Thursday, March 30, 2023

Some things we just don’t think about very much. A few weeks ago, my wife Elie and I were invited to lunch by new friends following a shul kiddush and, as is sometimes the case, our new host told us his cancer story after the soup. I enjoyed the soup very much—it was unusual. I enjoyed the story as well—it was also not the usual story.

A physician himself, he had noted a lump on his chest wall some 12 years earlier and had ultimately had it biopsied and, sure enough, it turned out to be breast cancer. He told us that, if it were not for the fact that the cadaver he had worked on during gross anatomy in medical school fortuitously had male breast cancer, and therefore he was attuned to that disease, he would have ignored it. As a result, his cancer turned out to be at an early stage, and surgery and treatment have proven to be very successful.

But about 1% of breast cancer does occur in men. In most respects, it is very similar to the breast cancers that occur in women. While about 65-70% of breast cancers in women are hormone-sensitive, virtually every breast cancer in men is hormone-sensitive (estrogen receptor positive).

Why do men get breast cancer? In general, circumstances which lead to increased estrogen levels or decreased androgen levels increase a man’s risk of breast cancer. Certain drugs can do this, such as the estrogenic or anti-androgen drugs used for the treatment of prostate cancer. Nowadays, drugs that are used in transgender conversions can also be implicated. Damage to a man’s testicles, with a concomitant decrease in testicular function, can also increase the risk of gynecomastia and breast cancer.

The classic example is diethylstilbestrol (DES), a synthetic form of estrogen. For those of you who are trivia buffs, the use of DES for metastatic prostate cancer starting in the early 1940s was the first use of systemic antineoplastic therapy. It was highly efficacious but did lead to the development of gynecomastia and thus it significantly increased the risk of male breast cancer.

One of the most common settings in which male breast cancer occurs is that of hepatic cirrhosis. The liver is responsible for the metabolism and excretion of sex hormones. Thus, if it is dysfunctional, as in cirrhosis, any circulating estrogen which is present in a male will fail to be metabolized and excreted. Instead, it will accumulate in the bloodstream, and will “feminize” the male. This is a common, well recognized symptom of cirrhosis in men. In this context, gynecomastia will occur, and gynecomastia in a man is a risk factor for breast cancer. While male breast cancer constitutes about 1% of breast cancer in the U.S. and the West, it comprises about 7% of breast cancer in Tanzania and in other parts of Africa. There has been speculation on why it is more prevalent in Africa than the West; the most compelling reason seems to be that liver diseases are more common there and thus the estrogen levels we discussed previously in conjunction with hepatic disease are a larger problem in that region.

We are also all aware that carriers of BRCA mutations are at increased risk of breast cancer. Of course, we are usually thinking in terms of women when we consider this genetic risk, but a man who carries these genes also carries the same increased genetic risk for breast cancer.

Breast cancer in males is treated in a similar fashion to breast cancer in women. Generally speaking, the prognosis of breast cancer is significantly worse for men than it is for women. Why this is so is not clear to me. Furthermore, it is well known that racial disparities between those of African descent and whites exist for women with breast cancer, i.e., Black people have significantly worse mortality rates. The reasons for this appear to be multifactorial, including issues of access to care but also biological differences. Studies on males with breast cancer interestingly demonstrate racial disparities similar to those found in women.

Psychological issues do appear to be more common in men than in women as well. These include more frequent anxiety and depression, problems with altered body image, and cancer related distress.

Alfred I. Neugut, MD, PhD, is a medical oncologist and cancer epidemiologist at Columbia University Irving Medical Center/New York Presbyterian and Mailman School of Public Health in New York.

This article is for educational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment, and does not constitute medical or other professional advice. Always seek the advice of your qualified health provider with any questions you may have regarding a medical condition or treatment.

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