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