Psychosomatics 43:326-330, August 2002
© 2002 The Academy of Psychosomatic Medicine
Male Breast Cancer: A Review of the Literature and a Case Report
Yvette Smolin, M.D., and
Mary Jane Massie, M.D.
Received December 14, 2001; accepted December 28, 2001. From the Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, Bronx, NY, and the Albert Einstein College of Medicine, Bronx, NY; the Barbara White Fishman Center for Psychological Counseling, the Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York; and the Weill Medical College of Cornell University, New York. Address correspondence and reprint requests to Dr. Massie, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021; massiem{at}mskcc.org (e-mail).
Key Words: Breast Cancer
Breast cancer in men is rare, and there are no large prospective studies that address either the medical/ surgical treatment of breast cancer or the psychological issues. We review the scarce psychological literature; summarize the common risk and prognostic factors, familial tendency, pathology, and primary treatments; and report a 2-year psychotherapy that illustrates both the psychological issues of a man treated for Stage III breast cancer and the similarity of men's and women's emotional reactions to this disease.
Breast cancer in men accounts for less than 1% of all breast cancer in the United States and less than 1% of all cancers in men.1 About 1,500 new cases of male breast cancer are expected to be diagnosed in 2002; about 400 men will die of the disease.2 Breast cancer in men was once believed to be biologically more aggressive than in women and more lethal.3–5 Because of the low incidence, until very recently there were few reported studies of treatment and survival among demographically matched male and female pairs6,7 and virtually no reports in mass media or professional journals describing the psychological issues of men with breast cancer. Most men and women were surprised to learn that men can "get" breast cancer, knowledge imparted during the last decade through reports about breast cancer susceptibility genes.8
The following report of a 2-year psychotherapy with a man with Stage III breast cancer illustrates the common cancer treatment and psychiatric/psychological issues in a man with breast cancer and a family history of breast cancer.
Case Report
Mr. T, a 43-year-old white, single man, requested a referral for a psychiatric consultation from his male medical oncologist because he was fearful about developing a recurrence of breast cancer. Two years prior to this request, he noticed nipple retraction of his right breast and sought consultation with his internist in the Midwest in a timely fashion, only to be told that there was "nothing to worry about." Though disturbed by this opinion, he let the issue drop. A year later, he saw an internist on the East Coast for a routine physical exam and was quickly referred to a surgeon. He underwent a right-modified radical mastectomy for a 3-cm tumor and axillary dissection (7/25 axillary lymph nodes positive) and was diagnosed as having Stage III intraductal breast cancer. His tumor was both estrogen and progesterone receptor positive; HER2 status was not evaluated. He banked sperm after his surgery while anticipating treatment with alkylating agents and elected to have high-dose chemotherapy (adriamycin, cyclophosphamide, paclitaxel, cisplatin, BCNU) followed by stem cell transplantation in the Midwest. This was a strenuous, physically exhausting treatment, and the life disruption resulting from his move back to the Midwest had significant adverse financial, social, and emotional consequences. At the time of the initial psychiatric consultation, he was finishing 3 weeks of post–stem cell transplantation irradiation therapy and had started tamoxifen 20 mg daily and alprazolam 0.5 mg infrequently and on an as-needed basis.
Family Cancer History. The patient said that he had always been more anxious than most people he knew. He had episodes of depression and anxiety that pre-dated his cancer diagnosis; the most significant episode occurred after his mother's death from breast cancer and his father's remarriage. He said that his illness was especially harrowing because of his mother's death at the age of 43 when he was 9 years old. When diagnosed, he felt "numb" that his "worst fear had been realized." He always "knew" that he would get breast cancer, as had she. He felt a strong connection to his mother and had vivid memories of her deterioration and painful death. He was fearful that his cancer would recur and that he would die, although his medical team had reassured him that he had a good prognosis. His life "no longer felt like his own," and relationships and work no longer held the same interest they once had. He knew of no other men who had breast cancer, and there was no family history of any other cancer.
Past Psychiatric and Medical History. Born in the Midwest, he had sought treatment by at least four mental health professionals prior to his breast cancer diagnosis in an attempt to understand his unhappy childhood, which he attributed to his mother's illness and death and his father's remarriage to a woman with her own children. Mr. T felt that in this new family environment, too little attention was given to his twin brother and two sisters but most of all to him. His past psychotherapies had been helpful to him because he gained a "sense of control" that had helped him better manage his anxiety. He drank alcohol to excess in his 20s but did not use drugs and had never taken psychotropic medication. He had no medical illnesses associated with hyperestrogenism (cirrhosis, Kleinfelter's syndrome) and had no history of treatment with estrogen or radiation exposure.
Personal and Social History. Mr. T described his life as more chaotic than he had wanted. He was embarrassed about not having finished college because it made him look like less of a success in the eyes of his girlfriend's parents. He had worked in a variety of jobs where he had achieved some level of economic comfort, but he never believed success would last because "the bottom might fall out at any time." Most relationships were unsatisfying with the exception of his relationship with his identical twin brother, whom he described as "very similar to himself." Throughout his cancer treatment, emotional support was provided by his brother and his girlfriend; he felt that no one else cared. His 3-year relationship with an educated, affluent, professional woman was described as conflictual. Though they spoke about marriage before his diagnosis, he believed that she would not marry him because of his "precarious" medical condition and that her family would be opposed to their marriage for the same reason.
When first seen, he appeared thin, dressed casually, and wore a baseball cap to hide alopecia. He seemed to like being interviewed and was somewhat flirtatious. His mood was both sad and anxious and congruent with his affect. He had no suicidal ideation or psychotic thought process or content; he was oriented, and memory was intact. His insight and judgment were fair. He feared cancer recurrence and knew that he had many problems, but he could not categorize or prioritize his concerns.
Case Formulation, Diagnosis, and Treatment Goals. Mr. T was a private, fragile, self-absorbed, and fearful man with previous anxiety and depressive episodes who was completing arduous treatment for a life-threatening illness while harboring resentment about the delay in his diagnosis and about his life in general. His episodes of emotional distress had their onset in childhood concurrent with his mother's treatment for breast cancer and subsequent death. His loneliness, anxiety, and depression were exacerbated by his father's remarriage. Throughout his life, he had had problems with relationships, particularly intimate ones, and saw himself as unmarriageable. His illness was seen as a manifestation of a life that was problematic and "out of control."
Mr. T's psychiatric diagnosis was adjustment disorder with mixed emotion. The initial treatment goals were to help him clarify his fears and concerns about his illness, to provide support to help him adjust to his situation, and to begin to assist him in planning a more fulfilling life.
The Psychotherapy. Mr. T has been seen three to four times a month for the past 2 years for emotional support and medication monitoring. Initially, he did not seem a likely candidate for psychodynamic psychotherapy because of his lack of insight into his situation and perceived lack of commitment to therapeutic work. During the first year of psychotherapy, he focused on issues that caused him greatest concern, primarily his desire for emotional support and his disappointment in others. He felt that his male physicians had failed to respond to his anguish. He felt "put off" by his twin brother, who was telling him to "move on with your life," and emotionally deserted by his demanding but distant female friend. He was greatly worried about his appearance, an exaggeration of a lifelong concern. Alopecia was a significant blow to his self-image, and he continued to wear a baseball cap after his hair regrew since he felt that it did not look the same as before chemotherapy. He worried about removing his shirt on the beach because of embarrassment about his mastectomy scar. Though he talked about ending his love relationship, he would cringe when he thought about having to show his body to a new partner.
He felt stigmatized having a "woman's disease." Attending a breast cancer support group was inconsistent with his need for privacy. He felt overwhelmed and was lacking self-confidence. Cancer had "changed his life," and he did not know how to proceed in taking the "next step."
Every ache and pain made him think that he had cancer "all over" his body, and he repeatedly asked, "What if this is it?" His "as-needed" benzodiazepine dose schedule was one of the few things he felt he could control.
By the end of the first year of psychotherapy, he realistically considered and decided against gene testing for BRCA2. He felt he did not need to know his status unless he decided to attempt to father children with his banked sperm. He sought referral information about high-risk breast cancer surveillance programs and facilitated his twin brother's ("my double") enrollment and regular participation in screening.
Although compliant with medical follow-up and consistently receiving "good reports" from his medical oncologist, uncomfortable tamoxifen side effects (i.e., feeling "spacey," mild depressive symptoms, decreased libido, and leg cramps) have made him briefly discontinue this drug on several occasions. His tamoxifen dose was changed from one 20-mg dose daily to 10 mg twice a day to lessen the side effects.
During the second year of psychotherapy, Mr. T made more of a commitment to therapy, demonstrated by his rearranging his schedule to keep appointments and commuting 3 hours round-trip for sessions. The reception of a delayed financial windfall from a business initiative, the severing of a maladaptive business partnership, and the passage of time from his cancer diagnosis and treatment have permitted him to explore different areas of his life and look at his cancer a little less anxiously. Though cancer was still in the forefront of concerns, it was slowly replaced by other life issues. Recent sessions contain information about how to make his business grow, his wish to marry, and how to feel happier. Though feeling better than during the first year of therapy, he still has episodes of depressive symptoms and has considered and reconsidered taking an antidepressant. In a moment of uncertainty about his relationship, he consented to take an antidepressant, filled the prescription, but never took a pill.
Body image concerns post-cancer treatment persist; he is currently normal weight but contemplates both liposuction and breast reconstruction by implant placement and nipple and areola construction. Although he continues to view himself as sexually undesirable and wears a shirt during sexual intercourse, he has commented that women are finding him attractive. In the light of his continuing conflictual relationship with his female friend, he is starting to feel more confident and to think that he might be ready to socialize again.
DISCUSSION
For many years, clinicians described male breast cancer as more aggressive and deadly than female breast cancer.3–5 As more information was accrued, male and female breast cancer were described as being biologically similar.5–7 The incidence of both male and female breast cancer increases with age and after exposure to irradiation (i.e., treatment for Hodgkin's disease). Diseases associated with hyperestrogenism predispose men to breast cancer. There is no conclusive evidence that male breast cancer occurs more often in men with gynecomastia.1
The similarities/differences in male and female breast cancer are summarized in Table 1. Men are slightly older at the time of diagnosis; they delay longer in presenting for medical attention.7 The symptom of breast cancer in 70%–90% of men is a discrete, painless, subareolar (centrally located) mass.9 In both sexes, the most common histologic type is invasive intraductal carcinoma; however, men are more often estrogen and progesterone receptor positive.10–12 Breast cancer is radiographically evaluated, staged, and treated the same in both sexes.5,12 Sentinel node mapping is used in men and women.13 For both men and women, the most powerful predictor of outcome is the status of axillary lymph node involvement.1 Lifelong follow-up includes mammography of the contralateral breast for the mastectomized patient. Overall survival is similar for stage-matched controls.5–7 Five percent of female breast cancer is associated with a mutated gene (BRCA1 or 2); a mutation in BRCA2 is found in 7% of all men with breast cancer.14
Mr. T's case is representative of male breast cancer in many ways: delay in workup, location and histologic type of tumor, nature of surgery, and treatment by chemotherapy and the antiestrogen tamoxifen, which often has treatment-limiting side effects.15,16 Less representative aspects are his family history of breast cancer (15% of men with breast cancer have one or more first-degree relatives with breast cancer),14,17 relatively young age at diagnosis, and treatment by stem cell transplantation.
Women's psychological adaptation to breast cancer has been described as dependent on medical factors (i.e., treatments required, side effects experienced, and prognosis) in addition to psychosocial and psychological factors (previous coping ability and personality style).18,19 In many ways, Mr. T's emotional reactions to breast cancer and the issues he considered in psychotherapy are very similar to those of younger, single women with breast cancer.20 He initially felt the shock of his diagnosis with vivid recall of his mother's death. Diagnosed in his early 40s, he was single, sexually active, and in a relatively new relationship. He experienced mastectomy as disfiguring, and both alopecia and his surgical scar were embarrassing. Breast cancer made him feel "less like a man." His decreased self-esteem, coupled with body image concerns, led him to believe he was undesirable as a sexual and marriage partner. His need for practical assistance and emotional support during high-dose chemotherapy and stem cell transplantation necessitated career disruption and a geographic move with financial implications back to his nuclear family. He experienced mixed symptoms of anxiety and depression and was angry at physician ignorance or nonchalance when he presented with a classic symptom of breast cancer. He perceived the disease as terrifying and was painfully aware of the lethality of breast cancer, having watched his mother's deterioration and ultimate death.
Cancer had altered his life patterns; much of his time over 2 years was taken up with hospitalizations, treatments, and medical appointments that increased the chaotic feeling to his already chaotic life. He confided in very few people about his cancer, which contributed to his feeling unsupported and alone. Though told that he is in remission, his fears of recurrence have diminished only somewhat with the passing of time. Although Mr. T had been reassured that he had a "good prognosis," with Stage III disease his likelihood of dying of breast cancer within 10 years is 40%.2
Until recently, little has been written on the psychological aspects of male breast cancer. Singh described two cases of men with breast cancer and attempted to explore whether the cancer onset was related to their identification to a significant other with breast cancer.21 Descriptive accounts of men's personal experiences with breast cancer have started to appear in newsletters and magazines.22–24 Because of the lack of public and physician awareness of male breast cancer, the chief of breast surgery at Memorial Sloan-Kettering Cancer Center has initiated a National Registry for men with breast cancer that was recently featured in Esquire, a popular magazine for men. Through this registry, psychiatrists collaborating with breast surgeons hope to better understand the psychological needs of men with breast cancer, albeit from a group of individuals who chose to self-disclose through a registry. Table 2 lists the 11 Web sites that currently provide information about male breast cancer.
For decades, women have fought to increase public awareness of breast cancer; advocated for research on prevention, early detection, and treatment; encouraged women's participation in controlled clinical trials; underscored the importance of psychological support; and brought a once-taboo topic into the political arena. Men are only beginning to "catch up" to women in their understanding of this potentially curable disease. In our experience, men with breast cancer have been reluctant to join women's breast cancer support groups and have been referred infrequently for psychiatric consultation. It is our hope that physicians (including psychiatrists) and patients alike will become better informed about this illness. The psychiatrist who begins treatment with a man with breast cancer can know that the heredity susceptibility testing issues, initial treatments, management of local or recurrent disease, prognosis, emotional reactions, and psychological concerns of a man with breast cancer are similar to those described for women with the same disease.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the assistance of Theresa Carpenter and Alex Pisani in the preparation of this manuscript.
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- Allen T: This man survived breast cancer. Esquire 2000; 133, 6:103-109
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