When I met Carl “Mac” Holmes, it was in the midst of a conference for breast cancer patients. Lt. Colonel Holmes, a former Air Force pilot, stood out from most other attendees, because he is a man who lives with metastatic breast cancer. He looked sharp, with gray-brown eyes, white hair and a polo shirt tucked in.
“It’s not a man’s world,” he told me. Indeed, male breast tumors accounts for a tiny proportion of cases. The CDC reports that 2,000 U.S. men receive a diagnosis of breast cancer annually. The number of women diagnosed with invasive disease exceeds 240,000 each year.
“I’m a happy-go-lucky guy,” he said. But it can be awkward. “At the doctor’s office, for instance, they asked, ‘Are we seeing your wife?’”
After his breast cancer diagnosis, in 2012, Holmes initially hesitated before telling friends and acquaintances about the condition. He felt embarrassed, and called it “chest cancer.” Now he’s forthcoming, and eager to promote education about male breast cancer. “A lot of the guys I flew with never thought about it. But I knew, it could happen,” he said. “A man can get breast cancer. People need to know.”
Holmes lives with his wife, Robin, in Collierville, Tennessee. He first noticed his breast tumor while he was lifting weights, in March, 2012. The lump felt hard, and the nipple was turning inward.
“My doctor, a general practitioner in Memphis, knew right away,” Holmes said. He had a mammogram and biopsy, followed by a mastectomy. The breast cancer had spread to lymph nodes under his arm. An Oncotype test was done, and Holmes was advised to take six rounds of chemotherapy. “There’s heart disease in my family. I chose not to have radiation, to spare my heart,” he said.
Treatment of male breast cancer can include surgery to remove the tumor, radiation, hormonal manipulation, chemotherapy and newer, targeted therapies. A limitation is that few of the breast cancer drugs, and particularly those which might be needed to treat advanced cases, have been tested in men. Because many people don’t realize that men can develop breast cancer, the diagnosis is often delayed.
Risk factors include genetic variants, obesity and high estrogen states. As with women, inheriting a BRCA mutation can play a role. In male breast cancer, BRCA2 mutations are implicated in a greater proportion of cases than BRCA1 mutations.
Dr. Sharon Giordano is an oncologist and professor at Houston’s MD Anderson Cancer Center, where she chairs the department of Health Services Research. She is the leading U.S. investigator in an international consortium that is studying male breast cancer.
The consortium has established a prospective registry for men with breast cancer. The registry includes patients in Europe, the United States and Latin America, with localized and also metastatic disease. The organization is collecting blood samples at the time of diagnosis for molecular and genetic analyses, reviewing quality-of-life questionnaires and following affected men over time. Already that group has acquired over 1,500 specimens of breast cancer, from men, for in-depth biological studies.
“The hormonal environment in men is obviously different,” Giordano said. While breast cancer occurs in many forms, the disease in men tends to be hormonally driven. “In men, the overwhelming majority of cases are estrogen-receptor positive,” she said. “So the question we’d like to address is, what are the best hormone treatments for men with breast cancer?”
The incidence of breast cancer in U.S. men may rise, Giordano considered. Because estrogens are produced in fat cells, being overweight adds risk. “Given that obesity levels are going up, and estrogen levels are linked to obesity, there’s reason to be concerned.”
Lt. Colonel Carl "Mac," Holmes, in April 2016 (Image courtesy of Carl Holmes)
Holmes spent his childhood in Missouri, where he worked on a farm. He rode on the back of his grandfather’s tractor and helped in planting crops, including soybeans and cotton. Chemicals were sprayed in the air while he was working. But Holmes doesn’t know if his exposure was toxic. “You could smell the defoliant,” he told me. “You could see, it knocked leaves off the cotton.”
He enlisted in the Air Force directly upon graduating from high school in 1974. While serving in the military, he studied engineering and graduated from the University of Memphis. He became a pilot and commissioned officer. Starting in 1993, he flew with FedEx, for which he instructed and educated pilots. He continued flying with the Air Force until his retirement.
None of Holmes’s relatives are known to have had breast cancer; his family history is not suggestive of a disposition. He had a test for BRCA mutations that was negative, he said.
The cancer turned out to have spread to Holmes’s spine. For that, he received stereotactic radiation, which helped relieve his bone pain. His doctor told him he has incurable, metastatic breast cancer. Since then, he’s been on hormone treatments.
“It can be an isolating experience, for men are diagnosed with breast cancer,” Giordano considered. She’s heard many stories of men who felt left out, or slighted, in treatment centers geared toward women. “A technician calls for Mrs. Jones, when they see Jones is the last name,” for instance. “We had one patient who, after mammography, was handed a pink floral ice pack.” The instructions said to place the cooling pack it inside your bra. “He thought it was hilarious, but other patients might not.”
The patient intake forms almost universally refer to women’s health, Giordano said. “At every step of the process, they’re constantly explaining, because people expect a breast cancer patient to be a woman.”
Although he receives most of his care in Memphis, he’s gone to see a male breast cancer specialist, Dr. Giordano, in consultation. “Usually I’m surrounded by women at the doctor’s office,” he said. “The day I saw her at MD Anderson, and she had seen six patients before me, men with breast cancer, that made me feel better.”
Holmes has become active in breast cancer advocacy. First he joined the Male Breast Cancer Coalition. This year, he participated in an LBBC campaign to educate and train patients with metastatic breast cancer in public speaking, and advocacy. He was selected to review grants for the U.S. Department of Defense’s breast cancer research program. This month, he’s headed to Washington DC, where he’ll speak at a rally for people affected by metastatic disease.
"I'm calling for more research," Holmes said. He's on dual mission. "I want to educate people, that men can get breast cancer,” he said. “I want to give hope for metastatic breast cancer. Although it’s incurable now, with research it might be like a chronic disease. People should know that.”
