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Increased awareness, expanded trial access ‘could save lives’ of men with breast cancer
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Like most men, Oliver Bogler, PhD, never worried about his risk for breast cancer.
Even when Bogler — a cancer biologist — felt a lump in his right breast in 2012, he did not feel alarmed.
“My wife is a breast cancer survivor, and the probability of us both having the same disease struck me as highly unlikely,” Bogler, senior vice president of academic affairs and professor in the department of neurosurgery at The University of Texas MD Anderson Cancer Center, told HemOnc Today. “I kept telling myself this, but after keeping an eye on it for a few months, I decided to have it checked.”
The diagnosis — stage III breast cancer — stunned him.
“I was not overly emotional or distressed,” Bogler said. “I was more shocked. Actually, I still may not be over the shock.”
Nearly 4 years after his diagnosis, Bogler is now cancer free. However, he continues to take tamoxifen to reduce his recurrence risk, and his posttreatment surveillance includes annual mammograms and twice-yearly clinical breast exams.
He created a blog — Entering a World of Pink, accessible at malebreastcancerblog.org — through which he raises awareness of male breast cancer and shares scientific data that offer insights into disease biology. In April, he spoke at the American Society of Breast Surgeons Annual Meeting about the need to expand clinical trial access for men with breast cancer.
“I am a small voice in the wilderness, to some extent,” Bogler said. “It is naive to expect things to change quickly. However, I remain optimistic and hopeful that things will change.”
HemOnc Today spoke with Bogler about the treatment he received, his long-term prognosis, and what he thinks needs to happen to improve outcomes among men with breast cancer.
Question: Did you feel your health care team was adequately prepared to treat a man with breast cancer?
Answer: I am lucky because I work — and underwent treatment — at The University of Texas MD Anderson Cancer Center. My oncologist, Sharon H. Giordano, MD, MPH, is an expert on male breast cancer, and the other members of my health care team had treated men with breast cancer, so I definitely felt they were adequately prepared. However, I have learned a lot of men are treated by care teams that are not as familiar with male breast cancer.
Q: Can you describe the treatment you received?
A: My wife and I both had invasive ductal carcinomas, and we both had hormone receptor-positive disease, so my treatment was similar to what she received. I underwent neoadjuvant chemotherapy, which is standard at my institution for this disease type. I had 11 cycles of paclitaxel instead of 12; ultrasound showed the tumor was not responding, so we dropped the last cycle. I received four cycles of fluorouracil, doxorubicin and ifosfamide. I had a month off treatment, then underwent modified radical mastectomy. After this, I had 6 weeks of radiation therapy. I have taken tamoxifen since early 2013.
Q: Did you feel the treatment regimen you received was tailored to you in any way given your sex?
A: My treatment was not at all tailored. There were only two subtle differences between my treatment and what my wife received: She was treated with aromatase inhibitors, which are not available to men because of a lack of data, and she had breast reconstruction surgery. The treatment I received was very effective, but it was not personalized. Given that it is a hormone-driven cancer, I cannot help but think there must be some differences between men and women.
Q: which clinical trials did you participate in?
A: I participated in one major therapeutic trial assessing immunotherapy to prevent cancer recurrence. Patients received either placebo or a peptide vaccine designed to help the immune system keep an eye on the breast cancer cells, and it was conducted after active therapy to prevent recurrence. I do not know yet if I received the peptide or placebo. I have given tissue samples to other tissue registry trials. I am a part of another observational trial where I am just being followed. I also have chemotherapy-induced peripheral neuropathy in my feet, and I have participated in two trials for that.
Q: Was trial access difficult?
A: Options for trial access are limited. I was lucky enough to be treated at a large academic center where a lot of trials are available, but men are only eligible for about one of every three breast cancer trials. I ask colleagues in the medical community to carefully consider whether men should be included and, if not, perhaps they should justify this from an ethical point of view just as they would justify including or excluding any other group. Sometimes men are excluded for good reasons. In other cases, the exclusion criteria do not make sense. Sometimes it seems researchers are simply following the template used in a previous trial. It really is a question of equal opportunity.
Q: Were you offered breast-conserving surgery?
A: No. My understanding is men are not offered breast-conserving surgery because we have relatively little breast tissue. Our cancers are found later so, typically, it does not make sense to do this. I was offered nipple reconstruction by one of our surgeons, but I did not do this because I wanted to keep things simple. Even if I had been offered breast-conserving surgery, I would not have opted for it because I was approaching things in a way of trying to do everything we could to fight the cancer.
Q: Prophylactic contralateral mastectomies are increasing among men. What do you think about this trend?
A: This is a very personal decision. If you have a genetic predisposition — such as a BRCA mutation, for example — it is a reasonable choice for a man. I do not have a BRCA mutation, so my doctor told me that — although the left breast is the most likely site for a future cancer — the odds are still not hugely high.
Q: You are cancer free now, but what have you been told about the possibility of recurrence?
A: This is the question that is foremost in my mind. I was 46 years old when I was diagnosed, whereas the average man diagnosed with breast cancer is in his early 70s.
The Kaplan-Meier curves show 5-year survival of 70% to 80% for people with stage III cancer. Given that I am younger and healthier than most men with breast cancer, I feel very confident I will probably be disease free for at least 10 years. That would put me in my mid- to late 50s.
There is a very good chance the cancer will come back. I have gotten to know a woman via social media who was disease free for 15 years. Her cancer came back metastatic and she just went into hospice. I sometimes wonder whether I should stop saving for retirement because I am not sure I am going to get to use it. It is the reality: I am a cancer biologist, so I think about this. I may live disease free for 30 years, but who knows?
I remain somewhat optimistic, because there are new immunotherapies being developed every day, but I do not feel as though breast cancer is something I have ‘been through’ and will never have to deal with again.
Q: Can you describe your advocacy work?
A: The most impactful thing I have done is connect with photographer David Jay on The Scar Project, a photography series designed to raise awareness that breast cancer can affect young women. He was kind enough to include men. My photo actually appeared in The New York Times in 2014. Most of my advocacy now focuses on talking about access to clinical trials and the lack of basic research in this area.
Q: Why is it important for you to promote awareness of male breast cancer, and what do you hope to accomplish?
A: There will never be mammography for all men because the risk is so low. Hopefully one day there will be a blood test that will be able to find many types of cancer. At the moment, though, the best weapon for men against dying of breast cancer is awareness of their bodies and having the knowledge that this can happen to them.
Q: Where is additional research most needed?
A: There has been some fantastic research into the biology of breast cancer, and it has led to some therapeutic discoveries. We have tamoxifen — which I am grateful to be on — because people learned that the estrogen hormone pathway was key to driving some types of breast cancer. We have trastuzumab (Herceptin, Genentech) because HER-2 was identified as an important androgen in some types of breast cancer. This work is all based upon many decades of research done by many gifted scientists. I am not asking for them to stop working on the disease in women, but men comprise 1% of the breast cancer patient population. The NCI spends about $600 million per year on breast cancer research, so maybe 1% — or $6 million — of this his can be earmarked for grants that specifically address men from the biological point of view.
Q: Have you learned anything that could be particularly beneficial for our clinician readership?
A: Although many specialists are aware of male breast cancer, it surprised me that there is not this level of awareness in the primary care community. I would encourage specialists to help transmit this knowledge to the physicians who refer patients to them. Increasing the awareness within the medical community could save a lot of lives. – by Jennifer Southall
For more information:
Oliver Bogler, PhD, can be reached at The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, Texas 77030; email: obogler@mdanderson.org.
Disclosure: Bogler reports no relevant financial disclosures.