“I’m kicking myself I had not gone earlier,” said Bogler, 46. “I should have gone right away. [But] my major worry during this time — and I wrote this down — is looking foolish and having my wife look at me: ‘Are you kidding?’ So I didn’t say anything to anybody.”
Bogler, the senior vice president for academic affairs at MD Anderson Cancer Center at the University of Texas in Houston, is undergoing chemotherapy treatments; so far, his tumor had stopped growing. The next step in his treatment is a modified radical mastectomy, then radiation and five years of tamoxifen, which inhibits estrogen from stimulating the grown of breast cancer cells.
According to the American Cancer Society, Bogler’s case is rare: About 2,240 cases of breast cancer are diagnosed in U.S. men a year, compared with about 232,000 cases of invasive cancer among women.
And because male breast cancer is rare, most men with the disease do what Bogler did and ignore the symptoms: lumps in a breast, discharge from a breast or other changes in a breast or nipple.
“Both the patient and the doctor often don’t have a high level of suspicion it is breast cancer,” said Sharon Giordano, Bogler’s oncologist. “Some men don’t come in, or some doctors don’t get biopsies. It is not a common disease, which leads men to being diagnosed at more advanced stages,” which are harder to treat.
Most of the time, women receive a diagnosis of breast cancer after a mammogram, said Robert Warren, oncologist and professor of medicine at Georgetown Lombardi Comprehensive Cancer Center. “Most male breast cancer is diagnosed with a presence of mass,” he said, which means that “right off the bat, the lump or mass is going to be a later-stage tumor.”
Estrogen as risk factor
Men rarely get breast cancer because they produce very little estrogen, which is associated with female sexual characteristics.
“Exposure to estrogen is the ultimate risk factor for developing breast cancer,” said Ben Park, a breast cancer specialist and researcher at the Sidney Kimmel Comprehensive Cancer Center of Johns Hopkins Medical School.
Some scientists wonder if some men who develop breast cancer may be producing more estrogen than is normal.
Whether there’s a relationship between estrogen and the male hormone testosterone is unclear, Park said. But when breast cancer develops in men, it more often occurs in older ones, at a time when testosterone production is waning.
According to the American Cancer Society, the average age for the discovery of breast cancer in men is 68; the disease most commonly strikes men (and women) between the ages of 50 and 70.
Other potential risk factors, Park said, include a family history of the disease, obesity (fat cells can convert testosterone into estrogen), and alcohol abuse or cirrhosis of the liver. The liver helps metabolize estrogen. Men born with Klinefelter syndrome, a rare condition where men have an extra X chromosome, may be more susceptible to breast cancer, as well as men who inherit a mutated gene. The most common culprit, for men and women, is the BRCA2 gene mutation.
Most breast cancer cells start in the lining of milk ducts in the breast, and they sometimes spread to lymph nodes or other organs.
The size of the tumor determines the stage of cancer, said Vered Stearns, co-director of the breast cancer program at the Kimmel center. Stage II breast cancer, which Bogler has, indicates that the disease has spread into surrounding breast tissue and the tumor is larger than in Stage I.
Treatment, Stearns said, is “based on the tumor stage,” which is calculated both on the size of tumor and the determination of how far it has spread.
“We look at how quickly the cancer is likely to grow,” she said. “In Grade 3 — that is, a relatively faster-growing tumor — Grade 1 is less likely to come back. In post-menopausal women, the prognosis is a little bit better for older women than younger; same with men.”
Much of the breast cancer found in men is receptive to tamoxifen, which works like a key blocking a keyhole, said Otis Brawley, chief medical officer of the American Cancer Society. Estrogen stimulates the growth of breast cancer cells; by inhibiting the growth of estrogen, the drug causes breast cancer cells to stop multiplying.
While tamoxifen is tolerated well by most men, the Lombardi Center’s Warren said, some of his male patients have developed hot flashes, reduced libido, weight gain and changes in moods — the “same kind of menopausal experiences as women.”
Male breast cancer deaths
Men who die from breast cancer — about 400 U.S. men per year (compared with 40,000 women annually), according to the American Cancer Society — often do so because they waited too long to have a troubling symptom checked out.
As a result, “the outcomes seem worse [for men than for women] probably because the breast cancer is often found at a later stage,” said the Kimmel center’s Park. “Male breast cancer is curable if found early enough.” Stearns said most men’s breast cancer is diagnosed at Stage II or III.
Doctors and scientists recommend that men with breast cancer or a family history of the disease undergo testing for the same genetic mutations — BRAC1 and BRAC2 — that put women in higher-risk categories. Knowing family history and genetic makeup can help a patient figure out possible next steps, said Beth Peshkin, a senior genetic counselor and associate professor of oncology at the Lombardi center.
“When [those mutations] are present . . . they affect cells’ ability to repair themselves properly,” she said. “But there is so much about the mechanisms we don’t know.”
That goes for male breast cancer in general. The disease appears to be the same as the female disease and is treated as such.
Yet, “is it the same disease? I don’t know that we know that,” said Giordano of MD Anderson. “The existing data points to more similarity than differences. But men have a different hormonal environment than women.”
Giordano and Park are trying to untangle the unknowns surrounding male breast cancer. Giordano is helping collect cancer specimens from male breast cancer patients around the world.
Park is studying differences in DNA in male breast cancers. “It is an orphan disease in terms of research,” he said, because there are so few cases, relatively speaking. “But that is starting to change. It’s all about the numbers.
“It’s a rare disease. We are looking at everything. Starting with the biopsy, as well as the surgical specimen and metastatic disease. How does this cancer adapt and change while a patient is getting therapy? It’s very complex.”
Hambleton is a freelance writer and documentary filmmaker.