美国乳腺外科医师协会年会上公布的一项迄今最大规模的男性乳腺癌研究显示，男性乳腺癌患者的死亡时间比女性乳腺癌患者提前2年以上。男性患者的疾病分期更晚，5年生存率较低且中位总生存期较短。此外，男性患者的放疗率或部分乳房切除率较低，但化疗率与女性患者无显著差异。

　　这项研究由加利福尼亚州奥克兰市的乳腺外科医生Jon M. Greif博士及其同事进行，分析的对象是美国国家癌症数据库1998~2007年收录的13，457例男性(占所有乳腺癌病例的0.9%)和1,439,866例女性乳腺癌患者。

　　分析结果显示，女性乳腺癌患者的5年总生存率为83%(中位生存期为129个月)，而男性为74%(中位生存期为101个月)，差异具有高度统计学意义(P＜0.0001)。

　　根据分期比较总生存率发现，0期(94% vs. 90%)、1期(90% vs. 87%)和2期(82% vs. 74%)乳腺癌女性患者的5年生存率均显著高于男性患者(P＜0.0001)，但3期(56.9% vs. 56.5%，P=0.99)或4期(19% vs. 16%，P=0.20)患者的5年生存率无明显性别差异。

　　与女性乳腺癌患者相比，男性患者中美国黑人的比例较高[9.9% vs. 11.7%，比值比(OR)=1.19]，西班牙裔的比例较低(4.5% vs. 3.6%，OR=0.74)，并且年龄较大(59岁 vs. 63岁)。男性乳腺癌患者的肿瘤较大(中位20.0 mm vs. 15.0 mm)，1级肿瘤比例较低 (16.0% vs. 20.7%)，淋巴结转移率较高(41.9% vs. 33.2%，OR=1.45)，远处转移率也较高 (4% vs. 3%，OR=1.39)。男性乳腺癌患者的小叶癌比例较低(10% vs. 18%，OR=0.51)，雌激素受体阳性率较高(88.3% vs. 78.2%，OR=2.10)，孕激素受体阳性率也较高(76.8% vs. 67.0%，OR=1.63)。男性乳腺癌患者的部分乳房切除率较低(33% vs. 62%，OR=0.31)，放疗率也较低 (35.9% vs. 50.4%，OR=0.55)。上述差异均具有高度统计学意义(P＜0.0001)，但可能不具有临床意义。男性和女性乳腺癌患者的化疗率相似(40.1% vs. 39.8%，OR=1.01，P=0.40)，激素治疗率仅存在轻微差异(41.2% vs. 42.4%，OR=0.95，P=0.006)。

　　Greif博士表示，特别高危的男性应每年进行1次详细临床检查，并考虑每年进行1次乳腺X线筛查。高危男性包括具有可导致风险增加的已知基因突变(如BRCA和Klinefelter综合征)、已接受治疗或胸部暴露于高水平放射、有乳腺癌病史、以及有强烈乳腺癌家族史的男性。目前，在男性中发现的乳腺癌多表现为可触及的乳晕后或乳晕旁肿块、乳头溢液或结痂、皮肤糜烂、或可触及的淋巴结。因此，男性在每年体检时应检查乳晕后和乳晕旁的组织有无肿块和(或)皮肤变化。此外，男性也应不定期自查。

　　男性乳腺癌的治疗与女性乳腺癌的治疗相似。几乎所有的男性乳腺癌均为激素受体阳性，因此几乎所有男性乳腺癌均应将抗雌激素内分泌治疗纳入辅助治疗。对于全身复发风险较高的肿瘤，应考虑化疗。对于具有局部复发风险的肿瘤[包括体积较大和(或)累及淋巴结的肿瘤]，治疗应包括辅助放疗。男性乳腺癌手术通常为全乳房切除术。有证据显示，前哨淋巴结活检不仅适用于检测女性乳腺癌，对男性乳腺癌的检测效果也较好。

　　该研究的部分资金来自阿尔塔贝茨高峰医学中心。研究者声明无经济利益冲突。

　　Men with breast cancer died more than 2 years sooner than did women with the condition, in the largest-ever study of male breast cancer, investigators reported.

　　Male breast cancer patients presented with more advanced disease and had lower 5-year survival rates as well as shorter median overall survival than did women, Dr. Jon M. Greif said at the annual meeting of the American Society of Breast Surgeons.

　　They were less likely to have radiation therapy or partial mastectomy, but chemotherapy rates were not significantly different, said Dr. Greif, a breast surgeon who practices in Oakland, California.

　　The data come from an analysis of 13,457 men – representing 0.9% of all breast cancers – and 1,439,866 women with breast cancer in the U.S. National Cancer Data Base spanning the years 1998 through 2007. The explanation for the differences in overall survival is most likely multifactorial, according to Dr. Greif.

　　“Certainly, one reason is that with well accepted screening for female breast cancer, and heightened awareness amongst women, female breast cancer is detected earlier. Evidence from our study is that male breast cancer is larger and more likely to have spread to lymph nodes and beyond when first discovered,” he said in an interview.

　　“However, male breast cancer was less likely to be low grade, and this would be a biological difference. And, finally, men were older, and more likely to die of other causes.”

　　Men at particularly high risk should have careful clinical examinations annually, and consider annual screening mammography, advised Dr. Greif. Among those at high risk, he included men with known gene mutations that increase their risk (BRCA and Klinefelter’s syndrome, for example), men who have been treated or otherwise exposed to high levels of radiation to the chest, men with previous breast cancer, and men with strong family histories of male or female breast cancer.

　　“Currently, breast cancer in men is found as a palpable retro- or periareolar mass, a nipple discharge or crusting, skin erosion, or palpable lymph nodes. Examination of the retroareolar and periareolar tissues for lumps and/or skin changes should be a part of every man’s annual physical exam, and men should check occasionally themselves,” Dr. Greif said.

　　Five-year overall survival was 83% for women with breast cancer (median survival 129 months) and 74% for men (median 101 months), a highly statistically significant difference (P less than. 0001), he reported.

　　A comparison of overall survival by stages showed significantly better outcomes for women with early disease, but similar outcomes in more advanced disease. Females had significantly better 5-year survival rates (P less than .0001) for stage 0 (94% vs. 90%), stage I (90% vs. 87%) and stage II (82% vs. 74%) breast cancer. No significant differences were seen in 5-year survival for stage III (56.9% vs. 56.5%, P = .99) or stage IV (19% vs. 16%, P = .20).

　　The following findings also were reported:

　　– Men with breast cancer were more often African American (11.7% vs. 9.9%, odds ratio 1.19), less often Hispanic (3.6% vs. 4.5%, OR 0.74), and older (63 vs. 59 years old).

　　– Men had larger tumors (median 20.0 vs. 15.0 mm), were less likely to have grade 1 tumors (16.0% vs. 20.7%), were more likely to have lymph node metastasis (41.9% vs. 33.2%, OR 1.45), and were more likely to have distant metastasis (4% vs. 3%, OR 1.39).

　　– Men were less likely to have lobular carcinoma (10% vs. 18%, OR 0.51) and more likely to be estrogen receptor positive (88.3% vs. 78.2%, OR 2.10) and progesterone receptor positive (76.8% vs. 67.0%, OR 1.63).

　　– Men were less likely to have been treated with a partial mastectomy (33% vs. 62%, OR 0.31) and less likely to have received radiation (35.9% vs. 50.4%, OR 0.55).

　　All of these differences were highly statistically significant, with P values less than .0001. However, the differences may not have been of clinical significance, the investigators said, citing the large numbers of cases.

　　The proportions of men and women receiving chemotherapy were similar (40.1% vs. 39.8%, OR 1.01, P = .40) and only small differences were seen in hormonal therapy rates (41.2% vs. 42.4%, OR 0.95, P = .006).

　　Treatment of male breast cancer is similar to that of female breast cancer, according to Dr. Greif. Nearly all male breast cancers are hormone receptor positive, so treatment with antiestrogenic endocrine therapy should be a part of the adjuvant treatment of nearly all male breast cancer.

　　Chemotherapy should be considered for tumors with higher risk of systemic return, he said. For tumors with risk of locoregional return, including those that are large and/or have lymph node involvement, adjuvant radiation should be part of the treatment.

　　The surgery for male breast cancer is almost always total mastectomy, he noted, and there is evidence that sentinel lymph node biopsy works for male breast cancer as well as in female breast cancer.

　　This study was funded in part by Alta Bates Summit Medical Center. None of the authors have any conflicts of interest or financial disclosures.

（责任编辑：赖静妮）