Hot flashes

Hot flash management has been well studied in female breast cancer survivors, but further study is needed in men. Lifestyle modifications such as sleeping in a cool room and dressing in layers may be beneficial, as may medications such as venlafaxine or citalopram.70–73 Because ~60%–80% of men with prostate cancer on androgen-deprivation therapy experience hot flashes, the literature on management of hot flashes in prostate cancer may inform recommendations for men with breast cancer.74,75 Multiple studies have evaluated venlafaxine, medroxyprogesterone acetate, diethylstilbestrol, and cyproterone acetate in men with prostate cancer, with the most promising results in favor of the hormonal agents (which may decrease the number of hot flashes by 75% or more).76–82 However, because of concerns about the safety of exogenous hormone use in patients with hormonally sensitive tumors, these agents have not been used frequently in male breast cancer survivors.

Acupuncture also appears promising for management of hot flashes in men. Frisk et al assessed the effect of traditional acupuncture versus electrostimulated acupuncture in 29 Swedish men on androgen deprivation for prostate cancer. Both forms of acupuncture significantly decreased the number of hot flashes, distress from hot flashes, and hot flash score (electrostimulated acupuncture 78% and traditional acupuncture 73%) in this population.83 A larger study intervened with self-acupuncture in 196 men and women (most of whom had prostate or breast cancer) who were experiencing at least 16 hot flashes daily. With self-acupuncture, 79% of patients experienced at least a 50% reduction in hot flashes over a mean duration of treatment of 9 months (range: 1 month–6 years).84 Therefore, although unstudied, acupuncture may be a useful adjunct in the management of hot flashes in men on endocrine therapy for breast cancer.


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Sexual dysfunction

Sexual dysfunction is a significant concern for many male breast cancer survivors.85 In a web-based survey, 40% of 42 respondents, with median age 64 years and median time since diagnosis approximately 2 years, self-reported their sexual functioning over the prior month as very poor on the Expanded Prostate Cancer Index Composite Sexual Scale. Ten percent of these respondents had Stage 4 disease, 62% had received chemotherapy, and 59% were on some form of endocrine therapy. Mean Expanded Prostate Cancer Index Composite Sexual Scale scores did not differ significantly between men on or off hormonal therapy, surprisingly.85 In addition to the physiological sexual dysfunction that men can experience secondary to their breast cancer treatment, they may also experience significant psychological trauma from their body changes, including loss of breast tissue, testicular changes, and secondary sexual changes that result from the use of hormonal treatments.

Thus, more attention to impotence, poor libido, and other aspects of sexual functioning may be of value to many male breast cancer survivors. This is consistent with the NCCN Survivorship Guidelines, which recommend an open dialog regarding sexual functioning between health care providers and cancer survivors of all types at regular intervals. These guidelines suggest the use of the Sexual Health Inventory for Men, a previously validated five-question survey, in the initial evaluation for erectile dysfunction.86 Depending on the severity of the sexual dysfunction, men may try lifestyle modifications, including weight loss, smoking cessation, and decreased alcohol consumption, and/or they may benefit from sexual counseling or phosphodiesterase type 5 inhibitors. Reconstructive surgeries may also be helpful to those who have body image concerns.

Emotional distress

Because breast cancer is so much more common in women, the emotional burden of this disease may be particularly striking in men. Some men feel embarrassed to have a woman’s cancer, and it may be difficult for them to find other male survivors with whom to connect for support. Kipling et al recently published on the psychological impact of breast disorders among males in the UK. Seventy-eight men undergoing workup at a breast clinic in Durham, UK, were surveyed over an 18-month period to assess their feelings about their diagnoses. Almost 30% of men reported feeling embarrassed to see their doctor and one-fourth reported anxiety related to their diagnosis.87

Male breast cancer survivors who are experiencing distress or feeling emasculated may benefit from contact with social workers, psychologists, and male breast cancer support groups. Farrell et al reported on the success of a pilot study evaluating telephone support groups in men with breast cancer.88 Eleven men were recruited using flyers in a breast oncology clinic, targeted mailings, and direct referral from their oncologists. A social worker facilitated monthly phone calls for this group, but the topics of discussion were participant driven. Over a course of 6 months, the men discussed sexuality/loss of libido, side effects of treatment, the isolation they felt, how to raise awareness of male breast cancer in their communities, and their frustration regarding the lack of resources for male breast cancer survivors. In response, the social worker engaged a sexual health expert and a medical oncologist to address some of these issues over the phone. Of note, there was no attrition over the course of the support group. On a survey 6 months after the last call, completed by approximately three-fourth of participants, 75% of the respondents reported that the group allowed them to gain access to new information, connect to others in a similar situation, find mutual support, and feel less alone. Ninety percent of respondents said that they would recommend participation in this type of support group to other men with breast cancer and that it met or exceeded their expectations.88 This small pilot study demonstrated that health care providers involved in the care of men with breast cancer can employ creative means to address the psychological, emotional, and sexual sequelae of this rare diagnosis.

Cardiotoxicity

Cardiac outcomes in male breast cancer survivors are also understudied, but the NCCN survivorship guidelines provide guidance for evaluation and management of the heart after cancer.89 Because many men and women with breast cancer are treated with anthracycline and/or HER2-directed therapies, both of which can damage the heart, and because those with at least one heart failure risk factor (hypertension, dyslipidemia, diabetes mellitus, family history of cardiomyopathy, age over 65 years, smoking, alcoholism, obesity, or known cardiovascular comorbidities, including atrial fibrillation, structural heart disease, or coronary artery disease) are at increased risk for progressive heart failure after receipt of anthracyclines, certain male breast cancer survivors may benefit from aggressive cardiovascular risk management with the help of a primary care provider and/or a cardiologist. Preliminary research suggests that if anthracycline-related cardiomyopathy is caught early, cardioprotective medications might help optimize long-term cardiac outcomes.90 Selected survivors with other cardiovascular risk factors may benefit from consideration of a post-anthracycline echocardiogram.89