Breast cancer in men: Yes, it happens
“Nip/Tuck”
FX, season premiere: Jan. 6 and 13, 10 p.m.
The premise
Plastic surgeon Dr. Christian Troy (Julian McMahon) takes his associate Dr. Liz Cruz (Roma Maffia) for a mammogram because he thinks he felt a lump in her breast. The test is negative but, while at the radiologist’s office, Troy admits that he himself has felt a lump in his own chest. He suspects it to be “an inflamed sweat gland from lifting weights,” but the radiologist persuades him to have a mammogram, saying that 450 men die of breast cancer each year. The results show a dark spot that the radiologist says could either be a ductal cancer in situ, in which the abnormal cells have not yet spread beyond the duct, or a more invasive form of the disease. Troy undergoes a needle biopsy that reveals Stage 2 invasive cancer. He undergoes surgery, with his partner Dr. Sean McNamara (Dylan Walsh) watching nervously to make sure that a “fresh frozen section” of the tumor is sent to the pathology department and that the wound isn’t closed until there are “clear [cancer-free] margins in every direction.” McNamara says that he will perform the breast reconstruction and that he hopes there will be enough tissue left for a DIEP procedure. Troy later receives chemotherapy, experiencing nausea and vomiting as a result; a fellow patient says such a reaction means the chemo is working but another person suggests that’s a myth.
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The medical questions
How common and how deadly is breast cancer in men? Is a mammogram useful in diagnosing it? Is a needle biopsy the standard procedure for making a tissue diagnosis? How extensive is Stage 2 cancer and how is it treated? Is a frozen section sent to the pathology department before the wound is closed? What is a DIEP procedure, and is this the standard reconstruction technique in men? Are nausea and vomiting signs that chemotherapy is working, or is that a myth, as the show suggests.
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The reality
Each year in the United States, almost 1,990 men are diagnosed with breast cancer, according to the American Cancer Society, and 450 die of the disease, as the show’s radiologist accurately states.
The disease is 100 times less common in men than in women, but as with women, mammography is a useful tool “to distinguish benign from malignant tumors in men,” says Dr. Daniel Roses, director of surgical oncology at the NYU Langone Medical Center. But the show’s description of how a mammogram is interpreted is inaccurate. “They won’t see a dark spot. Rather, they will likely see a white mass or calcifications,” says Dr. R. James Brenner, chief of breast imaging at the UC San Francisco School of Medicine.
A true mass on a mammogram is almost always cancer, Brenner says. Needle biopsy is usually the most reliable way of making the diagnosis of breast cancer, or distinguishing it from a benign swelling (gynecomastia) or lymph node. But a needle biopsy cannot establish the stage of the cancer.
Stage 2 breast cancer means that it has spread to the lymph nodes (which are not sampled in the core needle biopsy that the show’s radiologist performed). The staging would be done at the time of surgery and would include further diagnostic testing to rule out distant metastases. In Troy’s case, Stage 2 is consistent with the initial lump he felt under his arm. Though McNamara is right to be concerned about “clear margins,” frozen sections are almost never tested anymore because the results aren’t accurate, says Dr. Judy Garber, director of cancer risk and prevention at the Dana-Farber Cancer Institute at Harvard Medical School. Instead, in both men and women, the wound would be closed, with margins that are expected to be adequate, but that could always be re-excised.
The treatment for male breast cancer is generally a mastectomy that encompasses the cancer, Roses says. Men do not usually undergo reconstruction because they generally lack chest tissue. When such tissue is present (as with gynecomastia), restoration isn’t desired.
The DIEP (deep inferior epigastric perforator) flap is a reconstructive technique in which tissue from the lower abdominal wall -- skin, fat and blood vessels -- is transferred to the site of the mastectomy, and a new breast is created.
Men (and women) with Stage 2 breast cancer would be assessed for biomarkers (including hormone receptors) and would be considered for additional chemotherapy or hormone therapy. Brenner has recently published a study indicating that men with breast cancer should also be considered for genetic testing because the BRCA2 cancer gene can be transferred in families.
Finally, the show is correct that vomiting from chemo has nothing to do with effectiveness of the treatment. “It means inadequate anti-emetics,” Garber says.
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