Treatment of Breast Cancer in Men, by Stage

This information is based on AJCC Staging systems prior to 2018 which were primarily based on tumor size and lymph node status. Since the updated staging system for breast cancer now also includes the ER, PR and HER2 status, the stages may be higher or lower than previous staging systems. Whether or not treatment strategies will change with this new staging system are yet to be determined. You should discuss your stage and treatment options with your physician. 

Because there have been few clinical trials on treatment of male breast cancer, most doctors base their treatment recommendations on their experience with the disease and on the results of studies of breast cancer in women. With some minor variations, breast cancer in men is treated the same way as breast cancer in women.

The stage (extent) of your breast cancer is an important factor in making decisions about your treatment options. In general, the more the breast cancer has spread, the more treatment you will likely need. But other factors can also be important, such as:

• If the cancer cells contain hormone receptors (that is, if the cancer is ER-positive or PR-positive)
• If the cancer cells have large amounts of the HER2 protein (that is, if the cancer is HER2-positive)
• Your overall health and personal preferences
• How fast the cancer is growing (measured by grade or other measures)

Talk with your doctor about how these factors can affect your treatment options.

Stage 0 (ductal carcinoma in situ)

Stage 0 cancer means that the cancer is limited to the inside of the milk duct and is a non-invasive cancer. Stage 0 breast tumors include ductal carcinoma in situ (DCIS).

It is treated with surgery to remove the cancer. Most often in males, a mastectomy is done. If breast-conserving surgery is done, it is followed by radiation therapy to the remaining breast tissue.

Sometimes DCIS can contain an area of invasive cancer. The chance that an area of DCIS contains invasive cancer goes up with tumor size and how fast the cancer is growing. If there is concern of invasive cancer, the lymph nodes under the arm may be checked for spread, most often with a sentinel lymph node biopsy. If cancer cells are found in the sentinel lymph node, it means the tumor must contain some invasive cancer, and the man will be treated based on his invasive cancer stage.

Stage I

These cancers are still relatively small and either have not spread to the lymph nodes (N0) or there is a tiny area of cancer spread in the sentinel lymph node (N1mi).

The main treatment for stage I breast cancer is to remove it with surgery. This is usually done by mastectomy, but breast-conserving surgery (BCS) might occasionally be an option. If breast-conserving surgery is done, it is usually followed by radiation therapy.

The lymph nodes under the arm will be checked for cancer spread, either with an axillary lymph node dissection (ALND) or sentinel node biopsy (SLNB). If the sentinel lymph node contains cancer, a full ALND may be needed, depending on the size of the cancer in the lymph node as well as what other treatment is planned.

Hormone therapy, chemotherapy (chemo) and/or targeted therapy may be recommended as adjuvant (after surgery) therapy, based on the tumor size and results of lab tests. Hormone therapy with tamoxifen is usually recommended for hormone receptor-positive tumors. Adjuvant chemo is commonly used for tumors larger than 1 cm (about 1/2 inch) across and some smaller tumors that may be more likely to spread (based on features such as grade or a high growth rate). Men with HER2-positive tumors may also receive targeted therapy with trastuzumab (Herceptin).

Stage II

These cancers tend to be larger than stage I cancers and/or have spread to a few nearby lymph nodes.

Systemic (drug) therapy is often recommended for men with stage II breast cancer. Some systemic therapies are given before surgery (neoadjuvant therapy), and others are given after surgery (adjuvant therapy). Neoadjuvant treatments may be an option for men with large tumors, because they can shrink the tumor before surgery, possibly enough to make breast-conserving surgery (BCS) an option. The lymph nodes under the arm will be checked for cancer spread, either with an axillary lymph node dissection (ALND) or sentinel lymph node biopsy. If the sentinel lymph node contains cancer, a full ALND may be needed, depending on the size of the cancer in the lymph node as well as what other treatment is planned.

Radiation therapy may be given after surgery if the tumor is large or if it is found to have spread to several lymph nodes. Radiation therapy lowers the risk of the cancer coming back (recurrence).

The drugs used will depend on the man’s age and the tumor’s hormone-receptor status and HER2 status. They may include:

Chemotherapy: Chemo can be given before or after surgery.

HER2 targeted drugs: If the cancer is HER2-positive, HER2 targeted drugs are started along with chemo. Both trastuzumab (Herceptin) and pertuzumab (Perjeta) may be used as a part of neoadjuvant treatment. Then trastuzumab is continued after surgery for a total of one year of treatment.

Hormone therapy: If the cancer is hormone receptor-positive, hormone therapy with tamoxifen is typically used for 5 years after surgery. 

Stage III

This stage includes more advanced tumors (large or growing into nearby skin or muscle) and cancers with spread to many nearby lymph nodes.

Most often, these cancers are treated with chemo before surgery (neoadjuvant chemo). For HER2-positive tumors, the targeted drug trastuzumab is given as well, sometimes along with pertuzumab. This is usually followed by a mastectomy. Most men with this stage need a full axillary lymph node dissection (ALND). Often, radiation therapy is recommended after surgery. Adjuvant hormone therapy with tamoxifen is given for at least 5 years if the tumor is hormone receptor-positive. Men with HER2-positive cancers will probably also receive trastuzumab to complete one year of treatment. Adjuvant hormone therapy can typically be taken at the same time as trastuzumab. 

Another option for stage III cancers is to treat with surgery first. This usually means a mastectomy with an ALND. Surgery is usually followed by adjuvant chemo. Trastuzumab is given with chemo if the tumor is HER2 positive, and then it is continued to complete one year of treatment. Radiation is recommended after surgery and chemo. Adjuvant hormone therapy is given to men with hormone receptor-positive breast cancers for at least 5 years.

Stage IV (metastatic)

Stage IV cancers have spread beyond the breast and nearby lymph nodes to other parts of the body. Breast cancer most commonly spreads to the bones, liver, and lungs. As the cancer progresses, it may spread to the brain, but it can affect any organ and tissue.

Systemic (drug) therapy is the main treatment for stage IV breast cancer in men. Depending on many factors, this may be hormone therapy, chemo, targeted therapy, immunotherapy, or some combination of these treatments. 

Radiation therapy and/or surgery may also be used in certain situations, such as:

• When the breast tumor is causing an open wound in the breast (or chest)
• To treat a small number of metastases in a certain area, such as the brain
• To help prevent bone fractures
• When an area of cancer spread is pressing on the spinal cord
• To treat a blood vessel blockage in the liver
• To relieve pain or other symptoms

If your doctor recommends such local treatments, it is important that you understand their goal, whether it is to try to cure the cancer or to prevent or treat symptoms.

In some cases, regional chemo (where drugs are delivered directly into a certain area, such as the fluid around the brain or into the liver) may be useful as well.

Treatment to relieve symptoms depends on where the cancer has spread. For example, pain from bone metastases may be treated with external beam radiation therapy and/or bisphosphonates or denosumab (Xgeva). For more information, see Bone Metastases.

Advanced triple-negative breast cancer (TNBC) that makes the PD-L1 protein may be treated first with the immunotherapy drug atezolizumab along with albumin-bound paclitaxel (Abraxane). Another option might be treatment with the immunotherapy drug pembrolizumab (Keytruda) along with chemotherapy. The PD-L1 protein is found in about 1 out of 5 TNBCs.

Advanced cancer that progresses during treatment

Treatment for advanced breast cancer can often shrink or slow the growth of the cancer (sometimes for many years), but after a time it may stop working. Further treatment at this point depends on several factors, including previous treatments, where the cancer is located, and a man's age, general health, and desire to continue getting treatment.

Progression while on hormone therapy: For hormone receptor-positive cancers that were being treated with hormone therapy, switching to another type of hormone therapy is sometimes helpful. Another option might be a hormone drug along with a targeted therapy drug. If this isn't helpful, chemo is usually the next step.

Progression while on chemotherapy: For cancers that are no longer responding to one chemo regimen, trying another may be helpful. Many different drugs and combinations can be used to treat breast cancer. However, each time a cancer progresses during treatment it becomes less likely that further treatment will have an effect.

For breast cancers that are considered HER2-low and have spread to distant sites after trying chemotherapy, the antibody-drug conjugate fam-trastuzumab deruxtecan (Enhertu) might be an option. 

For advanced hormone receptor-positive, HER2-negative breast cancer or for triple-negative breast cancer in which at least 2 other chemo treatments have been tried, the antibody-drug conjugate sacituzumab govitecan (Trodelvy) might be an option.

Progression while getting HER2 drugs: HER2-positive cancers that no longer respond to trastuzumab may respond to other drugs that target the HER2 protein (sometimes along with chemo or hormone therapy drugs). Some options might include:

• Pertuzumab (Perjeta) with chemo and trastuzumab
• Ado-trastuzumab emtansine (Kadcyla)
• Fam-trastuzumab deruxtecan (Enhertu)
• Margetuximab (Margenza) with chemo
• Lapatinib (Tykerb) and the chemo drug capecitabine
• Lapatinib and an aromatase inhibitor (for hormone receptor-positive cancers)
• Neratinib (Nerlynx) and the chemo drug capecitabine (this combination can be helpful for cancers that have spread to the brain)
• Tucatinib (Tukysa), trastuzumab, and the chemo drug capecitabine (this combination can be helpful for cancers that have spread to the brain)

Because current treatments are very unlikely to cure advanced breast cancer, if you are in otherwise good health, you may want to think about taking part in a clinical trial testing newer treatments. You can also read about living with later-stage cancer in Advanced Cancer, Metastatic Cancer, and Bone Metastasis.

Recurrent cancer

For some men, breast cancer may come back after treatment – sometimes years later. This is called a recurrence. Recurrence can be local (in the same breast or in the surgery scar), regional (in nearby lymph nodes), or in a distant area. If cancer is found in the opposite breast but nowhere else in the body, it is not a recurrence—it's a new cancer that requires its own treatment.

Treating local recurrence: This includes cancer coming back in the breast or in the chest wall (near the mastectomy scar). If a patient has a local recurrence and no evidence of distant metastases, it might still be cured. Treatment depends on what other treatments have been given already. The treatment for local recurrence may be additional surgery followed by radiation therapy. If the area has already been treated with radiation, it might not be possible to give more radiation to the area without damaging nearby tissues.

Hormone therapy, chemo, trastuzumab, or some combination of these may be used after surgery and/or radiation therapy.

For people with triple-negative breast cancer  that has come back locally, cannot be removed with surgery, and makes the PD-L1 protein, immunotherapy with the drug pembrolizumab along with chemotherapy might be an option. If at least 2 other drug regimens have already been tried, the antibody-drug conjugate sacituzumab govitecan (Trodelvy) might be an option as well.

Treating regional recurrence: When breast cancer comes back in nearby lymph nodes (such as those under the arm or around the collar bone), it is treated by removing those lymph nodes. This may be followed by radiation treatments aimed at the area.

Systemic treatment (such as hormone therapy, chemo, targeted therapy, or some combination of these) may be used after surgery and/or radiation therapy.

Treating distant recurrence: Men who have a recurrence in places such as the bones, lungs, brain, etc., are often treated the same way as those found to have stage IV breast cancer with spread to these organs when they were first diagnosed (see above). The only difference is that treatment may be affected by the previous treatments a man has had.

Recurrent breast cancer can sometimes be hard to treat. If you are in otherwise good health, you may want to think about taking part in a clinical trial testing a newer treatment.

If your cancer comes back, see Understanding Recurrence for more general information on how to manage and cope with this phase of your treatment.

You can also read about treatments for metastatic cancer in Advanced Cancer, Metastatic Cancer, and Bone Metastasis.