The treatment of male breast cancer involves surgery, radiotherapy, chemotherapy and hormonal therapy. Management decisions are based mainly on data extrapolated from female breast cancer trials.
Operable breast cancer has been treated historically with radical mastectomy (RM), although the use of the modified radical mastectomy (MRM) has become accepted practice in many cases. Due to the small size of the male breast as well as the proximity of the tumor to the chest wall, it seems logical that RM would be the procedure of choice in male breast cancer cases. However, if selected properly, there is evidence that a less radical procedure with or without postoperative radiation therapy can provide equivalent results. Ouriel et. al. (14) compared the five year survival in 22 patients with stage I and II disease undergoing RM vs. MRM and found no significant difference in outcome (RM 76% VS. MRM 80%). Rebeiro et. al. (15) compared RM vs. simple mastectomy (SM) followed by chest wall radiation therapy and found no difference in local recurrence rates or overall survival. Finally, Erlichman et. al. (16) compared the local control and overall survival rates between patients undergoing surgery (n=28) vs. surgery followed by postoperative radiation therapy (n=55). The local control rate was significantly improved with postoperative RT from approximately 50% to 70% at 10 years (p=0.038). However, the overall survival rate (about 40%) was not significantly different between the two groups (p=0.72).
The main role of RT in male breast cancer has been as adjuvant therapy after primary surgery. As demonstrated by Erlichman et. al. (16), postoperative RT seems to improve local control rates. Robison and Montague (17) reviewed all cases of male breast cancer at the MD Anderson Cancer Center and found 21/30 recurrences (70%) were loco-regional and therefore advocated postoperative RT to the chest wall and regional lymph nodes for all locally or regionally advanced tumors. The use of lumpectomy followed by RT has also been reported in anecdotal cases (15,18), but no conclusions regarding the efficacy of this approach in men can be made due to the small numbers of patients treated in this manner.
The use of systemic therapy in the treatment of male breast cancer includes both hormonal therapy and chemotherapy. The chemotherapeutic regimens that have been used are based on data extrapolated from female breast cancer patients. There are, however, some reports of outcome using chemotherapy in male breast cancer. Bagley et. al. (19) reported on the results of 24 patients who underwent RM or MRM and received adjuvant CMF x 12 cycles for pathologically node positive disease. With a median follow-up of 46 months, four of 24 patients recurred, three distantly and one in the involved axilla. None of the patients received adjuvant RT. The five year actuarial survival rate was 80%.
Hormonal therapy has been used both in the setting of metastatic disease and as primary adjuvant therapy. Rebeiro et. al. (15) treated 23 patients with positive axillary lymph nodes or T3a lesions and showed improved overall survival in those receiving hormones compared to historical controls. Hormonal therapy is often the treatment of choice for metastatic disease and a wide variety of agents have been used including tamoxifen, progestins, LHRH agonists, aminoglutethimide and adrenalectomy (20).