Discussion
The majority of breast cancers diagnosed in men are classified as an infiltrating ductal carcinoma type.1 The incidence of ductal carcinoma in situ (DCIS) in women has increased primarily due to screening however, due to the fact that men do not routinely screen for breast cancer the incidence of DCIS is very rare. The majority of men only obtain a mammography when symptoms arise. Most male DCIS will be diagnosed after clinical findings develop yet, the time elapsing from the appearance of symptoms until the diagnosis of DCIS of the male breast can be as long as 20 years.6 Similar to the patient in this case, the most common presentation of male breast cancer is a unilateral, palpable, and painless subareolar mass. On physical exam a male may present with a nodular subareolar cystic lesion associated with serosanguinous nipple discharge and additional gynecomastia.1 Although subareolar cancers are common in men, they still are considered more difficult to diagnose and often missed on mammography and ultrasound6. Additionally, morphologically, DCIS in the male breast displays different than women with most common type being the intraductal papillary type and 43% of men with DCIS are of intermediate grade. High grade lesions are rare.6
The treatment of choice for males with DCIS is mastectomy and has been reported to be curative course of treatment in virtually 99% of DCIS cases.1 However, it has been demonstrated that men can undergo lumpectomy with radiation therapy over mastectomy and some male patients actually demand breast conserving surgery.8, 9 In addition, endocrine therapy is often recommended for patients presenting ER+ or PR + but similar to the patient presented in this case, there are high rates of men refusing endocrine therapy. For example, in a study investigating side effects of adjuvant tamoxifen treatment, 63% of male breast cancer cases complained of one or more side effects indicating low compliance with endocrine therapy.10 In regard to management of disease, it is important to consider the genetic risk associated with male breast cancer. BRCA2 mutations account for up to 14% of breast care cases in men and it is recommended that all male breast cancer patients should be tested for genetic mutations.11, 12
Lastly, it is important consider how racial disparities are associated with breast cancer in men. Studies have shown that black men were more likely to present with advanced-stage disease, larger sized and poorly differentiated tumor and positive lymph nodes compared with white men.4 Black men had a greater than three-fold increased risk of dying as a result of their breast cancer compared to non-Black patients.4 In female breast cancer, racial disparities have been attributed to advanced stage at diagnosis, negative HR status, higher tumor grade, and other socioeconomic factors. It is possible these factors also contribute to the reduced survival in black men.2, 4, 13, and 14