J Clin Psychol Med Settings (2008) 15:134–139 DOI 10.1007/s10880-008-9106-y
Breast Cancer in Men: A Need for Psychological Intervention John D. Robinson Æ Kenneth P. Metoyer Jr. Æ Neil Bhayani
Published online: 15 April 2008 Ó Springer Science+Business Media, LLC 2008
Abstract Male breast cancer is a serious issue that needs to be addressed more fully by the medical and public community. However, due to a lack of awareness and limited research on the topic, there is a general absence of knowledge concerning the psychological implications of this disease in men as well as a need for greater understanding of the medical diagnosis and treatment of male breast carcinoma. Similarly, there still remains a considerable gender difference between the awareness of female breast cancer and male breast cancer Although breast cancer in men makes up only 1% of all breast cancers reported in the United States, it is increasing in incidence. There are approximately 2000 new cases and approximately 450 deaths due to male breast cancer each year. Breast cancer diagnosis and treatment in men is very similar to that described in women, however, it has been shown that men are being diagnosed at a later stage of the disease than women.
Male breast cancer makes up only 1% of all breast cancers reported in the United States. Still, in the last decade it was responsible for approximately 2000 new cases as well as about 450 deaths per year (American Cancer Society, 2007). Public awareness of male breast cancer is relatively low due to breast cancer’s overwhelming association with females as it is 100 times more common among women. However, evidence is showing that in fact, the incidence of male breast cancer is rising, with a 25% increase from the years 1973 to 1998 and an increase of about 60% from 1990 to 2000 (Symptoms of Male Breast Cancer, 2007). Even so, this increase is not generally known due to the lack of public awareness concerning breast cancer in men. Being largely a disease in females, breast cancer goes mostly unnoticed in males and little research and information is generated regarding this condition in males.
Keywords Breast cancer Breast cancer in men Male breast carcinoma Breast cancer treatment Psychological effects of cancer Psychological effects of male breast cancer
Gender Differences
J. D. Robinson Department of Surgery, College of Medicine, Howard University, Washington, DC, USA J. D. Robinson (&) N. Bhayani Department of Surgery, Howard University Hospital, 2041 Georgia Avenue, N.W., Washington, DC 20060-0002, USA e-mail:
[email protected] K. P. Metoyer Jr. Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA
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Breast cancer in men is similar to breast cancer in women. For instance, the most common type of breast cancer found in women is infiltrating ductal carcinoma, a type that originates in the milk ducts which carries the milk from the lobules or milk producing glands, to the nipple (Pereiral, 2003). This type of cancer is also the most common breast cancer in men with an overwhelming 93% of all male breast cancers being of this type (Giordano, 2004). Other similarities that exist include some of the risk factors that are associated with the development of these cancers. Common risk factors of both male and female breast cancer are age (as incidence increases with age), high estrogen levels, strong genetic history, obesity, heavy alcohol intake, liver disease, and radiation exposure. Also of note is
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that symptoms, such as lumps, enlarged breasts, nipple pain, nipple discharge, and enlarged lymph nodes, are seen in both men and women (Giordano, 2004). The literature on genetic predisposition for breast cancer suggests the same genes, such as BRCA 1 and 2 (American Cancer Society, 2007), place an individual at increased risk for the disease regardless of gender. It is also believed that there is a larger percentage of men with genetic breast cancer than spontaneous breast cancer, and that breast cancer genes can be inherited from female and male relatives (Fortin, 2007). Adding to genetic risk, one possible explanation for the increasing rates of male breast cancer may be the disease’s association with obesity, which is also increasing in the United States at epidemic rates (Cubic, 2007). Diagnosis and treatment options, including mammography and needle biopsy, are exactly the same for both sexes. Men will usually present with a painless mass in the breast, however, when gynecomastia is present the cancer may be associated with a tender mass or area. Axillary adenopathy, nipple retraction, and skin involvement may also be present. Diagnosis is made by biopsy. Prognosis for men with breast cancer depends on the stage of the disease using the American Joint Committee’s Clinical Staging System; the earlier the stage at diagnosis, the better the chance for cure (R. DeWitty, personal communication, March 23, 2007). The rates of survival have been shown to be similar in men and women, with five year survival rates being 96% for Stage I, 84% for Stage II, 52% for Stage III, and 18% for Stage IV (Giordano, 2004). Another commonality is that, just as in breast cancer in women, there are racial disparities in diagnosis and treatment. One study has reported that although the five year survival rate for whites approached 90%, the survival of blacks was 66%. Moreover, black race was associated with increased male breast cancer-specific mortality (Crew, 2007). One possible explanation for this difference was the finding that black men were approximately 50% less likely to be referred to an oncologist and subsequently receive chemotherapy (Crew, 2007). Despite the common characteristics between male and female breast cancer, there are some aspects of male breast cancer that distinguishes it from its female counterpart. For example, men with breast cancer tend to be diagnosed at a later stage of the disease than women. At diagnosis, men are also twice as likely to have cancer that has spread to their lymph nodes than women and 20% of women have cancers measuring less than 1 cm at diagnosis as compared with 10% of men (Giordano, 2004). Additionally, the average time between the onset of the first symptom and diagnosis is 19 months for men (Symptoms, 2007). This time of over a year and a half could explain why when finally diagnosed, men are found to be in a later
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stage than women. Perhaps of greatest concern, it has been found that the vast majority of men interviewed about their diagnosis of breast cancer had not known that the disease could affect men, also delaying diagnosis (Pituskin, 2007; Naymark, 2006; France, 2000). This is important because early stage diagnosis usually correlates with positive prognosis. Another difference between men and women who develop breast cancer is that a larger percentage of male breast cancers may be hormone receptor positive. For example, Giordano (2004) showed that 91% of male breast cancers were estrogen-receptor (ER) positive compared with 76% percent of women and men had a higher percentage of progesterone receptor (PR) positive cancers as well. In fact, most men with breast cancer demonstrate ER/ PR positivity. It would be interesting to know if black men show a trend that aligns with gender, race, or neither as it has been shown that fewer black women have hormonally sensitive cancers as compared with whites (Giordano, 2004). The low incidence of male breast cancer has hindered investigators’ attempts to develop randomized prospective trials, so the disease is poorly understood. The bimodal age-related distribution seen in female breast cancer does not carry over into the male population. The median age at diagnosis is 67 years. The disease comprises up to 6% and 20% of all breast cancers in Egypt and Zambia, respectively. Likewise, Jewish men have had a higher annual incidence of breast cancer than the average worldwide male population (Iredale, 2006). Twenty percent of men with breast cancer have a first-degree relative with the disease. A positive family history confers a 2–5 times increase in relative risk (Baker & Dick, 2006).
Breast Cancer and Mental Health of Men An urgent topic to consider is the effect male breast cancer has on the mental health of men. Bunkley et al. (2000) summarized the psychological and social issues men face when diagnosed with breast cancer. This paper includes some suggestions on how to meet some of these needs in order to be of greater assistance to these men. Additionally, in one small study, it was shown that clinical levels of anxiety and depressive symptoms were reported by 6% and 1% of men, respectively, where 23% reported high levels of cancer-specific distress (Crew, 2007). This information is of concern because most of this anxiety and fear could possibly be reduced by raising public awareness and providing additional information to both patients and clinicians alike. This is evidenced by the study’s finding that body image, avoidance coping, referral to the study by a clinician, fear and uncertainty, and wanting to receive
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more gender-specific information accounted for 51% of the variance in cancer-related distress associated with male breast cancer (Crew, 2007).
the physical deformity afforded by surgery may serve to reinforce pre-existing insecurities about an individual’s masculinity.
Delayed Diagnosis
Physician’s Role
One reason that men present with advanced breast cancers is likely a general lack of awareness about the disease as shown by the fact that the vast majority of men with breast cancer were unaware that the disease could affect men (Pituskin, 2007; Naymark, 2006; France, 2000). Also, when they disclosed their diagnosis to friends and family, they found their potential social supports equally unaware, especially other men. There are very few celebrity spokespersons for male breast cancer and no screening guidelines. Broader public knowledge of male breast cancer must come before patients begin to present earlier. Early breast lumps are commonly brought to the attention of a physician by a woman’s periodic self exams, which men are not counseled to perform. Breast cancer usually occurs, initially, as a painless breast mass. Because these cancers are rarely symptomatic or tender, men are unlikely to notice them during normal activity and more likely to dismiss them once found. A factor in this dismissal is that males are more likely to view a breast as vestigial anatomy or something to flex on the beach. Additionally, males are reluctant to seek medical care in general in most circumstances. This is likely a combination of denial as well as other factors, including possibly limited access to healthcare because of poor insurance, work hours, or family obligations. In a study where patients had universal healthcare, 84% of British males sought medical attention within three months (Iredale, 2006). The patient’s wife or significant other often plays a vital role in bringing the problem to medical attention. Without a sense of urgency, males may accept an appointment months away to see their busy primary care physicians. All these factors delay the presentation of breast cancer and increase mortality rates in males. Male breast cancer and associated interventions, i.e. mastectomy, may also lead to a distorted self image. Breasts are most often associated with femininity and sexuality, with many men discounting male breasts as simple anatomy. Conversely, male breasts (or more commonly called, pecs) are viewed by most men in today’s society as a symbol of masculinity and strength. Therefore, it would be easy to see how significant stress could be generated after total or modified-radical mastectomy as evidenced by several studies showing a reluctance of men to go shirtless in public post surgical intervention (Pituskin, 2007; Iredale, 2006; Naymark, 2006). The perception of breast cancer as being a ‘‘woman’s disease’’ combined with
In reference to male breast cancer, among a physician’s ethics, shortly following ‘‘Primum no cecere,’’ (first, do no harm) could be ‘‘Mea culpa’’ (My fault). The physician’s and health care staff’s knowledge of and attitude towards this rare disease can pose a problem to a self-conscious and frightened patient. For a male to seek medical attention for a breast mass must be a difficult step. Many male breast cancer patients report feeling ignored by their physician, with symptoms initially dismissed (Pituskin, 2007). Patients with subtle breast findings are more likely to be reassured than referred for further evaluation. Even patients with an early diagnosis still commonly express a frustration about the medical field or providers’ paucity of knowledge about this problem (Naymark, 2006). Despite the infrequency of male breast cancer, physicians must remain vigilant and current on this disease. While accustomed to comforting or reassuring a female with breast disease, the staff may not know how to react to a male similarly diagnosed. Part of the initial male response to the diagnosis of breast cancer may be disbelief, and confusion at having a ‘‘woman’s disease.’’ The medical team must be sensitive to a psychologically difficult moment associated with breast cancer for anyone and especially a male. Similarly, the physician plays an integral role in the patient’s perception of the disease. The physician and their staff’s knowledge of and attitude towards this rare disease can pose a problem to a self-conscious patient. As many male breast cancer patients feel their physician has initially dismissed their symptoms (Pituskin, 2007) this misstep may lead to a general distrust in physicians and their ability to treat this disease further delaying intervention.
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Gender Roles A man with breast cancer, who is no longer able to work or provide for his family, may feel more frustrated if in a patriarchal or male-dominated social construct. The time and physical demands of therapy may prevent working, assisting at home, or participating in normal activities. The inability to work or even participate in normal activities because of the exhaustion of cancer therapy would certainly be a serious stressor for any patient but may be compounded in a male who feels de-masculinized by breast cancer. Feelings of uselessness and helplessness about their
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disease may be strong stressors that can precipitate depressive disorders. This would only be complicated in a single-income family with the resultant financial strains of lost income and medical bills.
Information Divide Because of the significantly higher incidence of breast cancer in women, there is a lack of male-specific or even gender-neutral information. Everything from marathons to logos, including the pink ribbon, and brochures are geared at women with breast cancer. The psychosocial implications of this disease are myriad and made more complex by the pink branding of breast cancer (Baker & Dick, 2006). Breast cancer literature often includes tips on menstruation, breast reconstruction and bra fittings, specific to women, which can discourage a male patient. In fact, most men reported receiving most of their information verbally rather than as patient information literature. A photo of a postmastectomy male and the side-effects of hormonal therapy were thought to be most important by patients (Iredale, 2006; Naymark, 2006). If disengaged, a patient will be less likely to learn about their disease, with subsequent implications for adherence to therapeutic plans. While our medical knowledge is biased towards female breast cancer because of the lower prevalence of male breast disease this creates a disservice to males. Additionally, the effects and side-effects of selective estrogen receptor modulators (SERMs) such as tamoxifen and raloxifene as well as aromatase inhibitors in men are not well known. This gap in knowledge can be disappointing and discouraging to male patients and every attempt should be made to provide gender-neutral information about breast cancer, if literature specific to males is unavailable.
Social Support Breast cancer in men, though very similar to breast cancer in females in diagnosis, treatment, and outcome, still does not have the recognition and widespread public awareness that female breast cancer does. Thus, women with breast cancer live in a society geared at raising awareness and support of women with breast cancer, whereas there are very few avenues of support for men. These support systems are important because they not only provide social connectedness, but create a social network that instills optimism. Males with breast cancer rely heavily on the support of their spouse or significant other, but are reluctant to tell anyone but the closest friends (Pituskin, 2007). Initially, most males feared too much emotional concern from others
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or a reaction they felt would diminish their masculinity (Iredale, 2006). Some patients reported that male colleagues and friends laughed at the time of disclosure. This reaction to a woman telling someone of a newly diagnosed breast cancer would be unheard of and not tolerated. After some time to adjust, men continue to hide their diagnosis; possibly because of embarrassment or fear of becoming the community’s medical oddity (Pituskin, 2007).
Support Groups Cancer survivor groups are common, especially in breast cancer. Participation in these groups not only provides for information exchange and patient education, but also gives social support. Studies interviewing men with breast cancer show an unwillingness of patients to join groups, regardless of whether they were all male or mixed gender groups (Pituskin, 2007; Naymark, 2006; France, 2000). Subjects expressed feeling awkward, and some even felt that they would make the women feel awkward. Women with breast cancer are more likely to participate in such groups, which points to a fundamental difference between genders and the way in which each gender perceives the disease. Attendance in support groups has been shown to improve quality of life and improve survival in breast, prostate, and colorectal cancers. Unfortunately, fewer men participate in these groups even with male specific diseases such as prostate cancer (Krizek, 1999). Men attending group meetings appreciate the information exchange more than the emotional support aspects (Thaxton, Emshoff, & Guessous, 2005). This information can be applied to creating and encouraging males with breast cancer to attend informative and education-based groups that might serve a secondary social and supportive function. The gender disparity between male and female breast cancer serves to create a divide that is evidenced by the longer time before diagnosis and the fact that men are diagnosed at a later stage than women, thus an increased mortality rate. The conventional wisdom that men do not have breasts and are not susceptible to breast cancer needs to be changed in order to decrease the differences that exist between men and women with this disease. This can be accomplished perhaps through competent and gender-specific subject research as well as an increase in public awareness and screening for men who may be at an increased risk for the development of male breast cancer.
Self Image Many males likely associate their chest with pride, strength, and masculinity. Total or modified-radical
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mastectomy drastically changes someone’s appearance and sometimes strength. As stated earlier several studies interviewing patients show a reluctance to go shirtless in public (Pituskin, 2007; Iredale, 2006; Naymark, 2006; France, 2000). Patients hesitate to go to the beach or may give up activities such as swimming, not just because of the appearance of a scar but also the absence of a breast. The physical deformity of surgery, coupled with the perception of breast cancer as a ‘‘woman’s disease’’ may psychologically reinforce pre-existing insecurities about an individual’s masculinity. Many of the risk factors for male breast cancer, infertility, undescended testes, hyperestrogenemia, Cowden’s Syndrome, and Kleinfelter’s Syndrome, likely create an inherent sense of diminished masculinity. For men whose work is more physically demanding, the inability to resume a previous job can have a serious psychological impact. For instance, men working around blast furnaces, high heat, and steel mills all have a higher incidence of breast cancer and may not be able to return to jobs requiring strenuous upper body labor (Iredale, Brian, Williams, France, & Gray, 2006). Breast reconstruction is available for men, but the prosthesis is usually the same as that used for women, lending a different contour to the breast and perhaps an overall less satisfactory appearance. There have been, however, improvements in breast reconstruction attempts with males. More recently, men do have options other than saline/silicone implants and can get firmer pectoralis muscle-like implants that have more of a muscle contour than that of a female breast (M. Baker, personal communication, July 20, 2007).
Summary and Recommendations As stated by Bunkley et al. (2000), we should not let the infrequency of breast cancer in men allow treatment providers to view breast cancer as a gender-exclusive disorder. There are psychological as well as medical commonalties for women and men diagnosed with breast cancer. Treatment providers should be made aware that breast cancer in men can have a variety of different psychological meanings for the men who are diagnosed with this illness. Just as the need for psychological support during prostate and colorectal carcinoma treatment in men has been underscored; we need to apply some of those same principles and treatment support options to men with breast cancer. This includes training health care professionals, especially mental health professionals, in the area of providing psychological services to men with breast cancer. Not only is literature of an educational nature on male breast cancer rarely found, but support groups for men with breast cancer tend to be almost nonexistent. Men tend to
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feel alienated from friends and society when diagnosed with breast cancer. Sometimes it is assumed that something must be wrong with the man for him to get a ‘‘woman’s disease.’’ Men observe very well known campaigns, such as the Susan Komen race, as a female event although it represents a disease that is found in men. The ‘‘pink ribbon’’ even implies that this is for women only. Greater education needs to take place with health care providers so that they can be sensitive to men with this disease and to allow the provider to respond appropriately. Men are frequently ignored by the health care industry when diagnosed with breast cancer. Just as men are examined for testicular, rectal, and prostate cancers, they should be regularly examined for breast cancer and taught to do self-examinations. This may decrease the poor prognosis of male breast cancer as well as enhance the psychological quality of life for men with this disease. Acknowledgements The authors would like to thank Robert DeWitty, MD, Associate Professor of Surgery, Howard University College of Medicine, for his suggestions, contributions, and comments on early drafts of this manuscript.
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