Cancer in men

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Warning signs and treatment options. Skin, prostate and breast cancer

Like so many things, cancer is different for men and women. And while we are living in a time of great promise, with many exciting breakthroughs in cancer research, it is still important to understand the risk factors, warning signs and treatment options for this disease. That is why we are focusing on cancer in men, zeroing in on three types– skin, prostate and breast cancer. We’ve asked three physicians from New York Oncology Hematology, the region’s largest cancer care provider, to share some common questions they hear from male patients and the answers they provide. As always, if you have further questions or are concerned about any changes you’ve noticed in your own body, talk to your doctor. You can also learn more on NYOH’s website: www.newyorkoncology.com

Skin cancer
Sunitha Sukumaran, MD, Medical Oncologist/Hematologist. NYOH/Rexford
Skin cancer is the most common form of cancer today, but it is important to understand the different types, treatment options and risks. While the majority of people diagnosed with melanoma — the most serious form of skin cancer — are white men over age 55, a recent survey by the Skin Cancer Foundation found just 51% of men in the U.S. reported using sunscreen in the last 12 months. That’s why it’s especially important for men to know the facts about skin cancer. Here are some common patient questions:
What are the warning signs of skin cancer?
It is always best to see a physician, who can conduct an exam and biopsy. However, there are some common signs that help determine if skin cancer is melanoma. These are referred to as the “ABCDE Rule” and include:
• Asymmetry: One part of a mole or birthmark doesn’t match the other.
• Border: The edges are irregular, ragged, notched, or blurred.
• Color: The color is not the same all over and may include shades of brown or black, sometimes with patches of pink, red, white or blue.
• Diameter: The spot is larger than ¼ inch across – about the size of a pencil eraser.
• Evolving: The mole is changing in size, shape, or color.
What kind of skin cancer do I have?
The type of skin cancer often determines your course of treatment. There are three major types of skin cancers: basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and melanoma. Basal cell and squamous cell cancer are the two most common types. These skin cancers usually form on the head, face, neck, hands, and arms–areas often exposed to the sun. However, skin cancer can occur anywhere.
Basal cell skin cancer grows slowly, is most common on the face and rarely spreads to other parts of the body. Squamous cell skin cancer is often found in high-exposure areas, but can occur in places with no sun exposure. It may also spread to lymph nodes and organs inside the body.
Melanoma, the most serious type of skin cancer, is increasingly common and can be found anywhere on the body. In the US, the percentage of people with melanoma has more than doubled in the past 30 years. Melanoma can spread quickly, but has a high cure rate when caught early.
What are my treatment options?
Treatment typically depends on the type and stage of skin cancer, as well as your overall health. Four types of treatment used, alone or in combination, include:
• Surgery
• Radiation therapy
• Immunotherapy
• Targeted therapy
You may also be eligible for clinical trials, including those offered at New York Oncology Hematology.  Immunotherapy is currently used for patients with disease that has spread to other parts of the body. It may also be used as an additional treatment, after surgery, to reduce the likelihood of reoccurrence in cases where the melanoma is at high risk of returning. Clinical trials have shown immunotherapy can help reduce this risk.
The most recently approved treatment is called a checkpoint inhibitor. This therapy helps the immune system recognize melanoma is present, stimulating the immune cells to kill the cancer cells.
If I have skin cancer, are my family members at risk?
Certain factors may put you at higher risk for developing skin cancer. Because skin cancer is easier to treat when detected early, it is important to know the risks and conduct regular skin exams. While they vary for different types of skin cancer, general risk factors include:
• Physical traits (fair skin, blue or green eyes, blonde or red hair, etc.)
• Family/personal history of skin cancer
• Excessive exposure to ultraviolet (UV) light, including a history of sunburns and/or a history of indoor tanning
• Skin that quickly reddens, burns, freckles or becomes painful in the sun
• Age (older people have had more exposure)
• Smoking
• Severe or long-term skin inflammation
• Certain types and/or a large number of moles
• Male gender
• Exposure to certain chemicals or radiation • Weakened immune system To learn more, visit: newyorkoncology.com.

Prostate cancer
David R Shaffer, MD, PhD, Medical Oncologist. NYOH
Prostate cancer is the second most common type of cancer among men in the US (after skin cancer). About one in seven men will be diagnosed with prostate cancer, but six in ten cases occur in men over age 65. When detected early, treatment for prostate cancer is highly effective.
I don’t have prostate cancer but I’m worried about it. Should I ask for a PSA screening test?
Prostate PSA testing is the most controversial topic around prostate cancer today because, until recently, we didn’t have clinical trials to show the benefit of PSA testing. Indeed, some of the most influential national guideline panels have historically recommended against PSA testing or discouraged it. The best data to date comes from the European ERSPC study, which showed a 20% reduction in prostate cancer mortality with PSA testing when done an average of every four years for patients between the ages of 50-74.
Those of us who treat prostate cancer know firsthand the danger of late diagnosis. And most concerns about PSA testing relate less to the accuracy of the test itself, but more to the cost and morbidity associated with subsequent steps in prostate cancer treatment. Therefore, I believe that early identification of men with prostate cancer by PSA testing and the sub-classification of those patients into “high risk” or “low risk” is a useful first step in disease management, but should not automatically lead to additional treatments.
I have recently been diagnosed with prostate cancer (localized to the prostate). What is the best treatment for me (surgery, radiation, or watchful waiting)?
This question can only be answered after an individualized assessment that includes tumor characteristics, other medical problems and, most importantly, fears and hopes surrounding the side effects of treatment.
For an average risk patient, with newly diagnosed prostate cancer, there is no published data proving that either surgery or radiation is superior. For many patients, with very low risk disease, emerging data does suggest watchful waiting is the most appropriate initial management.
The “Gleason score,” obtained from a prostate biopsy, grades a tumor based on characteristics under the microscope and has strong prognostic value in predicting how a tumor is likely to behave in the future. The score ranges from 6-10 and I believe those with a 6 should be considered for watchful waiting, in addition to consultation with a surgeon or radiation oncologist. For those with a Gleason score of 7-10 (unless there is a very short life expectancy), I typically recommend active treatment with radiation or surgery.
Why did my prostate cancer return if my surgeon/radiation oncologist said it was completely removed/destroyed?
When cancer recurs in men after surgery, patients often wonder if they should have had radiation. For those who opted for radiation, they wonder whether surgery was the better option. In truth, recurrence usually has less to do with the type of treatment and more about whether the initial tumor already disseminated to other sites, such as bone or lymph nodes, at the time of diagnosis.
We often order a bone scan and CT scan, proceeding with surgery or radiation if those tests show no evidence of the spread of cancer. However, no scan exists that is sensitive enough to detect small clusters of tumor cells that have escaped the prostate at the time of diagnosis. They are already beyond the reach of the surgeon or the radiation oncologist.
Because a “PSA only” recurrence, after surgery or radiation, is frequently related to the presence of these clusters of prostate tumor cells outside the region of the prostate, we do have to carefully consider whether it makes sense to treat the prostate region again, using radiation, after surgery has failed or vice versa.

Breast cancer
Maria Theodoulou, MD, Medical Oncologist. NYOH/Albany, Hudson
While far less common compared to women, men are diagnosed with breast cancer. Thanks to greater awareness, men now seek medical attention sooner when discovering a lump. We know that men can also carry the hereditary genetic mutation associated with breast cancer (BRCA1 or BRCA2), which means family members (male and female) can also be at higher risk for the disease.
How can this happen to me?
Approximately 1% of all breast cancers is found in males. Sounds like a small number, but if we are expecting about 250,000 new cases of breast cancer in the U.S. in 2017, then about 2,500 of those cases will be in men. The lifetime risk of breast cancer in women is 12%; in men it is still rare, with a tenth of a percent lifetime risk.
Two decades ago, the time between a male discovering a lump in his breast and getting medical attention was 14 months. As a result, many of these patients were found with advanced disease. Most men did not pay attention to the breast mass, as they never considered this “female cancer” developing in their body. With increased breast cancer awareness, education and media attention, that lead time has shortened to an average of less than four months.
Found earlier, the disease is easier to treat. Risks associated with the development of male breast cancer are very similar to those for women and include:
• Aging
• Radiation treatment to the chest
• Patients with lymphoma
• Higher estrogen levels from increased alcohol consumption, obesity and some medications
• A strong family history of breast cancer
• Hereditary gene mutations like BRCA1 and BRCA2
In men, presence of the BRCA1 and BRCA2 gene mutations increases the risk of developing breast cancer to 6-8% (compared to a tenth of a percent in the general population who don’t have the mutation). Because of the increased risk with inherited mutations, all men with breast cancer should have genetic testing, and their first-degree family members should also be tested.
Men have breasts, and lumps in their breasts are not all cancers but should always be evaluated by a medical professional.
How will I be treated? What’s next?
The same worries that women have, men share. And because men often feel isolated or embarrassed by the diagnosis, finding someone they can relate to or discuss their concerns with can be difficult. Surgery, potency and hair loss are all common worries.
Most males are diagnosed with a breast cancer that is similar to a postmenopausal estrogen-sensitive female breast cancer. Treatment can include radiation, surgery and systemic therapy (immunotherapy, targeted therapy, chemotherapy). It is decided based on the type, biology and amount of breast cancer found and whether it is limited to the breast or has spread outside of the breast tissue. Early breast cancer is highly treatable with an excellent prognosis. Patients with a smaller tumor, no lymph node involvement and favorable biology can often be successfully treated without chemotherapy.
Can my son develop breast cancer?
Genetic screening will aid in diagnosing a hereditary gene mutation. If present, the patient’s sons and daughters, as well as siblings, can then be tested to see if they have inherited the gene mutation. If present in an unaffected family member, consultation with a medical professional will help guide the family member to appropriate screening and recommendations.

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