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TREATMENT Powered By Docstoc

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, radiation therapy, chemotherapy, 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.

Overview of breast cancer treatment

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

      The patient’s age and general health

      The presence of known mutations in inherited breast cancer genes (BRCA1 or


surgery to remove the tumor. To ensure that the entire tumor is removed, the surgeon will
also remove a small area of tissue around the tumor. Although surgery aims to remove all
of the visible cancer, it is known that many times microscopic cells can be left behind,
either in the breast or elsewhere.

recurrence (return of the cancer) and to get rid of any hidden remaining cancer cells. This
hormone therapy, and/or targeted therapy (see below for more information on these types
of treatment). The need for adjuvant therapy is determined based on an estimate of the
chance of residual cancer in the breast or the body. Although adjuvant therapy lowers the
risk of recurrence, it does not necessarily eliminate it.
Other sophisticated tools can help determine prognosis and help you and your doctor
make decisions about adjuvant therapy. The website Adjuvant! Online
( is one such tool that your doctor can access to interpret a
your doctor. In addition, other tests that can predict the risk of recurrence (such as
Oncotype Dx, and Mammaprint; may be used to find out whether your doctor
recommends adjuvant chemotherapy.

hormone therapy, and/or targeted therapy may be used as the primary treatment.

first treated and the characteristics of the cancer mentioned above (such as ER, PR, and
HER2 status).

Additional descriptions of the most common treatment options for breast cancer are listed


Surgery is performed to remove the tumor in the breast and to evaluate the surrounding
axillary (underarm) lymph nodes. A surgical oncologist is a doctor who specializes in

      A lumpectomy is the removal of the tumor and a small, clear (cancer-free) margin
       of tissue around the tumor. Most of the breast remains. For both DCIS and
       invasive cancer, follow-up radiation therapy to the remaining breast tissue is
       generally recommended. A lumpectomy may also be called breast-conserving
       surgery, a partial mastectomy, or a segmental mastectomy.

      A mastectomy is the surgical removal of the entire breast.

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

Lymph node removal and analysis

Lymph nodes can trap cancer cells traveling away from the original tumor site. It is
important to find out whether any of the lymph nodes near the breast contain evidence of

In an axillary lymph node dissection, the surgeon removes many of the lymph nodes from
number of nodes removed varies.

Sentinel lymph node biopsy
nodes, reserving a bigger axillary lymph node dissection procedure for patients whose
sentinel lymph nodes show evidence of cancer. The smaller lymph node procedure helps
patients lower the risk of lymphedema (swelling of the arm) and decreases arm mobility
and range-of-motion problems.

In this procedure, the surgeon finds and removes the sentinel (first) lymph node (as a
practical matter, 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
The surgeon can find the node when it turns color (if the dye is used) or emits radiation
(if the tracer is used).

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, removing additional lymph nodes to look
for the presence of more cancer.

Most patients with invasive cancer will undergo either sentinel lymph node biopsy or an
axillary lymph node dissection. For those with sentinel nodes that indicate cancer, an
axillary lymph node dissection is still considered the standard procedure. If there is
obvious evidence of cancer in the lymph nodes before any surgery, then the preferred
approach is a full axillary lymph node dissection without a sentinel lymph node biopsy.


To summarize, surgical treatment options include the following:

      Removal of cancer in the breast: Lumpectomy (partial mastectomy) almost
       always followed by radiation therapy, or mastectomy (sometimes, but not always,
       followed by radiation)

      Lymph node evaluation: Sentinel lymph node biopsy and/or axillary lymph node

The most significant side effect of surgery is lymphedema (arm swelling), which can
use of sentinel node biopsy has been shown to reduce the incidence of lymphedema.

Radiation therapy
number of treatments given over a specific time.

The lowest risks of cancer recurrence in the breast after lumpectomy are associated with
the use of radiation therapy. Early randomized clinical trials showed, in general,
recurrence rates of 30% or more without radiation therapy, compared with 10%
recurrence rates with radiation therapy.

After surgery, adjuvant radiation therapy is given regularly for a number of weeks after a
lumpectomy 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
this approach is rare.

skin changes. A small amount of the lung can be affected by the radiation, although the
risk of pneumonitis, or a radiation-related inflammation of the lung tissue is rare. In the
past, with older equipment and techniques of radiation therapy, patients treated for left-
sided breast cancers had a small increase in the long-term risk of heart disease. Modern

Although 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 (usually a type of cancer called sarcoma) 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.

which is radiation therapy given from a machine outside the body. Many types of
radiation therapy may be available to you; talk with your doctor about the options,
advantages, and disadvantages of these options.

Radiation therapy schedule
daily for five days per week (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
undergo mastectomy do not require radiation therapy. However, for patients with large
cancers, many involved lymph nodes, or extension of cancer into the skin or chest wall,
radiation may still be recommended after a mastectomy. Standard radiation therapy after
a mastectomy is given to the chest wall for five days a week (Monday through Friday) for
five to six weeks.

Newer approaches to breast radiation therapy

Several newer radiation treatment approaches are being studied in women, but have not

      Hypofractionated radiation is giving a higher daily dose of radiation over a shorter
       time (usually 3 to 4 weeks instead of 6 to 7 weeks).

      Partial breast irradiation is radiation therapy given directly to the tumor area,
       usually after a lumpectomy, instead of to the entire breast. This approach also
       results in a shorter overall time patients need to undergo radiation therapy.

      Intensity-modulated radiation therapy (IMRT) is a more advanced way to deliver
       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 more than is possible with traditional radiation treatment. IMRT may
       reduce the dose to nearby important organs, such as the heart and lung, and reduce
       treatment. IMRT also may help to reduce long-term effects on the breast tissue


through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is
medication. Most people with breast cancer receive chemotherapy in their doctor's office
or outpatient clinic. An adjuvant chemotherapy regimen consists of a specific treatment
schedule of drugs given at repeating intervals for a specific number of times.

Chemotherapy may be given intravenously (injected into a vein) or occasionally orally
(by mouth), and is usually given in cycles. Chemotherapy may be given before surgery to
both shrink a large tumor and reduce the risk of recurrence or adjuvant therapy given
after surgery to reduce the risk of recurrence. Chemotherapy is also commonly given at
the time of a metastatic breast cancer recurrence. Patients in clinical trials may be offered
new drugs or new combinations of existing drugs.

used, but can include fatigue, hair loss, risk of infection, nausea and vomiting, loss of
patient’s survival time.

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 (Cytoxan) 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.

Trastuzumab and lapatinib (Tykerb) are HER2-targeted therapies that may be given with
chemotherapy in HER2-positive metastatic breast cancer. Bevacizumab (Avastin), a
blood vessel blocking drug (called anti-angiogenic), is another targeted therapy approved
in combination with chemotherapy in the treatment of metastatic breast cancer. (See the
Targeted Therapy section below.)

more about your prescriptions by using searchable drug databases.

Hormone therapy
Hormone therapy helps manage a tumor that tests positive for either estrogen receptors
(ER) or progesterone receptors (PR) for both early-stage and metastatic cancer. Because
more than 75% of breast cancers in men have estrogen receptors, hormone therapy is
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, then adjuvant hormone treatment may be used alone or after
chemotherapy. Hormone therapies for men include:

      Tamoxifen is the primary hormone therapy used in male breast cancer. It blocks
       the estrogen receptors activity inside the cancer cell. It is a pill taken daily,
       usually for many years.

      Aromatase inhibitors block the production of estrogen. These agents are effective
       in male breast cancer. Caution is urged in using these agents in men with intact
       testes, as androgen levels may increase.

      Megesterol (Megace) is a progesterone-like drug used to treat a hormone
       receptor-positive tumor. It is rarely used in male breast cancer.

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 specific genes, proteins, or the tissue
environment that contributes to cancer growth and survival. Currently the two main
classes of biologically targeted therapy approved in breast cancer treatment are targeted
to the HER2 molecule (HER2 targeted therapy) and the blood vessels in the area of the
tumor (anti-angiogenic therapy).

HER2 targeted therapy

      Trastuzumab is approved for both the treatment of advanced breast cancer and as
       an adjuvant therapy for early-stage breast cancer for HER2-positive tumors. At
       this time, one year of Trastuzumab is recommended for early-stage breast cancer.
       In the metastatic setting, the length of treatment is not limited (it is given as long
       as it is still working). Patients receiving Trastuzumab have a small (2% to 5%)
       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.

      Lapatinib is commonly used in patients with HER2-positive breast cancer that no
       longer responds to Trastuzumab. 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

Anti-angiogenic targeted therapy (blood vessel blocking therapy)

      Bevacizumab 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 keep it smaller for a longer time in
       patients whose breast cancer has spread compared with paclitaxel alone. Recent
       studies have shown benefit of adding bevacizumab to other chemotherapy as well.

Anti-osteoclast targeted therapy (drugs that block bone destruction)

      Bisphosphonates are a class of drugs that block the cells that cause bone
       destruction (osteoclasts). Bisphosphonates are commonly used in relatively low
       doses to prevent and treat osteoporosis. In patients with breast cancer that has
       complications of cancer in the bone, including bone fractures and pain.
       bisphosphonates used to treat breast cancer bone metastasis. Recent studies have
       suggested that these drugs may also be able to reduce breast cancer recurrences
       when given in the adjuvant setting, although more data are needed.

      Denosumab (Prolia) is in another new class of osteoclast-targeted therapies called
       RANK ligand inhibitors. Although not yet approved for patients with breast
       cancer, recent studies have shown great promise of these drugs in treating breast
       cancer bone metastases and osteoporosis.

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 (a
lungs, liver, and bones. A local recurrence is frequently considered curable with further
treatment. A metastatic (distant) recurrence is generally considered incurable, but is
frequently treatable. Some patients live years after a metastatic recurrence of breast
cancer. The goal of treatment for advanced disease is to prolong survival and/or improve
quality of life.

Generally, a recurrence is detected when a person has symptoms. These 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

      Abdominal pain or jaundice (yellow skin and eyes), which may be associated with
       liver 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

The treatment of metastatic or recurrent breast cancer depends on the previous
(such as ER, PR, and HER2 status).

      For men with a local recurrence within the breast after initial treatment with
       lumpectomy and adjuvant radiation therapy, the treatment is mastectomy. This
       usually results in cure.

      For men with a local or regional recurrence of the chest wall after an initial
       mastectomy, resection (surgical removal of the recurrence) followed by radiation
       therapy to the chest wall and lymph nodes is the treatment, unless radiation
       therapy has already been given (radiation therapy cannot usually be given at full
       dose to the same area more than once).

Total-body therapies such as chemotherapy, hormone therapy and targeted therapies are
generally the primary treatment in recurrent metastatic cancer. Radiation therapy and
Often radiation is used to treat painful bone metastases.

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