Men need imaging for breast cancer evaluation

Since clinical examination isn't sensitive enough to detect male breast cancer, men need to receive imaging tests for evaluation of suspected breast disease, according to researchers from Cambridge University Hospital in Cambridge, U.K.

From a 10-year retrospective review, the study team found mammography and ultrasound yielded significantly higher sensitivity than clinical examination.

"With the poor sensitivity rates that we found, we felt that all three modalities still have a role to play in examination, and were needed to ensure that we have the highest accuracy for diagnosis that we can manage," said Dr. Victoria Ames. "The poor sensitivity of the clinical examination meant that we needed to continue imaging [male breast disease]."

Ames presented the findings during a scientific session at the 2011 ECR, held earlier this month in Vienna.

First described in the 15th century, male breast cancer has more recently been the subject of media campaigns, including one involving popular 1970s movie "Shaft" actor Richard Roundtree, Ames said.

"Unfortunately, though, despite media campaigns like this, male breast disease has remained relatively untalked about," she said.

Male breast cancer constitutes about 0.5% to 1% of all breast cancers and probably about 1% of all male cancers, Ames said.

In examining male breast disease, the main thrust is to attempt to distinguish between the two mainstays of breast pathology in men: male breast cancer and gynecomastia. But significant overlap between these two pathologies can make this diagnosis a challenging task, Ames said.

At Cambridge University Hospital, current practice involves documenting full clinical history and examination of all male patients suspected of breast disease. Based on those findings, the patients would then go on to receive mammography and/or ultrasound, she said.

Mammography for men follows the same protocol as for women, with full-field digital mammograms and bilateral, mediolateral-oblique, and craniocaudal views, she said.

Concerned that male patients in their unit were being overimaged, the researchers wanted to quantitatively assess the individual components of male breast cancer examination. They retrospectively reviewed data on all male patients between January 2001 and December 2010, representing a patient population of 1,447 men.

Patients had a mean age of 49.3 years, with a range of 11-94. The researchers excluded 161 patients due to referral for axillary node biopsy only, nipple discharge as the only symptom, known breast cancer, or metastases.

All patients receive a score of 1 to 5 based on their clinical evaluation, mammography, and ultrasound exams. For the purposes of the study, scores 1 through 3 were considered negative, while 4 and 5 were classified as positive.

Of the 1,286 patients included in the final study, 98% had a documented clinical examination, 53% had a mammography study, and 32% had received an ultrasound exam.

"We wanted to know if we could actually decrease the number of patients who had mammography and ultrasound," she said.

Of the 1,286 patients, 22 (1.7%) were diagnosed with invasive breast carcinoma. In addition, there was one high-grade ductal carcinoma in situ (DCIS), one encapsulated papillary carcinoma with low-grade DCIS and two invasive foci, and one intracystic papillary carcinoma.

Performance for evaluating male breast cancer   Clinical exam Mammography Ultrasound Sensitivity 68.2% 80% 91.7% Specificity 99.5% 99.9% 99.2% PPV 71.4% 94.1% 88% NPV 99.4% 99.5% 99.5%

PPV = positive predictive value; NPV = negative predictive value

"While all three methods of examination were highly specific with good negative predictive value, we found, however, that we were not so good at being able to decide whether something was abnormal," she said. "So our sensitivity was a little lower than we expected."

Therefore, all three modalities are needed to ensure optimum diagnostic accuracy, she said.

Ames also added a cautionary note to beware of nipple discharge in these patients.

The researchers excluded nine patients who had nipple discharge as their only symptom since imaging usually didn't help in those cases, Ames said. However, two (22%) of these patients were subsequently diagnosed with breast cancer.