Treatment of Breast Cancer in Men by Stage

Because there have been few clinical trials on treatment of male breast cancer, most doctors base their treatment recommendations on their personal experience with the disease and on the results of studies of breast cancer in women. With some minor variations, breast cancer in men is treated in a similar way to breast cancer in women.

Stage I

These cancers are still relatively small and have not spread to the lymph nodes or elsewhere. For most men in this group, surgical removal of the cancer is the only treatment needed. This is usually done by mastectomy and either removal of lymph nodes under the arm (axillary lymph node dissection) or sentinel node biopsy and removal of the lymph nodes only if they contain cancer.

Lumpectomy or other breast-conserving surgeries are rarely an option. Because there is very little breast tissue in men, usually the whole breast (including the nipple) needs to be removed. If breast-conserving procedures are done, they are usually followed by radiation therapy.

Adjuvant (additional) therapy with chemotherapy and/or tamoxifen may be recommended for some men with stage I breast cancer, depending on its size and results of lab tests. Adjuvant therapy is commonly used for tumors larger than 1 cm (about 1/2 inch) across or with high growth rates. Men with HER2-positive tumors may also receive trastuzumab (Herceptin).

Stage II

These cancers are larger and/or have spread a few nearby lymph nodes. As with stage I cancers, mastectomy is usually the preferred treatment option. Radiation therapy may be given after surgery if the tumor is large, if it involves the chest muscle or the skin, or if it is found to have spread to several lymph nodes. Radiation therapy not only reduces the chance that the cancer will come back in the area of the breast, but it may actually increase the chance for cure.

Adjuvant hormone therapy (tamoxifen) is usually suggested for hormone receptor-positive tumors. Adjuvant chemotherapy may be also recommended, especially if the cancer has spread to the lymph nodes. Choices about chemotherapy may be influenced by a man's age and general state of health. It is less likely to be chosen for older men, particularly those in poor health. Men with HER2-positive cancer will probably also receive trastuzumab.

Stage III

This stage is treated with surgery, often followed by radiation therapy. Adjuvant tamoxifen therapy (if the tumor is estrogen- or progesterone-receptor positive) and chemotherapy are usually recommended as well. Men with HER2-positive cancers will probably also receive trastuzumab.

Stage IV

Stage IV cancers have spread beyond the breast and lymph nodes to other parts of the body. Therefore, local treatments such as surgery are unlikely to be helpful. Systemic therapy is the primary treatment, using chemotherapy, hormonal therapy, or both. Treatment with trastuzumab, either alone or combined with chemotherapy, is an option for men whose cancers are HER2-positive. Trastuzumab is usually started at the same time as the first chemotherapy for advanced breast cancer.

Radiation and/or surgery may also be used in certain situations, such as to treat a small number of metastases in a certain area, to prevent bone fractures or blockage in the liver, or to provide relief of pain or other symptoms.

Treatment to relieve symptoms depends on where the cancer has spread. For example, pain resulting from bone metastases may be treated with external beam radiation therapy and/or bisphosphonates, such as pamidronate (Aredia) or zoledronic acid (Zometa). (For more information about treatment of bone metastases, see the separate American Cancer Society document, Bone Metastasis.)

Advanced cancer that progresses during treatment: While treatment for advanced breast cancer can be effective in shrinking or slowing the growth of the cancer (sometimes for many years), it may stop working after a time. Further treatment at this point depends on several factors, including previous treatments, where the cancer is located, and a man's age, general health, and desire to continue getting treatment.

For hormone receptor-positive cancers that were being treated with hormone therapy, switching to another type of hormone therapy is sometimes helpful. If not, chemotherapy is usually the next step.

For cancers that are no longer responding to one chemotherapy regimen, trying another may be helpful. There are many different drugs and combinations that can be used to treat breast cancer. However, each time a cancer progresses during treatment it becomes less likely that further treatment will have an effect.

HER2-positive cancers that no longer respond to trastuzumab may respond to lapatinib (Tykerb), another drug that attacks the HER2 protein. This drug is usually used in combination with the chemotherapy drug capecitabine (Xeloda). Both of these drugs are taken as pills.

Because current treatments are very unlikely to cure advanced breast cancer, patients in otherwise good health are encouraged to take part in clinical trials of other promising treatments being studied.

Recurrent Cancer

Breast cancer can come back locally (in the breast or near the mastectomy scar) or in a distant area.

Local recurrence: If a patient has a local (breast or chest wall) recurrence and no evidence of distant metastases, cure may still be possible. Treatment of breast cancer that has recurred locally may depend on what other treatments have already been given. If the initial treatment was mastectomy, recurrence is treated by removing the tumor whenever possible. This may be followed by radiation therapy. If the area has already been treated with radiation, it may not be possible to give much or any additional radiation without severely damaging the normal tissues. Hormone therapy, chemotherapy, trastuzumab, or some combination of these may be used after surgery and/or radiation therapy.

Distant recurrence: In general, men who have a distant recurrence involving organs such as the bones, lungs, brain, etc., are treated the same way as those found to have stage IV breast cancer involving these organs at the time of initial diagnosis (see above). The only difference is that treatment may be affected by what previous treatments a man has had.