Treatment

The treatment of male breast cancer depends on the size and location of the tumor, whether the cancer has spread, and the man’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan. Male breast cancer may be treated with surgery, chemotherapy, radiation therapy, and hormone therapy. Each option is described below.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, read the clinical trials section.

Overview of breast cancer treatment

The biology and behavior of a breast cancer affects the treatment. Some tumors are small but grow fast, while others are large and grow slower. When planning the treatment for breast cancer, the doctor will consider many factors, including:

• The stage and grade of the tumor
  
  
• The tumor’s hormone receptor status (ER, PR) and HER2 status (see Diagnosis)
  
  
• The patient’s age and general health
  
  
• The presence of known mutations to breast cancer genes

Even though the doctor will specifically tailor the treatment for breast cancer for each patient, there are some general steps for treating breast cancer.

For DCIS and early-stage breast cancer, doctors generally recommend surgery to remove the tumor. To ensure the area around the tumor is free of cancer, the surgeon may also remove a small area of tissue around the tumor. The next step in the management of early-stage breast cancer is to lower the risk of recurrence (return of the cancer) and to get rid of any remaining cancer cells. This is called adjuvant therapy. Adjuvant therapies include radiation therapy, chemotherapy, hormone therapy, and targeted therapy. Although adjuvant therapy lowers the risk of recurrence, it does not necessarily eliminate it.

Along with staging, other sophisticated tools can help determine prognosis and help you and your doctor make decisions about adjuvant therapy. The website Adjuvant! Online (www.adjuvantonline.com) is one such tool that your doctor can access to interpret a variety of prognostic factors. This website should only be used with the interpretation of your doctor.

When surgery to remove the cancer is not possible, chemotherapy, radiation therapy, hormone therapy, and/or targeted therapy may be used.

The treatment of recurrent cancer and metastatic cancer depends on how the cancer was first treated and the characteristics of the cancer mentioned above (such as ER, PR, and HER2 status).

More complete descriptions of each treatment option are listed below.

Surgery

If the tumor is small, a biopsy may be all that is needed to remove the tumor completely. However, if more surgery is required, a mastectomy may be necessary. A simple (total) mastectomy involves removing the entire breast, but not the lymph nodes under the arm or underlying chest muscles. A modified radical mastectomy removes the breast tissue and lymph nodes, and a radical mastectomy removes the breast tissue, lymph nodes, and chest wall muscles under the breast.

Because men do not have much breast tissue, a lumpectomy, which remove only the tumor, is generally not an option.

Men may also have surgery to remove and examine the lymph nodes for cancer.

• Axillary lymph node dissection involves the surgeon removing lymph nodes from under the arm and having them examined by a pathologist for cancer cells. The actual number of nodes removed may vary.
  
  
• Sentinel lymph node biopsy is a procedure in which the surgeon finds and removes the sentinel (first) lymph node (generally one to three nodes) that receives drainage from the breast. The pathologist then examines it for cancer cells. To identify the sentinel lymph node, the surgeon injects a dye and/or a radioactive tracer into the area around the nipple. The dye or tracer will travel to the lymph nodes, arriving at the sentinel node first. The surgeon can find the node when it turns color (if the dye is used) or emits radiation (if the tracer is used). Sentinel lymph node biopsy often has a lower risk of lymphedema (swelling of the arm) than axillary lymph node dissection. If the sentinel node is cancer-free, research has shown that there is a good possibility that the subsequent nodes will also be free of cancer and no further surgery of the lymph nodes is performed. If the sentinel lymph node shows cancer is present, then the surgeon will perform an axillary lymph node dissection. For more information, read the What to Know: ASCO's Guideline on Sentinel Lymph Node Biopsy in Early Stage Breast Cancer.

The most significant side effect of surgery is lymphedema (arm swelling), which can occur when lymph nodes are removed or damaged during surgery. Because the lymph nodes are part of the channels that drain the lymphatic fluid from the arm, damage to the area may hold back the flow of lymphatic fluid and cause it to back up in the arm. The use of sentinel node biopsy has been shown to reduce the incidence of lymphedema.

For more information, read the Cancer.Net Feature: After a Mastectomy and the Cancer.Net Feature: After Treatment for Breast Cancer: Preventing Lymphedema.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The side effects of chemotherapy depend on the individual and the drug and the dose used, but can include fatigue, hair loss, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers, but studies have shown that these side effects do not shorten the survival time.

Chemotherapy may be given orally (by mouth) or intravenously (injected into a vein) and is usually given in cycles. Chemotherapy generally does not require a hospital stay; it is given in an outpatient setting. Chemotherapy may be neoadjuvant therapy (given before surgery to shrink a large tumor) or adjuvant therapy (given after surgery to reduce the risk that the cancer returns). Chemotherapy may also be given at the time of a breast cancer recurrence. Patients in clinical trials may be offered new drugs or new combinations of existing drugs.

Different drugs are useful for different cancers, and research has shown that combinations of certain drugs are more effective than individual ones. The most common combinations for male breast cancer include:

• CMF: cyclophosphamide (Clafen, Cytoxan, Neosar) methotrexate (multiple brand names), and fluorouracil (5-FU, Adrucil)
  
  
• CAF: cyclophosphamide, doxorubicin (Adriamycin), and 5-FU
  
  
• AC: doxorubicin (Adriamycin) and cyclophosphamide
  
  
• Cyclophosphamide and doxorubicin in combination with paclitaxel (Taxol) or docetaxel (Taxotere)

Other chemotherapy that may be prescribed includes paclitaxel, docetaxel, vinorelbine (Navelbine), gemcitabine (Gemzar) and capecitabine (Xeloda). Trastuzumab (see Targeted therapy below) is used to treat HER2-positive breast cancer (see Diagnosis).

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions. Learn more about your prescriptions through Cancer.Net’s Drug Information Resources, which provides links to multiple drug databases.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Adjuvant radiation therapy is given regularly for a number of weeks after a lumpectomy or partial mastectomy to eliminate any remaining cancer cells near the tumor site or elsewhere within the breast. Adjuvant radiation therapy is also recommended for some patients after a mastectomy depending upon the size of their tumor, number of cancerous lymph nodes under the arm, and width of the tissue margin around the tumor removed by the surgeon. Adjuvant radiation therapy is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is rare.

Radiation therapy can cause side effects, including fatigue, swelling, and skin changes. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related pneumonia, is rare. Modern techniques are now able to spare most of the heart from radiation damage. While exposure to radiation is thought to be a risk factor for cancer after many years, less than one in 500 survivors will develop a different kind of cancer, other than a breast cancer, within the area that was treated. Clinical trials comparing lumpectomy and adjuvant radiation therapy with mastectomy have not shown a difference in the number of patients developing or dying of other cancers within a 20-year time span.

The most common type of radiation treatment is called external beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. In this treatment, small radioactive pellets are placed in or near the site of the breast tumor within plastic catheters placed temporarily in the breast. A balloon catheter placed near the breast that delivers radiation therapy (called Mammosite) is another type of radiation therapy.

Standard radiation therapy after a lumpectomy or partial mastectomy is external-beam radiation therapy given for five days (Monday through Friday) for six to seven weeks. This usually includes radiation therapy to the whole breast first for four and a half to five weeks, followed by a more focused treatment to the site of the tumor bed in the breast for the remaining treatments. This focused part of the treatment, called a boost, is standard for patients with invasive breast cancer because it reduces the risk of a recurrence in the breast. This boost is also usually given for patients with in situ breast cancer and is the subject of an ongoing international clinical trial. Standard radiation therapy after a mastectomy is given to the chest wall for five days (Monday through Friday) for five to six weeks. If there is evidence of cancer in the underarm lymph nodes, radiation therapy may also be given to the lymph node areas in the neck or underarm near the breast or chest wall.

There has been growing interest in newer radiation methods to shorten the length of treatment from six to seven weeks to periods of three to four weeks. In one method (called hypo-fractionated radiation therapy), a higher daily dose is given to the whole breast each day so that the overall length of treatment is shortened to three to four weeks. This can also be combined with a higher dose given to the tumor bed in the breast either during or after the whole breast radiation treatments. Clinical trials from Canada and the United Kingdom have shown that these shorter schedules can be equally accepted by patients with the same cancer control rates and side effects as longer radiation treatment schedules. These shorter schedules may become more accepted in the United States and are one way to improve the convenience and time required to complete a course of radiation (see also partial breast irradiation below).

Partial breast irradiation

Partial breast irradiation (PBI) is radiation therapy that is given directly to the tumor area, usually after a lumpectomy, instead of the entire breast, as is routinely done with standard radiation therapy. This treatment can be done with external-beam radiation therapy or internal radiation therapy. Radiation is given twice a day for only one week using external-beam radiation, a temporary radiation catheter, or catheters implanted within the breast. Only some patients may be eligible for PBI. Although preliminary results have been promising, PBI is the subject of a large, nationwide clinical trial, and the results proving the safety and effectiveness compared with standard radiation therapy are pending.

Targeting the radiation to the tumor area more directly may shorten the amount of time that patients need to undergo radiation therapy. A large national clinical trial, which began in 2005, is being done to compare the standard treatment of six weeks of conventional external-beam radiation therapy with a one-week treatment of PBI.

Intensity-modulated radiation therapy

Intensity-modulated radiation therapy (IMRT) is a more advanced way to deliver external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to target the tumor more precisely, give a uniform distribution of radiation throughout the breast tissue, and avoid damaging healthy tissue than is possible with traditional radiation treatment. IMRT may reduce the dose to nearby important organs, such as the heart and lung, and reduce the risks of some immediate side effects, such as peeling of the skin during treatment. IMRT also may help to reduce long-term effects on the breast tissue that were common with older radiation techniques such as hardness, swelling, or discoloration.

Two prospective, randomized clinical trials have compared IMRT with conventional radiation therapy after lumpectomy for patients treated for breast cancer. Both studies showed an even distribution of radiation dose throughout the breast with IMRT. IMRT use also resulted in a decrease in areas of the breast that received a higher-than-desired dose of radiation, which led to a decrease in side effects. For example, in one clinical trial, there were fewer cases of moist peeling of the skin during IMRT. In the other clinical trial, there was an improvement in breast appearance and less fibrosis (hardness of the breast) five years after IMRT treatment. Additional research is being conducted to compare the long-term side effects, such as heart disease, between IMRT and conventional radiation therapy 10 years or more after treatment.

For more information on radiation therapy, read the Cancer.Net Feature: Understanding Radiation Therapy, Cancer.Net Feature: Radiation Therapy—Your Personal Experience, and the Cancer.Net Feature: Side Effects of Radiation Therapy.

Hormone therapy

Hormone therapy is useful to manage a tumor that tests positive for either estrogen or progesterone receptors for both early-stage and metastatic cancer. Because more than 75% of breast cancers in men have estrogen receptors, hormone therapy is often part of the treatment plan. This type of tumor uses hormones to fuel its growth. Blocking the hormones usually limits the growth of the tumor.

If it is determined that the tumor is hormone receptor-positive (uses estrogen or progesterone to grow [see Diagnosis]), then adjuvant hormone treatment may be used alone or after chemotherapy. Hormone therapies for men include:

Megesterol (Megace). Megesterol is a progesterone-like drug used to treat a progesterone receptor-positive tumor.

Aromatase inhibitors. Aromatase inhibitors block the production of estrogen. These agents are effective in treating breast cancer in women, but there is not much information on their use in male breast cancer.

Anti-androgen therapy. Male breast cancers often have receptors for male hormones. By lowering the production of androgens in the man’s body, oncologists have been able to shrink a tumor that has metastasized.

Side effects of hormone therapy can include hot flashes, decreased sexual desire or ability, and mood swings.

Targeted therapy

Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development.

• Trastuzumab is approved for both the treatment of advanced breast cancer and as an adjuvant therapy for early-stage breast cancer for tumors that have too much of the HER2 protein, called HER2 positive. Data presented at the 2005 American Society of Clinical Oncology Annual Meeting demonstrated an approximate 50% decrease in recurrence and an improvement in survival for patients with HER2-positive early breast cancer who received trastuzumab either with or after adjuvant chemotherapy. At this time, one year of trastuzumab is recommended. Patients receiving trastuzumab have a 4% risk of heart problems, and this risk is increased if a patient has other risk factors for heart disease. These heart problems do not always go away, but they are usually treatable with medication. Ongoing research is evaluating how much trastuzumab is enough (from nine weeks up to two years).
  
  
• For patients with HER2-positive breast cancer that no longer responds to trastuzumab, a drug called lapatinib (Tykerb) may slow the growth of breast cancer when combined with capecitabine. The combination of lapatinib and capecitabine is approved for the treatment of patients with advanced or metastatic HER2-positive breast cancer who have previously been treated with chemotherapy and trastuzumab.
  
  
• Bevacizumab (Avastin) is used to treat metastatic or recurrent breast cancer (see below). This drug blocks angiogenesis (the formation of new blood vessels), which is needed for tumor growth and metastasis. When combined with paclitaxel, bevacizumab appears to shrink the tumor and remain smaller for a longer time in patients whose breast cancer has spread compared with paclitaxel alone. This combination was approved by the U.S. Food and Drug Administration in 2008.

Recurrent and metastatic breast cancer

Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (a local recurrence); in the chest wall; or in another part of the body, including distant organs (such as the lungs, liver, and bones). Some patients live years after a recurrence of breast cancer.

Breast cancer may also spread to other organs such as the brain, the opposite breast, adrenal glands, and spleen and is called metastatic breast cancer. This type of cancer is treatable, but not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the growth of the tumor.

Generally, a recurrence is detected when a person has symptoms. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research shows that having such tests does not improve the response to treatments used for advanced disease, nor do they prolong life.

Signs and symptoms depend on the site of the recurrence and may include:

• A lump under the arm or along the chest wall
  
  
• Bone pain or fractures, which may signal bone metastases
  
  
• Headaches or seizures, which may signal brain metastases
  
  
• Chronic coughing or trouble breathing, which may signal lung metastases

Other symptoms may be related to the location of metastasis and may include changes in vision, changes in energy levels, feeling ill, or extreme fatigue. A biopsy of the recurrent site is often recommended to be certain of the diagnosis and to check for ER, PR, and HER2 status, because this may have changed from the time of the original diagnosis.

The treatment of metastatic or recurrent breast cancer depends on the previous treatment(s) and the characteristics of the tumor (such as ER, PR, and HER2 status). Once metastatic disease is detected, the treatment may involve surgery to remove the metastasis and/or chemotherapy, hormone therapy, targeted therapy, and radiation therapy (if it hasn’t been already given) to control it. In some circumstances, radiation therapy may also be given to relieve symptoms.

Treatment guides from ASCO for breast cancer include Aromatase Inhibitors for Early Breast Cancer,Bisphosphonates for Breast Cancer, Follow-Up Care for Breast Cancer, HER2 Testing for Breast Cancer, Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer, and Tumor Markers for Breast Cancer.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.