Breast Cancer in Men

Introduction 

Breast cancer is often thought of as a condition that only affects women, but men can also develop it.

However, breast cancer in men is much less common than breast cancer in women.

The most common symptom of breast cancer in men is a hard, painless lump that the develops on one of the breasts.

When to see Dr. B C Shah

You should always visit Dr. B C Shah if you notice a lump in your breast, or you have symptoms that affect your nipples, such as retraction or discharge.

While these symptoms are unlikely to be the result of breast cancer, they should be investigated further.

Treating breast cancer in men

In most cases of breast cancer, surgery is used to remove a section of the breast. This is usually followed by a long-term course of hormone therapy using a medication called tamoxifen.

Tamoxifen helps to block the effects of hormones on breast tissue that are known to stimulate the growth of cancerous cells. It should help to prevent the cancer from returning.

In some cases, radiotherapy and/or chemotherapy may be used for the same purpose.

Causes

The causes of breast cancer in men are unclear, but a number of risk factors for the condition have been indentified. These include:

• Age – most cases of male breast cancer affect men who are over 70 years of age
• Having a family history of breast cancer (both male or female)
• Obesity - a body mass index (BMI) of 30 or more
• Alcohol consumption

Who is affected?

The average age of diagnosis is 71 years of age.

Outlook

The outlook for breast cancer in men is less favourable than for breast cancer in women. This is because there is less awareness of the condition, so it often takes longer to diagnose.

Healthcare professionals assess the outlook for cases of cancer by measuring how many people survive for five years following the initial diagnosis. This is known as ‘the five year survival rate’. However, many men who are diagnosed with breast cancer survive for much longer than five years.

The estimated five year survival rate for:

• Stage 1 breast cancer is 75-100%
• Stage 2 to 3 breast cancer is 50-80%,
• Stage 4 breast cancer is 30-60%

Symptoms of breast cancer in men 

The most common symptom of breast cancer in men is usually a hard, painless lump in one of your breasts. However, in around 1 in 20 cases, the lump can be painful.

The lump is usually located underneath the nipple and areola (the circle of dark coloured skin that surrounds the nipple).

Less common symptoms of male breast cancer usually affect the nipple. These can include:

• the nipple begins to turn in on itself (nipple retraction)
• the nipple becomes hard, inflamed, and ‘sore looking’ (nipple ulceration)
• fluid leaking from the nipple (nipple discharge)

Additional symptoms usually only develop if the cancer spreads from your breast to other parts of the body, such as your bones, liver or lungs. This is known as metastatic breast cancer.

Symptoms of metastatic breast cancer include:

• Bone pain
• Swelling of the lymph nodes (glands) near your breast; usually in, or around, the armpit
• Shortness of breath
• Feeling unusually tired all the time
• Feeling sick (nausea)
• Itchy skin

When to seek medical advice

You should always visit Dr. B C Shah if you notice a lump in your breast or if you have symptoms that affect your nipples, such as retraction, ulceration or discharge. While symptoms such as these are unlikely to be of the result of breast cancer, it is important that they are investigated further.

Causes of breast cancer in men 

Cancer begins with an alteration to the coding information in cells that tells them when to grow and replicate. The code is read from the deoxyribonucleic acid (DNA) that is found in all human cells. A change in the code is called a mutation and can alter the instructions that control cell growth.

If a mutation occurs, the cells carry on growing instead of stopping when they should. The cells reproduce in an uncontrollable manner, producing a lump of tissue that is known as a tumour.

How cancer spreads

Left untreated, cancer can quickly grow and spread to other parts of your body. There are two ways that breast cancer can spread:

• Directly - where the cancer spreads outs of the breast tissue into surrounding muscle and skin
• Indirectly - where cancer cells spread via the blood or lymphatic system (see below) to more distant parts of the body, such as the lungs and liver

The lymphatic system is a series of glands (or nodes) that are distributed throughout your body in a system that is similar to the blood circulation system.  The glands produce many of the specialised cells that are needed by your immune system.

Risk factors for breast cancer in men

It is not clear exactly what causes the DNA inside the cells of the male breast to behave in this manner. However, a number of risk factors that can increase your risk of breast cancer developing have been identified (see below).

Due to the rarity of breast cancer in men, even if you had most of the risk factors outlined below (with the exception of having Klinefelter's syndrome), your risk of developing the condition would still be very small.

Genetics and family history

A genetic mutation is where the instructions that are carried in all living cells become scrambled in some way which means that one or more of the body’s processes do not work in the way they should.

There are a number of genetic mutations known to increase your risk of developing breast cancer. The most significant mutation identified to date is known as the BRAC2 mutation. One study that was carried out in the UK found that 1 in 20 men with breast cancer have the BRAC2 mutation.

There is also evidence that breast cancer can run in families, as 1 in 5 men who develop breast cancer, have a first-degree relative, such as a mother or sister, who also has a history of breast cancer.

Oestrogen exposure

There is evidence that prolonged exposure to the hormone oestrogen can increase the risks of breast cancer in men.

Compared to women, men tend to have low levels of oestrogen, but there are a number of circumstances that can increase the levels of oestrogen in men. 

These include:

• Hormone treatments – man-made (synthetic) versions of oestrogen are often used to treat prostate cancer and are also given to transsexuals who are undergoing a male to female sex change
• Obesity – obese men have higher levels of oestrogen than normal

There is also rare genetic condition called Klinefelter's syndrome where baby boys are born with much higher levels of oestrogen than normal. It is estimated that 1 in every 1,000 people are affected by Klinefelter's syndrome.

Klinefelter's syndrome is a major risk factor for breast cancer in men. Men who have the condition are 20 times more likely to develop breast cancer than the male population at large.

Occupational risks

There is evidence that men who work in hot environments are twice as likely to develop breast cancer compared with men who work in cooler environments. Environments that have been linked to an increase risk of breast cancer in men include:

• Blast furnaces
• Steel works
• Rolling mills – a factory where metal (usually steel) is shaped using rollers
• Car manufacturing plants

One theory to help explain the link between working environment and the increased risk of developing breast cancer is that excessive heat may damage the testicles, which could lead to an increase in oestrogen levels.

Another theory is that working in hot environments usually involves exposure to certain chemicals which may increase a the risk of developing breast cancer in men.

Rates of breast cancer are also unusually high in men who manufacture perfumes and soaps. 
They are seven times more likely to develop breast cancer than the male population at large. The reason for this increased risk is still unclear, although exposure to certain chemicals seems to be an obvious, although as yet unproven, factor.

Radiation

Exposure to radiation has been linked to an increased risk of developing breast cancer in men.

Research has found that men who received a course of radiotherapy (where high energy X-rays are used to kill cancerous cells) directed at the upper chest were seven times more likely to develop male breast cancer compared to the population at large.

However, it is important to put the increase risk in context. Even a seven-fold increase means that the chances of developing breast cancer is still very low at around 1 in 14,285.

Breast cancer in men – Diagnosis 

If you have symptoms which might indicate breast cancer, such as a hard, painless lump in one of your breasts, Dr. B C Shah will carefully examine your breasts. During the examination, they  will also be looking for other possible signs of male breast cancer, such as swollen lymph nodes (glands).

It is likely that your Dr. B C Shah will refer you for further tests. There are three tests that are used to help diagnose  male breast cancer. These are:

• A mammogram,
• An ultrasound
• A biopsy

Mammogram

A mammogram is a type of X-ray that can help determine whether there are any changes in breast tissue that could be the result of cancer.

During the mammogram procedure, a radiographer (a specialist in taking X-rays) will compress one of your breasts between two X-ray plates. This should not be painful, but you should tell the radiographer if you find it uncomfortable.

Once your breast has been correctly positioned, an X-ray will be taken which will produce a clear image of the inside of your breast. The procedure will then be carried out on your other breast.

Ultrasound

Ultrasound uses high frequency sound waves to produce an image of the inside of your breasts (in the same way that an unborn baby can be seen in the womb).

An ultrasound probe or sensor will be placed over your breasts to create an image of the inside of your breasts on a screen. The image will highlight any lumps or abnormalities that may be present in your breasts.

Biopsy

A biopsy may be recommended if a mammogram or an ultrasound scan highlight any lumps or abnormalities in your breasts. A biopsy is a test that can either confirm or rule out a diagnosis of male breast cancer. It involves taking a sample of suspected cancerous tissue and examining it in a laboratory for the presence of cancerous cells.

A type of biopsy that is known as a core biopsy is usually recommended for the diagnosis of breast cancer in men. This type of biopsy can usually indicate whether the cancer has started to spread from the breast into the surrounding area, which is known as invasive breast cancer.

During a core biopsy, a local anaesthetic will be used to numb your breasts. A hollow needle will then be used to remove a number of small tissue samples from the breast lump.

If cancer is found, it will also be possible to check whether there are special proteins, known as oestrogen receptors, on the surface of the cancerous cells. This is important because if oestrogen receptors are found (they are in an around 90% of cases), it is possible to treat the cancer using a medication called tamoxifen.

Staging

After breast cancer has been diagnosed, your care team should be able to provide information about what stage your cancer is at.

Staging is a system that is used to describe how far a cancer has spread at the point of the diagnosis. The higher the stage, the more advanced the cancer and the further it has spread. The staging system for male breast cancer is outlined below.

• Stage 1 - the cancerous tumour is less than 2cm (three quarters of an inch) across and there are no signs that the cancer has spread to the lymph nodes near the armpit.
• Stage 2 - the cancerous tumour is 2-5cm (three quarters to two inches) across and/or there are signs that the cancer has spread to the lymph nodes near the armpit.
• Stage 3 - the cancerous tumour is larger than 5cm (2 inches) across and has started to move into surrounding tissues, such as skin and muscle. Near-by lymph nodes are also affected but there is no sign that the cancer has spread beyond the breast and armpit.
• Stage 4 - there are signs that the cancer has spread to other parts of the body, such as the lungs or bones. This is known as secondary, or metastatic, cancer.

A cure may be possible in cases of stage 1, 2 and 3 male breast cancer. In cases of stage 4 breast cancer, a cure is unlikely but it may be possible to control the symptoms and slow the spread of the cancer.

Coping with a diagnosis

Being told that you have breast cancer can cause a wide range of emotions, such as shock, fear, confusion and, in some cases, embarrassment.

Most people assume that breast cancer only affects women, so it can be difficult for many men to come to terms with the diagnosis.

Feelings of isolation and being alone are common in men with breast cancer. This may be because there is little in the way of advice and support for men with breast cancer, particularly when compared to the support that is available for women with the condition.

Sometimes, men who find themselves in this situation can become depressed. You may be depressed if during the past month you have felt very down and you are no longer interested in doing activities that you used to enjoy. If you think that you may be depressed, you should visit your Dr. B C Shah. There are a range of effective treatments, such as medication and counselling, that can help relieve feelings of depression.

Treating breast cancer in men 

Many hospitals use multidisciplinary teams (MDTs) to treat breast cancer in men. MDTs are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Members of your MDT may include:

• A surgeon
• A clinical oncologist (a specialist in the non-surgical treatment of cancer)
• A pathologist (a specialist in diseased tissue)
• A radiologist (a doctor who specialises in analysing the results of imaging tests such as X-rays and ultrasound scans)
• A dietitian
• A social worker
• A psychologist

As well as having a specialist MDT, you may also be assigned a key worker who will usually be a specialist nurse. They will be responsible for co-ordinating your care.

Deciding what treatment is best for you can often be confusing. Dr. B C Shah will recommend what he think is the best treatment option but the final decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions that you would like to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.

Your treatment plan

Your recommended treatment plan will depend on how far the cancer has spread. If the cancer has not spread significantly beyond your breast (stage 3 or below), a complete cure may be possible.

Surgery to remove the affected breast is usually recommended followed by radiotherapy, hormone therapy and /or chemotherapy to help prevent the cancer returning.

If the cancer has spread beyond your breast into other parts of your body, such as your lungs (stage 4 breast cancer), a complete cure will not be possible. However, hormone therapy and chemotherapy can be used to relieve symptoms, slow down the spread of the cancer  and prolong lifespan.

Surgery

Surgery is the first treatment option that is often recommended for breast cancer and usually involves an operation called a modified radical mastectomy. This is where Dr. B C Shah removes the entire breast as well as the lymph nodes (glands) in the armpit.

Once surgery has been completed there will be a scar where your nipple used to be and an indentation in your chest where the breast tissue was.

It is possible to have reconstructive surgery after having a modified radical mastectomy. Tissue can be taken from other parts of your body, such as your lower abdomen or buttocks, and be used to recreate the shape of the breast.

An alternative option is to use breast implants that are similar to those that are used in cosmetic surgery. However, they are obviously much smaller. In many cases, reconstructive surgery can be carried out immediately after a mastectomy has been performed.

It is also possible to restore the appearance of a nipple by having a tattoo on your chest. ‘Nipple tattoos’ can be created in around 30 to 40 minutes and have a very realistic appearance.

You should discuss the various options for reconstructive surgery with Dr. B C Shah.

After surgery

Most men are well enough to leave hospital three to five days after having surgery for breast cancer. After the operation, it is likely that you will feel very tired and it may take several weeks before you are well enough to start carrying out relatively strenuous activities, such as lifting objects or driving. 

Dr. B C Shah will be able to give you a more precise recommendation.

The wound at the site of the surgery will take about two to three weeks to heal. It is important to keep the wound clean during this time using unscented soap. You should look out for any signs that the wound may have become infected, such as redness and swelling around the wound or a discharge of pus. 

Inform Dr. B C Shah as soon as possible if you suspect that the wound may have become infected.

It is difficult to predict when you will feel able to return to work. Some people choose to remain off work until other treatments, such as radiotherapy, have been completed. Others prefer to return to work in between treatments. Dr. B C Shah will be able to provide you with advice but the final decision will be yours.

It can take several months to fully recover from the effects of a mastectomy. A structured exercise programme  where the intensity and amount of time spent exercising  is gradually increased  will probably be recommended. 

Dr. B C Shah will be able to provide you with more advice or refer you to physiotherapist (a specialist with training in rehabilitation using exercise).

Complications of surgery

Following surgery, you may experience numbness or tingling at the site of the scar and in your upper arm. This is common and is caused by nerve damage that occurs during surgery. The numbness and tingling should pass within a few weeks or months although it can occasionally be permanent.

Another common complication that can occur after a mastectomy is painful swelling in the arms and legs and, occasionally, in other parts of the body, such as the head and chest. This is called lymphoedema and it is caused by the disruption of the lymphatic system (a series of channels and lymph nodes which is normally responsible for removing excess fluid from tissue).

If multiple lymph nodes are surgically removed, as in the case of a modified radical mastectomy, it can disrupt the lymphatic system’s ability to drain fluid which can lead to swelling.

There is no cure for lymphoedema, but it is possible to control the symptoms using a combination of different techniques, such as massage and compression garments.

Radiotherapy

Radiotherapy is a type of treatment that uses a machine that releases high energy waves to destroy cancerous cells. It can be given a few weeks after surgery to prevent the cancerous cells returning.

A course of radiotherapy usually involves five sessions a week over the course of six weeks. The sessions are short and usually only last for 10 to 15 minutes.

Radiotherapy is not usually painful although you will probably experience some side effects. This is because the energy that is released during radiotherapy can also damage healthy cells.

Common side effects of radiotherapy include:

• Extreme tiredness (fatigue)
• Feeling sick (nausea)
• Sore, red, and irritated skin on the breast (similar in appearance to sunburn)

The side effects of radiotherapy should pass after your course of treatment has finished, although some men experience prolonged fatigue for several months.

Radiotherapy can also be used in cases of advanced breast cancer to slow down the spread of the cancer and to relieve the symptoms of pain. This is known as palliative radiotherapy. Palliative radiotherapy is usually given in just one or two doses and does not usually cause any side effects

Read more about radiotherapy.

Hormone therapy

About 90% of cases of breast cancers in men are oestrogen receptor positive or ER+ (E is used because the American spelling of oestrogen is ‘estrogen’). This means that the cancerous cells require oestrogen to grow. Oestrogen is a type of hormone that is found in low levels in men and in  much higher levels in women.

Therefore, the aim of hormone therapy is to block the effects of oestrogen on the breast tissue to prevent the cancer reoccurring after surgery. 

Hormone therapy can also be used in cases of advanced breast cancer in order to slow down the spread of the cancer.

Tamoxifen

Tamoxifen is a medication that is widely used during hormone therapy for breast cancer.

It prevents oestrogen from entering the breast tissue cells which helps prevent breast cancer reoccurring. Tamoxifen is available in tablet or liquid form.

It is unclear what the ideal length of a course of tamoxifen should be. Studies in women with breast cancer suggest that a five year course of treatment is the most effective in preventing the return of cancer and extending survival rates. However, it is not known whether this also applies to men.

Tamoxifen can cause unpleasant side effects, so you will need to balance the potential advantages of taking the medication with the possible disadvantages. You should discuss the pros and cons of long-term treatment with tamoxifen with Dr. B C Shah.

Side effects of tamoxifen include:

• Reduced interest in sex (low libido)
• Inability to obtain or maintain an erection (erectile dysfunction)
• Headache
• Feeling sick – taking your medication with food may help to alleviate this side effect
• Changes in mood, such as feeling irritable or depressed

You should inform Dr. B C Shah if you experience side effects that become particularly troublesome because alternative medications are available.

Aromatase inhibitors

Aromatase inhibitors are a type of medication that are an alternative hormone treatment to tamoxifen.  They may be used if tamoxifen proves to be unsuccessful or if the side effects of tamoxifen are particularly troublesome. Aromatase inhibitors can also be used to slow the spread of advanced breast cancer.

In men, oestrogen is created when a protein called aromatase converts another hormone called androgens. Aromatase inhibitors block the effects of aromatase which, in turn, lowers the amount of oestrogen in the body.

Aromatase inhibitors are usually given in tablet form and are taken daily for two to five years. As with tamoxifen, there is very little available evidence (compared with female breast cancer) regarding what the most effective length of dosage is.

Side effects of aromatase inhibitors include:

• Joint pain
• Lack of energy
• Hot flushes
• Skin rashes
• Feeling sick
• Being sick
• Thinning of the hair

The side effects are usually mild to moderate. It is also unlikely that you will experience all of the side effects that are listed above.

Chemotherapy

Chemotherapy is used to treat cases of breast cancer where the cancerous cells are not oestrogen receptor positive (ER+), which meaning that hormone therapy would be mostly ineffective. Chemotherapy is usually given after surgery to help prevent the cancer returning or it is used to treat the symptoms of incurable cancer.

Chemotherapy for breast cancer usually involves taking a combination of cancer-killing medications. Treatment is usually given every two to three weeks, over the course of six months.

You may be given chemotherapy tablets (oral chemotherapy) or chemotherapy injections (intravenous chemotherapy) or a combination of both.

The side effects of chemotherapy include:

• feeling sick
• being sick
• diarrhoea
• loss of appetite
• mouth ulcers
• tiredness
• skin rashes
• infertility
• hair loss

However, the side effects should resolve once your treatment has finished. Following treatment, your hair should take between three to six months to grow back.

Chemotherapy can also weaken your immune system, making you more vulnerable to infection.

It is therefore important to report any symptoms of a potential infection to Dr. B C Shah such as:

• A high temperature of 38C (100.4F) or above
• Flu-like symptoms, such chills or joint pain
• A general sense of feeling unwell

You should also avoid close contact with people who are known to have an infection.

If you are sexually active, you should use a condom for 48 hours after receiving a dose of chemotherapy medication. This is because the medication used in chemotherapy could pass into your semen and cause irritation in the tissue of your partner’s genitals.

You should avoid having children while receiving chemotherapy because many of the medications can damage your sperm and increase your chances of having a baby with a birth defect. Again, using a reliable method of contraception, such as a condom, is recommended

Depending on the medications that are used, it may be several months after your course of chemotherapy has ended before you can safely have children. Dr. B C Shah will be able to give you a more detailed recommendation.

Biological therapy

As with oestrogen receptor positive (ER+) types of cancer, some cases of breast cancer can be stimulated by a type of protein called human epidermal growth factor receptor 2 (HER2).

Biological therapy uses medication to block the effects of HER2 on breast tissue. 

Biological therapies are sometimes referred to as targeted therapies because they are designed to target biological processes that cancers rely on to grow and reproduce.

If you have high levels of the HER2 protein and you are able to have biological therapy, you will probably be prescribed a medicine called trastuzumab. Trastuzumab, also known by the brand name Herceptin, is usually used after radiotherapy and/or chemotherapy to prevent cancerous cells returning.

Trastuzumab

Trastuzumab is a type of biological therapy known as a monoclonal antibody. Antibodies occur naturally in the body and are created by the immune system to destroy harmful cells, such as viruses and bacteria. The trastuzumab antibody targets and destroys cancer cells that are designed to respond to the HER2 protein.

Trastuzumab is given intravenously (directly in to a vein) through a drip. You will receive the treatment in hospital. Each treatment session takes up to one hour and the number of sessions that you need to have will depend on whether your breast cancer is in its early or more advanced stages. On average, for early breast cancer you will need to have a session once every three weeks, and for cancer that is more advanced you will need to have weekly sessions.

Trastuzumab can cause side effects, including heart problems. This means that it is not suitable if you have a heart problem, such as angina, uncontrolled high blood pressure (hypertension) or heart valve disease. If you need to take trastuzumab, you will need to have regular tests on your heart to ensure that it is not causing any problems.

Other side effects of trastuzumab may include:

• An initial allergic reaction to the medication, which can cause nausea, wheezing, chills and fever
• Diarrhoea
• Tiredness
• Aches and pains