Clinical Investigation:Breast Cancer
Management of Male Breast Cancer in the United States:A Surveillance,Epidemiology and End Results Analysis Emma C.Fields,MD,*Peter DeWitt,MS,y Christine M.Fisher,MD,MPH,*
高考英语改错and Rachel Rabinovitch,MD*
*Department of Radiation Oncology,University of Colorado School of Medicine,Aurora,Colorado;and y Colorado Biostatistics Consortium,University of Colorado,Aurora,Colorado
Received Feb13,2013,and in revid form Jun24,2013.Accepted for publication Jul13,2013
Summary
This is the largest evaluation of male breast cancer in the United States with a focus on management and outcomes. Breast conrvation is less frequently performed for males with localized dia but should be considered for its equivalent outcomes, improved cosmesis,and potential psychosocial bene-fits.Postmastectomy RT is greatly underutilized in men. Outcomes for MBC are improving over time,
reflecting improved therapy and/or their u in this unscreened population.Purpo:To analyze the stage-specific management of male breast cancer(MBC)with surgery and radiation therapy(RT)and relate them to outcomes and to female breast cancer (FBC).
Methods and Materials:The Surveillance,Epidemiology,and End Results databa was queried for all primary invasive MBC and FBC diagnod from1973to2008.Analyzable data included age,race,registry,grade,stage,estrogen and progesterone receptor status,type of surgery,and u of RT.Stage was defined as localized(LocD):confined to the breast;regional (RegD):involving skin,chest wall,and/or regional lymph nodes;and distant:M1.The primary endpoint was cau-specific survival(CSS).
Results:A total of4276cas of MBC and718,587cas of FBC were identified.Male breast cancer constituted0.6%of all breast cancer.Comparing MBC with FBC,mastectomy(M)was ud in87.4%versus38.3%,and breast-conrving surgery in12.6%versus52.6%(P<10À4). For males with LocD,CSS was not significantly different for the4.6%treated with lumpec-tomy/RT versus the70%treated with M alone(hazard ratio[HR]1.33;95%confidence interval[CI]0.49-3.61;P Z.57).Postmastectomy RT was delivered in33%of males with RegD and was not associated with an improvement in CSS(HR1.11;95%CI0.88-1.41; P Z.37).There was a significant increa in the u of
postmastectomy RT in MBC over time: 24.3%,27.2%,and36.8%for1973-1987,1988-1997,and1998-2008,respectively(P<.0001). Cau-specific survival for MBC has improved:the largest significant change was identified for men diagnod in1998-2008compared with1973-1987(HR0.73;95%CI0.60-0.88; P Z.0004).
Conclusions:Surgical management of MBC is dramatically different than for FBC.The majority of males with LocD receive M despite equivalent CSS with lumpectomy/RT.Post-mastectomy RT is greatly underutilized in MBC with RegD,although a CSS benefit was not demonstrated.Outcomes for MBC are improving,attributable to improved therapy and its u in this unscreened population.Ó2013Elvier Inc.
Reprint requests to:Emma C.Fields,MD,Department of Radiation Oncology,University of Colorado School of Medicine,Mail Stop F706, 1665Aurora Court,Suite1032,Aurora,CO80045.Tel:(720)848-0705;E-mail:emma.fields@ucdenver.edu
Prented at the54th Annual Meeting of the American Society for Radiology Oncology(ASTRO),October28-November1,2012,Boston, MA.
Conflict of interest:none.elaborate
Int J Radiation Oncol Biol Phys,V ol.87,No.4,pp.747e752,2013 0360-3016/$-e front matterÓ2013Elvier Inc.All rights rerved. dx.doi/10.1016/j.ijrobp.2013.07.016Radiation Oncology International Journal of biology physics
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Introduction
Male breast cancer(MBC)is uncommon and rarely studied prospectively.As such,therapy recommendations are generally extrapolated from the female breast cancer(FBC)literature.
A large population-bad study conducted in Europe and Asia demonstrated that males with breast cancer(BC)were signifi-cantly less likely to receive surgery and radiation therapy(RT) than females with BC.However,rates of u of chemotherapy and hormonal therapy were similar(1).Little is known about how MBC is treated across the United States,specifically with regard to the u of RT.
The goals of this study were to evaluate the stage-specific surgical and radiotherapeutic management of males with BC in the United States and relate them to outcomes with comparisons to the management and outcomes in FBC.United States population-bad data were extracted from the Surveillance,Epidemiology and End Results(SEER)registry.
Methods and Materials
The SEER databa is a National Cancer Institute databa that now incorporates17registries reprenting approximately26% of the population of the United States.Before2001,when Kentucky,Louisiana,New Jery,and all of California were added,approximately14%of the US population was repre-nted.To identify cas of MBC and FBC,the SEER databa [SEER17Regs Rearch DataþHurricane Katrina Impacted Louisiana Cas,Nov2010Sub(1973-2008)]was queried for all males and females diagnod with primary invasive breast cancer(BC)from1973to2008.SEER*Stat software(version 7.0.5)was ud to perform all queries and calculate incidence rates(2,3).Analyzable data included x,age,year of diagnosis, race,tumor registry,grade,stage,estrogen receptor(ER)status, progesterone receptor(PR)status,type of surgery,and u of RT. The reference population for incidence was the2000US stan-dard population.
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Age at diagnosis was collected as a categoric variable,with 5-year age intervals from birth to85þyears.For the data analysis, age was consolidated in3groups:10-49,50-69,and!70years. The age groups reprent premenopausal,postmenopausal,and more elderly patients in FBCs and were ud to group both males and females identified in this study population.Similarly,year of diagnosis was combined into3groups:1973-1987,1988-1997, and1998-2008,according to divisions in data codi
ng within SEER.Race was recorded as white,black,or other;tumor grade was1-4or unknown.Only2%of the patients had grade4tumors; the were combined with the patients with grade3tumors for this analysis.For consistency between the decades,stage was defined using SEER historic stage A as localized:dia confined to the breast without involvement of the skin or chest wall;regional: dia involving the skin,chest wall,or both(including inflam-matory BC)and/or dia involving regional lymph nodes(low, mid,or high axilla);and distant:M1.Estrogen receptor and PR status were either yes,no,or unknown,and markers were not reported until the1988era.The type of surgery was grouped into none(none,biopsy only),lumpectomy(partial mastectomy), mastectomy(simple,modified radical,radical,or extended mastectomy),or unknown(not otherwi specified[NOS], unknown),and u of radiation was recorded as yes,no,or unknown.The distribution of patient and tumor characteristics was compared using the c2test.
The primary endpoint was cau-specific survival(CSS),which was ascertained by specifying BC as the cau of death.Cau-specific survival was measured from the time of diagnosis until death from BC and was measured in months.Known non-BC deaths were censored and were not counted as events,and patients with an unknown cau of death were excluded in the CSS analysis.
Kaplan-Meier curves were generated for CSS with median survival time and95%confidence intervals
(CIs).Hazard ratios (HRs)of CSS with95%CIs are provided.Univariate analysis for CSS was performed for all patients(467,197)and for males only (2761)with known age,gender,race,stage,and grade at the time of diagnosis.Univariate analysis for CSS was also performed on all patients with known age,gender,race,stage,grade,and ER/PR status(298,966).Multivariate analysis was performed by using a Cox proportional hazard regression model including interactions between gender and stage,and gender and grade.Using the models an HR of<1indicates a better prognosis,and>1indicates a wor prognosis.Data analysis was done in R version2.15.1 (2012-06-22).Statistical significance was t at the.05level.
2013北京高考英语Results
Incidence and patient characteristics
The original data t consisted of848,940;after removing patients with unrecoverable or missing data,a total sample size of722,863 remained and was ud for this analysis.The reprented4276 cas of MBC and718,587cas of FBC.Male breast cancer constituted0.6%of all BC,and FBC constituted99.4%.Median follow-up for all patients was66months(range,0-431
months).
Fields et al.International Journal of Radiation Oncology Biology Physics 748
Male breast cancer was diagnod at an older median age than FBC:65-69years versus 60-64years (P <.0001).The incidence of MBC incread with age:2,3.8,and 5.9cas per 105persons aged 55-59years,65-69years,and 75-79years,respectively.Only 12%of all MBC was diagnod before the age of 50years,half the proportional incidence of FBC.Forty percent of MBC was diagnod after the age of 70years,compared with 30%of FBC.Male breast cancer and FBC were diagnod in 82.8%and 84.3%of whites,11.6%and 8.6%of blacks,and 5.7%and 7.2%other/unknown races,respectively (Table 1).
The average incidence of MBC was 1.5cas per 100,000males,and FBC was 164.2cas per 100,000females (P <.0001).The incidence of FBC and MBC emed to increa over the analysis period (Fig.1).Unlike FBC,no clear decline in MBC incidence was apparent after 2003,with rates of 1.6-1.8per 100,000in 2003-2008.
Dia characteristics
Grade distribution was numerically similar for males and females,though the differences reached statistical significance in this large data t.Stage distribution of MBC was significantly different (P <.0001)from that of FBC,with incread regional (42%vs 31%)and distant (8%vs 6%)dia,repres
enting more advanced dia prentation in males.The rates of regional and distant dia at prentation remained numerically constant for males over the three eras.
In the most recent time period,1998-2008,when ER and PR status were most frequently reported,ER positivity for males and females was 77.1%and 67.1%,respectively (P <.0001),and the rate of PR positivity was 65.5%and 55.8%(P <.0001)(Table 1).For regional dia (RegD),males were more likely than females to have ER-and PR-positive tumors than females:ER positive in 55.6%versus 47.6%(P <.0001)and PR positive in 47.5%versus 39.9%(P <.0001).White males were more likely to have both an ER-and/or PR-positive tumor compared with black males,78.4%versus 71.6%(P Z .019).
Breast cancer treatment
Surgical management differed significantly between males and females:overall,mastectomy was ud in 67.5%of males versus 38.3%of females (P <.001)and breast-conrving surgery in 9.7%of males versus 42.6%of females (P <.0001).When patients with noncurative surgical procedures were excluded from the analysis (no surgery,biopsy only,NOS,unknown,regional/distant surgery only),13%of 3303MBC patients were treated with breast conrvation,compared with 53%of 581,619FBC patients (P <.0001).
Of 1951males with localized dia (LocD),1371(70.3%)received a mastectomy,and only 90(4.6%)were treated with lumpectomy and RT;the remainder were coded as unknown surgery,NOS,or biopsy (n Z 490,25.1%).Of the 1461males coded as having curative therapy,94%were treated with mastectomy and 6%lumpectomy plus RT.This is in contrast
to
Fig.1.Point estimates of incidence of male breast cancer and female breast cancer per 100,000people from 1973to 2008.
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women treated curatively for LocD:46%treated with mastectomy and 54%treated with lumpectomy plus RT (P <.0001).
Of the 187,884females and males with RegD,rates of RT were low regardless of the primary breast surgery received.Males received RT for RegD in 33.6%of cas and females in 44.8%of cas.In 1379males with RegD who were treated with mastec-tomy,450(33%)were treated with postmastectomy RT (PMRT).Over time there was a significant increa in the u of PMRT in males with RegD:24.3%,27.2%,and 36.8%for 1973-1987,1988-1997,and 1998-2008,respectively (P Z .002).Males who received PMRT were more likely to be younger ( 69years,P Z .011)and have grade 3dia (P <.0001).Sixty-one percent of women with regional stage dia received a mastectomy (35.6%received breast-conrving surgery);however,only 30%received PMRT.
Outcome by patient characteristics
incread
Univariate analysis showed that males older than 70years had a poorer CSS compared with males aged 10-49years (HR 1.38;95%CI 1.02-1.87;P Z .03).Cau-specific survival was wor for black males than white males (HR 1.98;95%CI 1.58-2.47;P <.0001).Inferior CSS for older males and black males was maintained on multivariate analysis (Table 2).
Outcome by dia characteristics
Like FBC,improved CSS in MBC is associated with ER positivity (HR 0.69;95%CI 0.59-0.81;P <.0001)or PR positivity (HR 0.65;95%CI 0.55-0.76;P <.0001).Incread grade and stage were both significant prognostic factors on univariate analysis for poorer CSS in MBC (Table 2).
Median CSS was not yet reached for MBC or FBC with LocD.Median CSS was numerically inferior for MBC with RegD compared with FBC (192vs 275months),though this did not reach statistical significance.In contrast,median CSS was better
for MBC than FBC with distant dia (33vs 24months;HR 0.82;95%CI 0.69-0.97;P Z .015).
Over time,regardless of patient or dia characteristics,CSS for MBC improved.The largest significant improvement was identified for men diagnod in 1998-2008compared with men diagnod in 1973-1987(HR 0.73;95%CI 0.60-0.88;P Z .0004).
Outcome by treatment
Univariate analysis showed that for males with LocD (n Z 1951),lumpectomy plus RT (n Z 90,4.6%)yielded improved but not significantly different (HR 1.33;95%CI 0.49-3.61;P Z .57)CSS than males treated with mastectomy (n Z 1371,70.3%).The esti-mated CSS at 5years was 98.8%for lumpectomy plus RT versus 95.5%for mastectomy.For males with RegD,PMRT was not associated with any improvement in CSS (HR 1.11;95%CI 0.88-1.41;P Z .37).
Discussion
To our knowledge,this is the largest study of MBC to address the utilization and impact of surgery and RT.As demonstrated in this and other studies,MBC is rare,with an incidence of 0.6%in the United States;it has an older age of dia ont and a greater likelihood of advanced dia prentation than FBC (1,4,5).The initial surgical management of MBC is dramatically different than that of FBC.In this analysis the overwhelming majority of males treated definitively received a mastectomy (87%),compared with less than half of all females (47%).Only 6%of the 1461males treated definitively for early-staged dia received a lumpectomy and RT;the remaining 94%received a mastectomy.Studies published in the 1990s have similarly shown that 87%to 100%of males receive mastectomy and
that
Fields et al.International Journal of Radiation Oncology Biology Physics
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only a small subt are treated with a breast-conrving approach (6-10).One of the largest multicenter ries with detailed treat-ment analysis showed that of397males with BC,only13%had breast-conrving surgery,and of tho only8%received adjuvant breast RT(8).
Breast-conrvation therapy with lumpectomy and breast RT is considered standard of care for women with early-stage BC,with equivalent outcomes to mastectomy in appropriately lected patients(11,12).In this study,the CSS for men treated with breast conrvation was not statistically different from that for mastec-tomy,lending support to the approach that breast conrvation is no less appropriate for men than women in lected patients. Although small breast size and subareolar location of most MBCs impact surgical management,lumpectomy is nevertheless a reasonable option from an oncologic standpoint.Even when loss of the nipple e areolar complex is necessary,the benefits of a lumpectomy are substantial:less anesthesia time,no hospital stay or indwelling drains,and a much smaller scar that can be incorporated into a reconstructed areola.The psycho-xual effects of a mastectomy and the potential benefits of breast conrvation in men are areas worthy of future rearch.
Standard indications for PMRT in FBC include!4positive axillary lymph nodes and tumor invasion of the skin or chest wall (13).Postmastectomy RT has also recently been shown to benefit and be ud
in women with lower nodal counts(1-3,14).Despite this,for men with RegD treated with mastectomy,PMRT was delivered in only24.3%,27.2%,and36.8%of cas across the three study periods.Although the u of PMRT in MBC incread over time(P<.0001),it is clearly underutilized.The rate of PMRT for MBC in this study is low compared with multiple retrospective studies evaluating patients between1958and1997. The u of PMRT in the studies varies between3%and100%, with most reporting at least two-thirds of patients receiving RT (6-10,15,16).The majority of the studies were single-institution ries,whereas the data here reflect a wide range of nonuniform practices across the United States and potentially reflect a lack of consistent indications for PMRT in MBC. However,the results here may also reflect inconsistent reporting of radiation u within the SEER databa.Underascertainment of u of RT within SEER has been reported in up to32%of patients in some SEER registries(17).
In addition to improved local and regional control,PMRT has demonstrated a consistent survival benefit in multiple large randomized studies for FBC(18-20).The same expected benefit of PMRT was not found in this analysis of males with RegD.The prent study,although large,is retrospective and subject to an imbalance in the treatment groups.Additionally,becau SEER provides no information regarding systemic therapy,the impact of other treatment factors that could influence out
come in this subt could not be accounted for.In the abnce of data demonstrating that the biology of MBC is fundamentally different than that of FBC,we propo that the indications for PMRT in men should be no different than tho for women.If the same relative benefits of PMRT obrved in FBC are applied to the MBC population,the obrved underutilization of PMRT in men with RegD in the United States could be costing many MBC recurrences and deaths.
Although the incidence of MBC is small,there is a suggestion that its incidence is increasing.Giordano et al(4)ud the SEER data and reported an increa in MBC from0.86to1.08per 100,000people between1973and1998,reprenting a26% increa in incidence.Similarly,Anderson et al(5)reported on MBC from the SEER databa during the period of1973to2005 and found an annual increa in incidence of1.19%,with a peak in2000of1.24cas per100,000men.The incidence of MBC over the broad time period analyzed in this report documents wide variability,preventing definitive conclusions about incidence trends.Review of Figure1,however,would em to indicate that MBC is indeed increasing.If this is indeed the ca,the reasons for this are unknown.
Outcomes for MBC have improved over time and must be attributed to more effective therapies and/or their utilization in this unscreened population.The largest significant improvement in CSS was
identified for men diagnod in1998-2008,the most recent period evaluated,compared with men diagnod in1973-1987(HR0.73;95%CI0.60-0.88;P Z.0004).
In summary,this is the largest longitudinal evaluation of MBC with a focus on the management and outcomes of US men with BC.Male breast cancer ems to be increasing in incidence,for reasons that are unclear.Breast conrvation is rarely performed in men with LocD and should be considered for its equivalent outcomes,improved cosmesis,and potential psychosocial bene-fits.Postmastectomy RT is greatly underutilized in men with RegD,although a benefit in CSS could not be identified from this datat.Outcomes for MBC are improving over time,reflecting improved therapy and/or their utilization in this unscreened population.
References
1.Miao H,Verkooijen HM,Chia K,et al.Incidence and outcome of male
breast cancer:An international population-bad study.J Clin Oncol 2011;29:4381-4386.
2.Surveillance,Epidemiology,and End Results(SEER)Program.
artistry
SEER*Stat Databa:Incidence-SEER17Regs Rearch DataþHurricaneKatrina Impacted Louisiana
Cas,Nov2010Sub(1973-2008)-Linked ToCountyAttributes-TotalU.S.,1969-2009Counties,National Cancer Institute,DCCPS,Surveillance Rearch Program,Surveillance Systems Branch,relead April2012,bad on the November2011 submission.Surveillance,Epidemiology and End-Results program web-site.Available at:v/data/access.html.Accesd February29,2012.
3.Surveillance Rearch Program,National Cancer Institute.SEER*Stat
software version7.0.5.Available at:v/erstat.Surveil-lance Rearch Program,National Cancer Institute SEER*Stat soft-ware version7.0.5.Available at:v/erstat.
Accesd February29,2012.
4.Giordano SH,Cohen DS,Buzdar AU,et al.Breast carcinoma in men:
A population-bad study.Cancer2004;101:51-57.
5.Anderson WF,Jatoi I,T J,et al.Male breast cancer:A population-bad
comparison with female breast cancer.J Clin Oncol2010;28:232-239.
6.Cutuli B.Strategies in treating male breast cancer.Expert Opin
Pharmacother2007;8:193-202.
7.Donegan WL,Redlich PN,Lang PJ,et al.Carcinoma of the breast intarc
males:A multi institutional survery.Cancer1998;83:498-509.
8.Cutuli B,Lacroze M,Dilhuydy JM,et al.Male breast cancer:Results
of the treatments and prognostic factors in397cas.Eur J Cancer 1995;31A:1960-1964.
9.Stierer M,Ron H,Weitensfelder W,et al.Male breast cancer:
Austrian experience.World J Surg1995;19:687-693.
10.Borgen PI,Wong GY,Vlamis V,et al.Current management of male
breast cancer:A review of104cas.Ann Surg1992;215:451-459.
11.Fisher B,Anderson S,Bryant J,et al.Twenty-year follow-up of
a randomized trial comparing total mastectomy,lumpectomy,and
lumpectomy plus irradiation for the treatment of invasive breast cancer.N Engl J Med2002;347:1233-1241.
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