapy. Due to the late stage of the disease, 2 patients were treated conservatively � with chemotherapy and radiotherapy. Palliative treatment was undertaken only in 9 cases because of the poor health of the patients. In addition, 53 patients received a combined treatment: a er mastectomy 23 patients were treated with radiotherapy, 9 patients with chemotherapy, 14 patients with radiotherapy and chemotherapy, and 7 patients with tamoxifen. Another 7 patients received tamoxifen a er adjuvant therapy: 4 patients a er chemotherapy, 2 a er radiotherapy and chemotherapy, and 1 patient a er radiotherapy. e treatment options and disease stages are shown in Table 4. Follow-up results e last follow-up treatment was carried out in December 31, 2007. Out of the 100 patients, 34 patients survived and 66 died (Table 5). Data on the 5-year survival rates of patients with male breast carcinoma are presented according to disease stage in Table 6. e 5-year survival rate of patients in stages I and IIA was 71.9% (95%, CI 34.2�90.4) and 79.5% (95%, CI 57.3�90.9), respectively. In stage IIB it was 53.5% (95%, CI 57.3�90.9), and for patients in stages IIIA and IIIB it was only 15.8% (95%, CI 2.7�39.1) and 11.2% (95%, CI 0.9�41.1), respectively. None of the patients in stage IV survived a 5-year period. Only 6.7% (95%, CI 0.4�26.0) of patients in stage IV survived for 2 years. ose surviving

for 5 years and more were 42.7% (95%, CI 31.9 � 52.9) of the entire group. e 10-year survival rate was 22.58% (95%, CI 13.2�33.6), while the 15-year survival rate was 14.1% (95%, CI 6.0�25.6). e majority of patients were 65 years old and older (67.2%). e age of a patient was inversely related to the rate of survival. For example, patients younger than 60 years in stages I�II lived longer than older patients (Figure). e results of the follow-up of patients in stage III indicate that the cancer treatment regimen was not satisfactory. Many of these patients presented large tumours with ulceration and were of older age; these factors had a negative influence on the survival of patients in stage III. e latest results of treatment produced favourable outcomes only in the early stages of the disease. Statistical analysis of the survival rate of patients surgically treated for breast carcinoma showed that the stage of the disease had a significant positive effect on the survival.
Table 5. Patient follow-up status (through December 31, 2007)
Stage of disease
I II III IV Total

Number of patients on follow-up
13 41 31 15 100

Alive
9 21 4 0 34

Dead
4 20 27 15 66

Table 6. The disease stage and 5-year survival rate
Stage of disease
I IIA IIB IIIA IIIB IV

5-year survival of patients (%)
71.9 79.5 53.5 15.8 11.2 �

95% con dence interval
34.2�90.4 57.29�90.9 57.3�90.9 2.7�39.1 0.9�41.1 �

122

Algirdas Jackevicius, Leonarda Sarakauskien, Valerijus Ostapenko, Juozas Kurtinaitis et al.

Figure. Survival of patients in stages I�III according to age

e overall survival of patients not included in the study group (101 of 200) was approximately the same as that of the cancer patients, i. e. 46.3% (95%, CI 38.1�54.0), with the log rank test showing no significant difference (log rank test, p = 0.253). DISCUSSION Compared to Nordic countries, studies of patient survival in the Baltic countries still lack power. A joint Nordic study encompassing 1429 patients diagnosed over a 25-year period and reported to the Nordic cancer registries indicated a 5-year survival below 50%, where the factors of age at diagnosis and late stage of detection were the most likely explanations for the unfavourable prognosis (10). Similar findings were observed in our study. According to the anamnesis of the disease, our patients had no risk factors such as radiation exposure, hepatic schistosomiasis, or Klinefelter's syndrome (11�14). Many of our patients were agricultural workers who employed many chemical agents in their work. Also, 10% of our patients had female relatives with breast cancer. We agree with Canadian authors (15) that obesity and family history increase the risk of breast cancer. Similar factors were observed among our patients. Among the medical conditions examined, a new finding emerged regarding an increased male breast cancer risk associated with a history of bone fracture (16). Gonadal insufficiency and low testosterone levels also contribute to bone density and osteoporosis (17). Some authors note that c-erbB-2, p-53, bcl-2 are significant in the prognosis of male breast cancer (18); however, data regarding the oncogenes and their prognostic significance in male breast cancer are limited (19). While the lack of physical activity is suggested as an important risk factor for developing male breast cancers, most of our retired patients had been blue-collar workers and so our observations do not support this suggestion (15). Male breast carcinoma is a rare oncological disease. ere are no randomized trials for the treatment of male breast car-

cinoma. According to published sources, the clinical management of male breast cancer is similar to that of women with breast cancer. Because of the central location and small size of the male breast, modified mastectomy with axillary dissection sparing pectoralis muscles is the treatment of choice for male breast carcinoma. We agree with Schuchardt and coauthors (20) that patients with central lesions and positive axilla should receive irradiation of homolateral lymphatic nodes including the parasternal and homolateral infra- and supraclavicular region. It is necessary to optimize the treatment of male patients with positive lymph nodes: systemic chemotherapy must o en be used together with radiotherapy. We agree with the recommendations of Czene et al. and other authors to increase the public awareness of male breast cancer, which ought to result in an earlier diagnosis of cancers. e more negative outcome for men compared with that for females may also be due to men's receiving less optimal therapies (21�23). CONCLUSIONS 1. e incidence of male breast cancer in Lithuania shows an insignificant increase over the last decades. 2. e majority of male breast cancer patients are diagnosed at an advanced stage of the disease, and early detection is still lacking power. 3. e overall 5-year survival rate was estimated at 42.7%. e stage of the disease was the major determinant of the patients' survival. Patients treated at major hospitals had no advantage in survival as compared to the patients treated elsewhere. ACKNOWLEDGEMENTS e authors cordially thank Dr. Aloyza Luksiene for valuable remarks.
Received 10 April 2009 Accepted 30 October 2009

Male breast cancer: temporal trends and treatment in Lithuania

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References
1. Jackevicius A, Ostapenko V, Sarakauskiene L, Mudenas A, Bruzas S, Kurtinaitis J. e clinical signs of male breast cancer. In: XIV World Congress Breast Diseases, May 18�21 (ed. Ivan Drinkovic). Senologic International Society S. I. 2006: 183�7. Weiss JR, Moysich KB, Swede H. Epidemiology of male breast cancer. Cancer Epidemiol Biomarkers Prev 2005; 14: 20�6. Guinee V, Olsson H, Moller T, Shallenberger R, Blink J, Peter Z et al. e prognosis of breast cancer in males: a report of 335 cases. Cancer 1993; 71(1): 154�61. Ravandi-Kashan Fand, Hayes TG. Male breast cancer: a review of the literature. Eur J Cancer 1998; 34: 1341�7. Borgen P, Wong G, Vlamis V, Potter Ch, Ho mann B, Kinne D et al. Current management of male breast cancer: a review of 104 cases. Annals of Surgery 1992; 215(5): 451�9. Pollan M, Gustavsson P, Floderus B. Breast cancer, occupation, and exposure to electromagnetic elds among Swedish men. Amer J Industr Med 2001; 39: 276�85. Brinton LA, Richesson DA, Gierach GL, Lacey JV, Park Y, Hollenbeck et al. Prospective evaluation of risk factors for male breast cancer. J Natl Cancer 2008; 100: 1477�81. Jaiysemi I, Buzdar A, Sahin A, Ross M. Carcinoma of the male breast. Ann Intern Med 1992; 17: 771�7. Park S, Kim J-H, Koo J, Park B, Lee K. Clinicopathological characteristics of male breast cancer. Yonsei Med 2008; 49(6): 978�86. Volm M, Gradishar W. How to diagnose and manage male breast cancer. Contemp Oncol 1994; 4: 17�20. Eldar S, Nash E, Abrahamson J. Radiation carcinogenesis in the male breast. Eur J Surg Oncol 1989; 15: 274�8. Friedman M, Ho man P, Dandolos A. Estrogen receptors in male breast cancer: clinical and pathologic correlations. Cancer 1981; 47(1): 134�7. Ramantanis G, Bebeas S, Garas J. Breast cancer in the male: a report of 138 cases. World J Surg 1980; 4: 621. Jackson A, Muldal S, Ockey Ch, O'Connor P. Carcinoma of the male breast in association with Klinefelter syndrome. Br Med J 1965; 1: 223. Johnson K, Pan S, Mao Y. Risk factors for male breast cancer in Canada, 1994�1998. Eur J Can Prevenetion 2002; 11(3): 253�63. Idelevich E, Mozes M, Ben-Baruch N, Husar M, Kruglikova A, Katsnelson R et al. Oncogenes in male breast cancer. Am J Clin Oncol 2003; 26(3): 259�61. Schuchardt U, Seegenschmiedt H, Kirschner M, Renner H, Sauer R. Adjuvant radiotherapy for breast carcinoma in men: a 20-year clinical experience. Amer J Clin Oncol 1996; 19(4): 330�6. Adami HO, Hakulinen T, Ewertz M, Tretli S, Holmberg L, Holmberg L et al. An analysis of 1429 patients from the Nordic countries. Cancer 1989; 64: 1177�82. Nahleh Z, Girnius S. Male breast cancer: a gender issue. Nature Clinical Practice Oncology 2006; 3(8): 428�37. Czene K, Bergqvist J, Hall P, Bergh J. How to treat male breast cancer. e Breast 2007; 16: 147�54.

2.

21. Robinson JD, Kenneth P, Metoyer J. Breast cancer in men: a need for psychological intervention. J Clin Psychol Med Settings 2008; 15: 134�9. 22. Wernberg JA, Yap J, Murekeyisoni T, Mashtare T, Wilding GE, Kulkarni SA. Multiple tumors in men with breast cancer diagnoses � a SEER database review. J Surg. Oncol 2009; 99: 16�9. 23. Marchal F, Salou M, Marchal C, Lesur A, Desandes E. Men with breast cancer have same disease-speci c and eventfree survival as women. Ann Surg Oncol 2009; 16: 972�8.

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Algirdas Jackevicius, Leonarda Sarakauskien, Valerijus Ostapenko, Juozas Kurtinaitis, Saulius Bruzas, Algimantas Mudnas VYR KRTIES VZYS ISPLITIMO TENDENCIJOS IR GYDYMAS LIETUVOJE Santrauka Vyr krties vzys yra reta onkologin liga Lietuvoje, sudaranti tik 0,2% vis vyr piktybini navik. Pastaruoju desimtmeciu nepastebta didesni sios onkologins ligos daznio pokyci, kiekvienais metais uzregistruota po 10�15 nauj sios ligos atvej. 2006 m. nustatyta 16 vyr krties vzio atvej is 8000 naujai uzregistruot piktybini navik. Rinkinyje ,,Cancer incidence in Five Continents (1978�2002)" paskelbti duomenys nerodo didesni sio naviko paplitimo pokyci per kelis desimtmecius. Medziaga ir metodai. Pateikta 100 vyr, gydyt 1988�2006 m. Vilniaus universiteto Onkologijos institute ir Kauno medicinos universiteto Onkologinje ligoninje, krties vzio atvej analiz. Vidutinis pacient amzius buvo 67,5 metai (nuo 31�90 met). Pagal ligos stadij ligoniai pasiskirst: 13 sirgo I stadijos, 41 � II stadijos, 31 � III stadijos ir 15 ligoni � IV stadijos vziu. Nustatyti 68 invazyvios duktalins karcinomos atvejai, lobulins karcinomos � 9 atvejai, adenokarcinomos � 6 atvejai. Dazniausiai buvo atliekama modifikuota mastektomija pagal Madden � 75 ligoniams. Kombinuotas gydymas taikytas 53 pacientams: 23 pacientai gydyti spinduline terapija, 9 pacientai � priesnavikiniais preparatais, 14 � spinduline terapija ir chemoterapija, 14 � tamoksifenu. Rezultatai. Panaudojus gydymo staig ir gyventoj registro duomenis, vlyvieji pacient gydymo rezultatai stebti iki 2007 m. gruodzio 31 dienos. Penkerius metus gyveno 42,7% vis vyr, sirgusi krties vziu, is j 71,9% pacient, sirgusi I stadijos liga, 79,5% � IIA stadija, 53,5% � IIB stadija sirgusi pacient. Trumpiau gyveno pacientai, sirg IIIA ligos stadija (15,8%) ir IIIB ligos stadija (11,2%). N vienas pacient, sirgusi IV ligos stadija, nepragyveno penkeri met. Is sios grups dvejus metus gyveno 6,7% pacient. Isvada. Krties vziu serganci vyr, gydyt pagrindinse Lietuvos onkologinse klinikose, isgyvenamumas buvo mazesnis nei 50%. Priezastis, kodl krties vziu sirg vyrai gyveno neilgai, buvo j pavluotas kreipimasis gydymo staigas, dl to nustatytas jau isplits krties vzys, kai nebegalimas optimalus gydymas. Raktazodziai: vyr krties vzys, gydymas, gyvenimo trukm

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