Women 55+ aren't the only ones wearing pink ribbons!

I've struggled greatly writing this blog because of hearing recently about 2 friends with breast cancer. Nothing brings home the indiscriminate terror of breast cancer more than learning in the same week about two "non-typical" individuals with the disease.

Joe is an athletic male friend from my high school days. He was diagnosed with breast cancer six years ago. Agnes is a very dear young female friend who recently received a breast cancer diagnosis. (Not their real names). Joe has the BRCA2 gene. It runs in his family  - one of his four daughters carries the gene and his mother died of breast cancer. Agnes does not have a BRCA 1 or 2 gene mutation nor does she have a family history of breast cancer. Joe has lived his entire life in Northern NJ, whereas Agnes has lived all of her life in rural Northern VA. Joe is 67 and Agnes is 34.

After hearing from Joe and while waiting for Agnes to receive her diagnosis, I set about scouring the web for information on breast cancer in men and younger women. That's when I realized the overwhelming focus on the standard 55+ female version of an illness that can and does afflict others outside of the norm. Breast cancer in both groups is mentioned at best in passing on most websites, but not often addressed in any depth. The most apparent reason is because neither group has been as closely studied as women 55+.

The National Cancer Institute projects in 2014 there will be:

• 232,670 females and 2,360 males diagnosed with breast cancer
• 40,000 female deaths and 430 male deaths from breast cancer

While writing this blog I amassed pages of stats on breast cancer, its victims, and cancer in general. Trying to make sense of the numbers and put them into perspective was even more difficult. A report on breast cancer by the US DoD (Department of Defense) states a caveat for all statistical survival rate estimates:

Survival rates are skewed by screening: the more women that are screened, the more early cancers are found, resulting in a larger denominator of breast cancer cases, i.e., more women will be counted as alive at 5 years. Evidence suggests that many women would not have died of breast cancer in that time frame, even if they had not been screened. In addition, these numbers do not take recurrence into account. A sizable proportion of the women reported to have survived for 5 years will have their breast cancer recur... and there is no known method to prevent recurrence.

90% of deaths due to breast cancer are a consequence of metastatic disease and there is no cure once metastatic disease has occurred. While the risk of recurrence is greater in the first 5 years after a diagnosis of estrogen receptor (ER)-negative breast cancer, patients with ER-positive tumors have a consistent long-term risk of death from breast cancer and a greater risk after 7 years. Approximately 75% of breast cancer is ER-positive, and most breast cancer deaths occur in ER-positive women.

What’s going on with breast cancer in men and younger women?

According to an article in the Journal of Clinical Oncology, Dr. Carey Anders, MD states that "More and more evidence tells us that breast cancer (in women) before age 40 differs biologically from the cancer faced by older women." The American Cancer Society says that compared to older women, young women generally face more aggressive cancers and lower survival rates.

Like young women, men have worse odds than the average older woman with breast cancer. Even those with early-stage breast cancer are more likely to die from the disease than women. Moreover, the lower breast cancer survival rate in men was only seen in those diagnosed with early-stage breast cancer. For men with advanced-stage breast cancer, survival was about the same for men and women.

What are the possible causes of breast cancer in men and young women?

One possible cause is radiation exposure. According to the Radiological Society of North America, researchers now believe that use of nuclear medical examinations and the increased use of CT scans between 2000 and 2010 may result in an increased risk for breast cancer. When I asked Joe (a lifelong athlete) about CT scans, he groaned and admitted he had had a lot of chest CTs over the years.

Females have been studied for 10 years but unfortunately not males. However, when a body undergoes a CT or nuclear medicine imaging of the chest, abdomen or spine, the breast tissue will absorb some radiation. Breast tissue is one of the body tissues known to be sensitive to developing cancer as a result of radiation exposure. This fact grounds one of my personal fears. 

How are men diagnosed and how does their treatment differ from females (of any age) with breast cancer?

Breast cancer usually strikes men between ages 60-70. Male breast cancer is usually ductal carcinoma (DC) not ductal carcinoma in situ (DCIS) which is very common in women of the same age group. Male breast cancer is more likely to be hormone-receptor positive. Men do not usually receive post-surgical hormonal medications as part of their treatment plan. They also do not normally receive radiation.

Joe’s cancer evidenced as a non-painful lump. His doctor’s first response was “wait and see” but Joe insisted on a biopsy. It turns out he was wise to have followed his instinct because the cancer had already moved into his lymph nodes. Considering he tested positive for BRCA2, he opted for a double mastectomy. As a result, Joe went through 2 months of chemotherapy and no radiation. He then took 5 years of hormone therapy in the form of Tamoxifen tablets and continues to take them on the advice of his oncologist. 

Because so few men get breast cancer, there is no clinical data on what is the best course of treatment. In fact, there have been no clinical trials in men to determine what medicine, if any, would be effective in fighting the disease. There is also no information on the effects of using these follow-up medications, although some men have reported the same symptoms as women.

According to MD Anderson Cancer Center, “On average, men are diagnosed at an older age and at a more advanced stage of the disease than women. However, when comparing patients of the same age and the same stage, the survival rates are similar. The overall 5 year survival rate for men was 63%, whereas the survival rate for older women is over 89%.”

Peter Criss, drummer and co-founder of the rock group KISS is a 7+ year breast cancer survivor. Like Joe, he too noticed a lump on his breast. Both men had the common sense to investigate rather than to ignore what must seem like an out-of-the-blue alarm bell. 

Despite being considered a female cancer, the fact remains that men have breast tissue and should not treat or put off any lump or other sign of breast cancer as something to ignore. Better safe than sorry is a better plan of action.

Why is breast cancer in young women and men hard to diagnose?

Naturally, men have less breast tissue than women. However, men can have the same diagnostic tests as women including: mammograms, sonograms, MRIs, needle biopsies and lymph node biopsies.

One reason diagnosing breast cancer in younger women is more difficult is because they have denser breasts. Standard mammograms miss cancer detection in dense breasts. Another reason is that like men, symptoms are often ignored and the disease becomes more aggressive because of detection delay. Like men, younger women's cancer might be likely to have been instigated by a mutated gene (BRCA1 or BRCA2), or exposure to radiation. Again, like men, it has also been linked to having a disease that causes high levels of estrogen such as cirrhosis, certain autoimmune diseases (in both sexes) or Klinefelter syndrome (in males). Cirrhosis can be caused by alcohol abuse, but it can also be the result of viral hepatitis or certain genetic conditions.

Aggressiveness of Breast Cancer in Young Females

Breast cancers in younger women tend to be fast-growing, higher grade and hormone receptor negative. All of these are factors that make the cancer aggressive and more likely to require chemotherapy. Increasingly, according to the National Institute of Health paper “Breast Cancer Before Age 40 Years," evidence suggests that breast cancer before age 40 is biologically different from the majority of breast cancer that occurs in older women.

Young women have a poorer survival and higher risk for recurrence compared with their older counterparts. Again, a key factor is that regular mammography is not an effective diagnostic tool for young women. The newer 3-D tomosynthesis mammography which uses new density software and imaging hardware makes it easier to spot tumors in the dense breast tissue of younger women. Is it perfect? No, but it's better than nothing or traditional mammography.

How does the treatment of young women with breast cancer differ from that of older women?

Breast cancer in young women is also treated differently than in older women. Not because of the cancer but mainly because of the cancer stage and tumor characteristics such as larger sizes, HER2 status/BRCA1 or BRCA2/hormone receptor status, and a higher incidence of lymph node involvement. 

Hormone therapies like AI's (aromatase inhibitors) are only used for post-menopausal women and chemo can cause menopause, which is why Tamoxifen is usually prescribed until there is no chance the patient is still premenopausal. Treatment options include lumpectomy, mastectomy (very common option), radiation following a lumpectomy, chemo/and or hormone therapy...but with way different consequences than with older women. 

According to the Oxford Journals Annals of Oncology, “Chemotherapy remains an important and frequently used treatment option for younger women.” Everyone is aware of the short term effects of chemo, but there is little study data on the long-term effects on younger women. Researchers do know that some long-term effects of breast cancer treatments include cardiac toxicity, congestive heart failure, hypertension and coronary artery disease, secondary cancers such as leukemia, wound infections, peripheral neuropathy, lymphedema, impaired cognitive function, neurotoxicity and psychological distress. 

Chemo and hormonal therapy can and do effect fertility and sexual functioning in all women with more serious QoL (Quality of Life) effects on younger women resulting in impaired fertility and early menopause (both temporary and permanent). For younger women, the higher the age at diagnosis and the higher the number of chemotherapy cycles, the lower the age of developing menopause. The newly released gel form of Tamoxifen apparently does not carry the side effects of oral Tamoxifen. Because of the side effects of oral Tamoxifen, Joe is planning to ask his oncologist about switching from the pill to the gel from.

The Oxford Journals Annals of Oncology advises "Current evidence suggests that sexuality is often not addressed with breast cancer patients, and even when discussed, it is done at an unsatisfactory level. Interest in sexual activity is one of the most relevant problems regarding QoL issues that remains altered over time.”

Most websites and doctors never mention the problem or at best, skirt the issue when discussing breast cancer treatment options to patients. When you’re more focused on life vs. death, statements like “might cause psychological distress or QoL issues” are easy to ignore. That in my personal experience is a grave disservice to all breast cancer patients. The patient is a key part of any treatment decision making process. To omit what might be for some physicians and patients alike an uncomfortable discussion of all the facts and consequences does not provide the patient with sufficient data on which to make personal, life altering decisions.

Although this blog is rather long, it only touched on several serious and disturbing topics for which information is scarce and results are uncertain. As the numbers of positive diagnoses continues to grow, so does the need for information, answers, solutions, treatments and prevention. Hopefully research and treatment approaches will broaden outside of the current focus on the usual suspects. If medical professionals are reluctant to fully discuss all aspects of cancer treatment, perhaps the media will step up and fill in the blanks.