Breast Cancer For Men

i wanted to thank cancer australia for giving me the opportunity to talk at this forum and also pay my respects and acknowledge the traditional owners of this land. thank you. a lot of my talk, especially the first part, has already been covered by previous speakers, so i apologise for repetition. i have some slides of breasts, quite a few of them, so for those of you who find it

confronting, i'm warning you ahead. i'm sorry about that but it's difficult to talk about breast cancer especially surgery and not show some slides like that. this is a picture of a breast cancer cell, beautiful but deadly. this is the first case of breast cancer and mastectomy in history that i could find. she's actually a persian princess called semiramis.

two and a half thousand years ago, she had a left mastectomy. if you can see, she's got a right breast and flat-chested on that side, and she's using her elaborate hairdo to hide the fact. now, it is the most common cancer in australian women and that's excluding non-melanoma skin cancers which fortunately are not deadly. it accounts for 28% of all new cancers in the women. in 2010, there were over 14,000 new cases in

women, 127 new cases in men. most of these men have family history of breast cancer. they have some genetic disposition and they've got sisters, mothers, cousins, or daughters who've been affected by cancer. average age of breast cancer is just over 60. now, the risk increases with age. it's not confined to any particular age group, but it's commonest in middle life, 50 to 69

years, hence the breast screen emphasis on screening women in those years, but there is still almost 23% of new cancer diagnosis in younger women, younger than 50 and almost 25% in older women. once their screening days are over, it doesn't mean that women are not going to get cancer. in fact, the incidence can increase with age. risk of developing breast cancer in australian women is 1 in 8.

it has increased from 1 in 12 in early 2000. what we've got, in 1982, there were over 5,000 new cases of breast cancers. it has tripled in 2014 although the population of australia hasn't tripled in that period. we expect more and more cancers being diagnosed in women. in fact, it seems that the rates have become stable now and it's 116 in every 100,000 women. the rate for men has increased as well.

in 1982, there were only 61 men who were diagnosed and more recently that had doubled up to 127. fortunately, the mortality has reduced. it is the second leading cause of cancer-related death in australia after lung cancer. it accounts for 15.6% of cancer deaths in women and there were almost 3,000 deaths from breast cancer in women in 2011 and 23 in men. the mortality has reduced over the years from 30%

to 21.9 which is much, much better. in 2008, the mortality rate in australia was better than many countries in the world including the northern and western europe, central and eastern europe, and new zealand and south africa. survival has improved with better treatment and maybe earlier detection with screening. in 1982 to 1987, over the 5-year period, the survival was 72% for all stages of breast cancer.

it's now almost 90%. also relative to the size of the cancer, of course the smaller the cancer, the better the survival although that's not always the case, but in most cases it is so. it's as good as almost 100% if you've a got a, sorry, if you've got a small cancer up to a centimetre, but it gets much less with a three centimetre or greater cancer. the survival for men is worse than the women.

that's the figure for the women, that's the figure for men. maybe later detection or maybe less compliance with treatment or maybe we're not treating them as well as we should. now, this is from western australian health department, the figures unfortunately are not all that accurate. these are the to the best of their knowledge that in 2003 there were eight cases of breast cancer diagnosed in aboriginal women in australia. remember, the aboriginal population in western

australia is 3.8% and if we've got a population of 2 million in this state, there's probably 76,000 people. in 2003, there were only eight cases and that has increased over the years. in 2012, it's 21. in total, about 17 to 18 cases per year. i apologise for this busy slide. it's from cancer registry and these are the figures at our hospital. we diagnosed few cases of cancer in aboriginal people.

the ab is aboriginal population, female. nk, ethnicity is not known. ot is others. over the years, those who are alive of breast cancer, the numbers have increased and the mortality has reduced, which is good to know. now, breastscreen, this is personal communication from breastscreen wa. they reckon that the participation is lower on average than the non-aboriginal population.

it hasn't changed all that much over the last few years and although they don't have any good figures on detection rates for aboriginal cancers, but they think it's lower than the rates for non-aboriginal population. they can screen around 2,000 over a two-year period and the normal detection rate for all ages with cancer at breastscreen wa is 60 cancers per 10,000 screens, so hopefully that's not a big

number for aboriginal population. this is from australian institute of health and welfare, a government organisation. they reckon that indigenous women who are diagnosed with breast cancer, they have 100% higher risk of dying from any cause, not just the breast cancer but any cause than the non-indigenous women and poorer prognosis could be due to lower participation.

but frankly, i think a lot of it is also due to tyranny of distance especially in our state or places like here in queensland where the remote communities have to travel six hours to get to somewhere like port hedland where there is hardly any services for breast cancer detection or treatment. from there, they have to fly to perth, which another few hours of flight. once they have the diagnosis, the treatment means

several months or if not a year of staying somewhere 2,000 miles away from their family. so compliance is not always great. this is just a comparison between lung and breast cancer. professor louis is following me and his job is much harder than mine in that you can see the lung cancer much more common indigenous australians than non-indigenous whereas breast cancer is still less common in indigenous

although it's probably catching up. the mortality unfortunately is higher. my personal experience is, it's also in younger women which will mean that it's got a much more impact on community and the family life. the survival is less for indigenous population than it is for non-indigenous population. now this, just to refresh your anatomy, breast is sitting on the chest wall on pectoralis muscles.

it's surrounded by these lymph nodes which drain the breast and also the chest wall and the arm. a cross-section of breast basically made of breast tissue, globules which make the milk, ducts which convey the milk to the nipple, the skin envelope, the fascia, and a lot of fat and also sitting on the muscle. now, a breast lump thankfully is not always a cancer, but you have to prove that is not cancer.

now there are many benign lesions in the breast. the younger women have more benign lesions although you can diagnose cancer at any age and the youngest patient we've had at our centre was 19 years old. with the benign lesions, there are fibroadenomas, juvenile giant fibroadenomas which can be up to like 10 centimetres or so in an 8 or 9 year old child, and so it's important to remember.

things like papilloma and radial scar, although mostly benign, a small proportion are associated with in situ or invasive cancer so our policy has been to remove all these lesions once they're diagnosed as papilloma or radial scar. galactocele which is a milk cyst, which unfortunately is a common diagnosis in women who have a lump post-partum or during pregnancy. i've had a patient who is 29 years old when she

presented with 6 months of a breast lump which had grown and grown and grown till the affected breast was twice the size of the other breast and she had attended 6 gps and they had all patted her on the back and said, "oh, you've got a milk cyst. don't you worry." in the end, she brought herself to the emergency department at our hospital and said, "for god's sake, somebody look at me. i know this is not a milk cyst.

i know there's something wrong with my breast." so, as much as i ... to be honest, i don't see many galactoceles. maybe the midwives deal with them and they never come to our attention. but it's important to take every lump seriously, even around pregnancy, before or after birth. haematoma is a sort of collection of benign tissues in the breast that you don't need to either remove them, but it's important to make a

diagnosis like lipoma which is the fatty lump. you've got phyllodes tumour which is stromal tumours like fibroadenomas are, but they've got the potential to become malignant so even the benign ones need to be removed with a good margin of normal tissue. now, with the malignant lesions, they're either from the primary, from the tissues in the breast or they are secondary from elsewhere.

most commonly, we see melanomas and lymphomas. with the primary ones, it could be in situ cancer or invasive cancer arising from the ducts or the lobules or it could be a malignant phyllodes or liposarcomas and angiosarcomas which can be caused by radiation to the chest wall. younger women with lymphoma who might need chest radiotherapy, they are at increased risk of developing breast cancer, but also angiosarcomas.

now the common types of breast cancer as we said, in situ, dcis and lcis, and invasive, ductal carcinoma, ilc, invasive lobular carcinoma, and phyllodes. with dcis, if you cut a duct and look at the transection of it, you can see it's lined with normal epithelium. professor thompson showed a similar slide than this. if the cells start multiplying on the influences such as normal hormonal influences during the cycle or hrt, etcetera, you get hyperplasia.

once the cells are much faster in their multiplication and also become disorganised, you can see abnormal cells. we call them atypical ductal hyperplasia. now, if you do a biopsy in the breast and you find this condition, the patient is 3 to 4 times more likely to develop breast cancer in the future. these are things that need to be taken seriously and they need yearly screening, mammogram.

with the ductal carcinoma in situ, the cells have gone a bit fair that they become cancerous but for as long as they stay within the duct, then this in situ cancer. once they spill out of the basement membrane of the duct into the periphery, then it becomes invasive cancer. this is another picture showing of invasive cancer. one thing to remember, the difference between ductal cancer and invasive cancer, the ductal cancer and lobular cancer is that the ductal

cancer cells like each other, they hang together. even small ductal cancer is palpable by the woman or by the gp or health worker and it's also easier to see on imaging like a mammogram ultrasound. in contrast, the lobular cancer cells, they don't like each other that much. they go for walkabout in single files. it makes it a lot more difficult to find them because you need a huge number of cancer cells to

see the abnormality. quite often, people complain of a bit of a reach or a bit of dimpling of the skin, a bit of abnormality, no more than that. now, the diagnosis has to be by triple test. this is quite important that we have to adhere to all 3 parts of the test. history and clinical examination which is done by the gp or the breast physician or the breast surgeon, and imaging and also tissue diagnosis.

the imaging being mammogram ultrasound, mri, and now we're also experimenting with things like tomosynthesis. tissue diagnosis is either cytology with a fine-needle aspiration or histology with core biopsy. this is what i was talking about that a bit of dimpling especially when the arm is raised, a bit of abnormality, nothing too great. maybe a bit of a vague thickening which might take quite a while for a person to notice.

this is a picture of a large cancer that anybody could see. hopefully, less and less patient will come to you or me with something this obvious. this is an inflammatory cancer. quite often, we see women who come with a sore red or purple breast which has come up overnight almost and they've been treated by several courses of antibiotics without any response and people assuming all the time that they've got an infection.

mastitis in non-lactating women is not all that common. in fact, it's rare. unless people are smokers and they can get little abscesses and fistulas around the nipple areola, what we call periductal mastitis, but a picture like this with a breast going all purple and large in volume is unusual and should be taken seriously. you have to exclude breast cancer and then if you excluded that, maybe you can start thinking about infection and treating infection.

these are the other cases of inflammatory cancer. you can see on this side the breast is red, inflamed looking, larger. the same on this side, the breast is much larger and when you pinch the skin, you get that orange skin with a ruched look with dimpling. the mammogram is not really helpful. it just looks like whiteout. quite often, even on ultrasound, you can't see

anything and then you do just the random biopsy and you find that there is wide-spread cancer. they definitely need a full triple test to exclude breast cancer if you see an inflamed breast. now, imaging examples. this is a symmetry. there is opacity there which is not on the other side and that's a cancer. the same thing on an ultrasound, the lesion is taller than wider. it's hypoechoic.

it's darker than the rest of the breast tissue. it breaks up the normal lines of the breast tissue and it's got posterior shadowing. that's all the whole marks of a cancer on ultrasound. this is an mri picture of the breast cancer. another mri picture of breast cancer. now when a person's diagnosed with breast cancer, then if they come to a teaching hospital like ours, they're usually looked after by a large

team of people who are involved in the management, what we call a multidisciplinary care. in our breast centre, we've got breast care nurses, we've got precision nurses who help the radiologist, we've got breast physicians, surgeons, radiologists, radiographers, pathologists, pathology technicians, physiotherapists, psychologists, and admin staff all under the same roof.

at our weekly multidisciplinary meeting, we have the additional radiation and medical oncologists. we've got rural nurse coordinator, social workers, genetic services, experts, menopause clinicians, cancer registry personnel and also research people. now what are the treatment options? i put these things up; surgery, chemotherapy, radiotherapy, hormone treatment, targeted

therapy, but it's not necessarily in that order. for example, if you are dealing with inflammatory cancer, then you have to start with chemotherapy. if you had a very large, locally advanced cancer, you start with chemotherapy. so most cancers, you can start with surgery, if they're operable, and then depending on their pathology on the size, whether the lymph nodes are involved or not, patient might need chemotherapy.

most often, if you've done just the lumpectomy, what we call wide excision, then you need to complement that with radiotherapy to make the breast safe. the other thing is, about two-thirds of the women need hormone treatment and we are finding that as in the old days, we were giving just 5 years of hormone treatment, we're realising that actually, 10 years is even better and improves the survival. then there are targeted therapies like herceptin

which in those who have her2 positive tumours can also improve survival and reduce recurrence. with the surgical options, it's wide local excision which taking their tumour with a good margin of normal tissue down to the chest wall and mastectomy in cases where the cancer is quite wide spread or large in relation to the size of the breast. quite often, we do more mastectomies for in situ cancer than we do for invasive cancer, which

ironical but that's just basically how it is especially with dcis, it could be quite widespread in the breast and quite a few younger women have to have mastectomy. central node biopsy is just sampling the 1 or 2 lymph nodes in the armpit or on the sternum. axillary clearance is removing more of the regional lymph nodes. with older patients that we treat especially the

ones who've had mastectomy, they can be offered either immediate or delayed reconstruction depending how suitable they are. reconstruction is not all that suitable for people who are very overweight or they're smokers. once they reduce weight or give up smoking, almost anybody could benefit from these operations. am i going over? ok. we'll go over this. this is us finding central lymph nodes with using

either blue dye or using a radioactive protein and the scan afterwards. this is a tumour in transection. it's white, rubbery and if you can see, it's got sort of these tentacles going outside. it looks like a star or starlet. chemotherapy in cases where it's needed and radiotherapy which has become a lot more sophisticated. they do planning scans and they can just point it to their breast rather than on the lung or heart.

hormonal treatment and many different forms of reconstruction, this is just using a tissue expander and then an implant, and delayed reconstruction pictures using latissimus dorsi. what we do mostly in our hospital is using deep inferior epigastric vessels bringing a fat and skin from the tummy to the breast area. this is preoperative and postoperative. the good thing is people get a flat tummy out of

it and a very realistic looking breast compared to an implant. that's some post tran pictures. i'll just leave you with a picture of the breast cancer cell again. thank you. so that you can see firsthand how breast cancer diagnosis can affect your emotions and your whole life. annette, i've known you since 2010 when you first presented with your breast cancer. tell us how you first found out about it? hello everyone.

firstly, i'd like to acknowledge the local people, traditional custodians of this land on which we meet today. sorry. how were you diagnosed? my husband actually found the lump and i think i hear that a lot of the husbands do find the lumps. i just sort of went ahead and had it followed up. i went to the doctors, had the ultrasounds and there it was. that's right. when you found out you had cancer, how did you

feel about it? there's a lot of mixed emotions. obviously it's terror and you don't know if you're going to die within the next couple of months or ... it's just mixed emotions everywhere. but the doctor who actually spoke to me on the day said that there was good news and bad news, so i was kind of wondering what was the good news because there just couldn't be any good news. but the good news was i've got it early.

i think the other good news about breast cancer is that there's so many treatment options available. if we were to choose a cancer, i guess i would go for breast rather than pancreas or lung or others. so good news and bad news. what treatments did you receive? i had a lumpectomy and followed by 7 weeks of radiotherapy treatment which i had to stay in perth. at the time, i was living in collie which is a couple of hours from perth, so going up to perth

wasn't a problem for me. the cancer council in wa, they have places where we can stay and my daughter stayed with me for the 7 weeks, so that was good. it's coming up to 5 years when you would be discharged from our breast centre at charlie's back to your gp with the yearly mammograms. how do you feel about that? probably a little bit worried because i'm going

to like not get that confirmation of having the checks up in perth because i'm obviously, still going back to charlie gardner's and having the mammograms and seeing roshi, so it's going to be a little bit weird going back to my gp in the country. we'll see how we go, but i think it'll be a good thing. how has this diagnosis and treatment impacted your family? the impact it had on my family was, i have a daughter so she's quite anxious about it.

i had a sister ... i have a sister. sorry, i don't mean to say had. she just turned 74. she got hers at the age of 50, so she's having a good old life at the moment. i'm hoping i can do the same. just my daughter probably who's a little bit worried. she's 32 so hoping that she doesn't have to do what i had to do, but she's assured me that she knows exactly what to do having followed the whole journey with me. that's lovely. thank you very much for coming today and sharing

your story. thank you. thank you.