Many of us who are fighting advanced prostate cancer struggle with the perplexing side effects of non-steroidal antiandrogens (like Casodex). These side effects include gynecomastia (breast enlargement) and breast pain. In most cases as we use these drugs our breasts grow, become very sensitive and/or painful. In my case my breasts have grown to the point that my son has asked me to put on my shirt while I am at the beach. We all have seen that cartoon where an older couple (man and women) stand looking at each other, both with similar, substantial breasts. The man says to the women, aren’t you embarrassed, put on your bra!

To stop these male breast problems many doctors offer a “shot” of radiation to the breasts. Despite the radiologist’s claims that this is a safe procedure, I remain concerned about the possible unexpected side effects, especially secondary cancers. Maybe this concern comes from more personal over sensitivity to developing additional cancers; I am already a survivor of four primary cancers.
Additionally, radiation will not reverse breast growth or sensitivity, once you have them they are yours for life.

Some men become so upset about their breast grow they elect to have breast reduction surgery!

An alternative treatment to radiation and surgery seems to be in the wings. Tamoxifen is now being used as a potential management option as an alternative to surgery or radiotherapy.

There was recently a systematic review designed to assess the benefits and harms of tamoxifen, in comparison to these other treatment options. The review included an evaluation of tamoxifen both as a prophylaxis (preventive) and as a treatment of already existing breast events in men with advanced prostate cancer.

The review searched CENTRAL, MEDLINE, EMBASE, reference lists, the abstracts of three major conferences and three trial registers to identify ongoing randomized controlled trials. Two authors independently screened the identified articles, assessed their qualityand relevance and then extracted data. The protocol was prospectively registered (CRD42011001320; .

For the purpose of this analysis the researchers identified four separate studies that they then evaluated. They found that:

Tamoxifen significantly reduced the risk of suffering from gynecomastia (RR 0.10, 95% CI 0.05-0.22) or breast pain (RR 0.06, 95% CI 0.02-0.17) at 6 months compared to untreated controls.

Tamoxifen also showed a significant benefit for the prevention of gynecomastia (RR 0.22, 95%CI 0.08-0.58) and breast pain (RR 0.25, 95% CI 0.10-0.64) when compared to anastrozole after a median of 12 months.

One study showed a significant benefit of tamoxifen for the prevention of gynecomastia (RR 0.24, 95%CI 0.09-0.65) and breast pain (RR 0.20, 95% CI 0.06-0.65) when compared with radiotherapy at 6 months. Radiotherapy increased the risk of suffering from nipple erythema and skin irritation, but there were no significant differences for any other adverse events (all p>0.05).

The researchers concluded that tamoxifen has efficacy for the prevention and treatment of breast events brought about by taking non-steroidal antiandrogens. None of these studies evaluated the impact of tamoxifen therapy on long-term adverse events, disease progression and overall survival.

In conclusion we need additional large, well-designed trials, including long-term follow-ups, to clarify these questions as well as the optimal dose needed to do the job safely.

Reference: Kunath F, Keck B, Antes G, Wullich B, Meerpohl JJ; BMC Med. 2012 Aug 28;10(1):96. doi: 10.1186/1741-7015-10-96

Joel T. Nowak, M.A., M.S.W.