Breast Cancer in Men
Breast cancer is often thought of as a condition that only affects women,
but men may also develop the condition. Breast cancer in men
is much less common than breast cancer in women, affecting just 1 in
every 100,000 men in the USA and the UK.
The cancer develops in the small amount of breast tissue men have
behind their nipples. The most common symptom is a
hard, painless lump in one of the breasts. However, it is important to
note that the vast majority of breast lumps are due to a benign condition
called gynaecomastia. This is a common, non-cancerous condition where male
breast tissue becomes enlarged.
Breast cancer in men can also cause nipple problems, such as the
nipple turning in on itself (retraction) or nipple discharge.
You should always talk to your doctor if you notice a lump in your
breast, or you have problems affecting your nipples, such as nipple
discharge or nipple retraction. While these symptoms are
unlikely to be caused by breast cancer, they should be investigated
further.
The cause of male
breast cancer is unclear, but factors known to increase your chances of
developing the condition include:
- age - most cases affect men over 60 years of age
- having a family history of breast cancer (male or female)
- obesity - a body mass index (BMI) of 30 or more
Breast cancer is much rarer in men than women. Only about 1 in 1000 men
develop breast cancer in their lifetime. Around 350-400 new cases of
breast cancer are diagnosed in men in the UK every year. The condition is most
often diagnosed in men aged 60-70 years old.
In most cases, surgery is used to remove the cancer along with 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 prevent the cancer from
returning. In some cases, radiotherapy, or chemotherapy, may be used for
the same purpose.
The outlook for breast cancer is less good in men than in women. This is
because there is reduced awareness of the condition and it may take longer to
diagnose.
The survival rates for breast cancer in men largely depend on how far
the cancer has spread before it is diagnosed. Breast
cancer diagnosed at an
early stage can often be treated successfully,
but effective treatment is
more difficult if the cancer has spread beyond the breast tissue. Unfortunately, many cases are diagnosed after
the cancer has already started to spread.
Causes of breast cancer in men
It is not clear exactly what causes breast cancer in men, although
several things that can increase your risk of developing the condition have
been identified.
Schematic diagram showing the anatomy of the male breast
The body is made up of millions of different cells. Cancer happens when
cells multiply in an abnormal way. When cancer affects organs and solid
tissues, it causes a growth called a tumour to form. Cancer can occur in any
part of the body where cells multiply abnormally.
In breast cancer, cells in the breast tissue are affected.
Left untreated, cancer can quickly grow and spread from the breast
into nearby tissue or other parts of the body. This usually happens
through the lymphatic system, but can also spread through the bloodstream.
The lymphatic system is a series of glands located throughout the body
and linked together in a similar way to the blood circulation system. Once the cancer reaches your lymphatic system, it can spread to any
other part of your body, including your bones, blood and organs.
A number of things that can increase your risk of breast
cancer developing have been identified.
Like many cancers, men have an increased risk of developing breast
cancer as they get older. Most cases are diagnosed in men aged 60-70.
It's rare for young men to develop the condition.
A genetic mutation is where instructions carried in all living cells
become scrambled in some way which means 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 is known as
the BRAC2 mutation. One study carried out in the UK found 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 has developed breast cancer.
Routine testing for the faulty genes that cause breast cancer in men is
not usually carried out on the NHS. However, some private clinics offer
gene testing. Tests can be expensive with prices ranging from around
£2,000 to £3,000.
There is evidence that high levels of the hormone oestrogen, or
prolonged exposure to it, can increase the risks of breast cancer in men. Compared to women, men tend to have low levels of oestrogen, but there
are 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 undergoing a male to female sex change
- obesity - obese men have higher levels of oestrogen than normal
- cirrhosis - long-term scarring of the liver often caused by long-term alcohol misuse.
There is also a rare genetic condition affecting males called
Klinefelter's syndrome. This is a congenital condition (boys are born with it)
and it means affected males produce less of the hormone testosterone than
usual. As testosterone usually helps to limit the effect of oestrogen, men
with Klinefelter's syndrome are more likely to develop breast cancer than
the general male population.
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 linked to an increased 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 hypothesis 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 hypothesis is that working in hot environments usually
involves exposure to certain chemicals which may increase 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. Exposure to certain chemicals seems to be an obvious possibility, but this has not yet been proven.
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. Exposure to certain chemicals seems to be an obvious possibility, but this has not yet been proven.
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, even a seven-fold increase means the chance of developing
breast cancer is still very low.
Diagnosing breast cancer in men
If you have symptoms of breast cancer - such as a hard, painless
lump in one of your breasts - your physician will carefully examine you. During the examination, they will also look for other possible
signs of male breast cancer, such as swollen lymph nodes (glands). It is likely your doctor will refer you for further tests if there is a
possibility you may have breast cancer. These tests are described below.
A mammogram is a type of X-ray used to 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.
An ultrasound scan 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.
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 breast cancer in men. 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 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.
During a core biopsy, a local anaesthetic will be used to numb
your breast. 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 around 90% of cases), it is possible to treat the cancer with hormone
therapy. See treating breast cancer in men for more information.
After breast cancer has been diagnosed, your care team should provide
information about the stage of the cancer. Staging is a system used to describe
how far a cancer has spread at the point of the diagnosis.
A cure may be possible if breast cancer is diagnosed at an early stage.
However, treatment can only be used to control symptoms and slow the spread of
the cancer if it is diagnosed at a later stage. Unfortunately, more than 40% of
breast cancers in men are diagnosed at a late stage.
In some cases, men are diagnosed with a type of breast cancer called
ductal carcinoma in situ (DCIS). This means there are cancer cells in the
breast, but they are contained within the breast ducts and cannot spread. If
left untreated, DCIS can lead to invasive breast cancer.
Being told you have breast cancer can cause a wide range of emotions,
such as shock, fear, confusion and, in some cases, embarrassment. Most people assume breast cancer only affects women, so it can be
difficult 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 available for women with the condition.
Sometimes, men who find themselves in this situation can become
depressed. You may bedepressed if during the past month you have felt very
down and no longer interested in doing activities you used to enjoy. If you
think you may be depressed, visit your physician. There are a range of
effective treatments, such as medication and counselling, that can help relieve
feelings of depression.
You may also find it useful to talk to other men affected by the
condition. Breast Cancer Care is a breast cancer charity that
provides an online forum for men diagnosed with breast cancer.
Symptoms of breast cancer in men
The main symptom of breast cancer in men is a hard lump in one of your
breasts. The lump is almost always painless. The lump is usually located underneath the nipple and areola (the circle
of dark coloured skin that surrounds the nipple).
However, it is important to note that the vast majority of breast lumps
are due to a condition called gynaecomastia. This is a common, non-cancerous
condition where male breast tissue becomes enlarged.
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 looks sore (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), usually in or around the armpit
- shortness of breath
- feeling unusually tired all the time
- feeling sick (nausea)
- itchy skin with jaundice (yellowing of the skin and whites of the eyes)
You should always visit your doctor if you notice a lump in your breast
or if you have problems affecting your nipples, such as retraction,
ulceration or discharge. These problems are unlikely to be of the result of breast cancer,
but they should be investigated further.
Treating breast cancer in men
Treatment for breast cancer in men largely depends on how far the cancer
has spread. Most hospitals use multidisciplinary teams (MDTs) to treat men with
breast cancer. These are teams of specialists who work together to make
decisions about the best way to proceed with your treatment.
Deciding which treatment is best for you can often be confusing. Your
cancer team will recommend what they think is the ideal 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 you would like to ask the specialist.
For example, you may want to find out the advantages and disadvantages of
particular treatments.
Your recommended treatment plan will depend on how far the cancer has
spread. If the cancer has not spread significantly beyond your breast, a
complete cure may be possible. In these cases, surgery to remove the affected breast is usually
recommended. This is often 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, a complete cure will not be possible. However,
hormone therapy and chemotherapy can be used to relieve symptoms and slow down
the spread of the cancer.
Surgery is usually recommended as the first treatment for breast cancer.
Specifically, this involves an operation called a mastectomy. A mastectomy procedure involves the removal of the entire breast, often
along with the nipple and lymph nodes (glands) in the armpit. In some
cases, part of the muscle under the breast may also be removed if there is a
risk the cancer has spread to this area.
Once surgery has been completed there will be a straight scar across
your chest where your nipple used to be and possibly an indentation around that
area where the breast tissue used to be.
Most men are well enough to leave hospital one to three days
after surgery. After the operation, it's likely you will feel very tired
and it may take a few weeks before you are well enough to start carrying out
relatively strenuous activities, such as lifting objects or driving. Your MDT
specialist nurse will be able to offer more specific advice about this.
The wound will take about two to three weeks to heal. It is important to
keep the wound clean during this time. You should look for any signs that
the wound may have become infected, such as redness and swelling around the
wound or a discharge of pus. Inform your MDT as soon as possible if you suspect
an infection.
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.
Your MDT will be able to advise you, but the final decision will be yours.
It can take several weeks 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.
Your MDT will be able to provide you with more advice or refer you to a physiotherapist (a specialist with training in rehabilitation using exercise). The Royal College of Surgeons (RCS) have produced a useful leaflet for people who are recovering after having a mastectomy.
Your MDT will be able to provide you with more advice or refer you to a physiotherapist (a specialist with training in rehabilitation using exercise). The Royal College of Surgeons (RCS) have produced a useful leaflet for people who are recovering after having a mastectomy.
Following surgery, you may experience numbness or tingling at the site
of the scar and in your upper arm. This is common and caused by nerve
damage during surgery. The numbness and tingling should pass within a few weeks
or months, although it can occasionally be permanent.
Another common complication is painful swelling in the arms and legs
and, sometimes 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 (glands) are surgically removed 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. See treating lymphoedema for more information.
Radiotherapy is a type of treatment involving 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 typical course of radiotherapy involves two to five sessions a
week over the course of three to 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 released during
radiotherapy can also damage healthy cells.
Common side effects of radiotherapy can 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 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.
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 the cancerous cells require oestrogen to grow.
Oestrogen is a type of hormone found in low levels in men and in much higher
levels in women.
The aim of hormone therapy is to block the effects of oestrogen on the
breast tissue to prevent the cancer reoccurring after surgery. It can also
be used in cases of advanced breast cancer in order to slow down the spread of
the cancer.
Tamoxifen is a hormone medication widely used for breast cancer. It
is available in tablet or liquid form and it prevents oestrogen from entering
the breast tissue cells. However, the ideal length of treatment with tamoxifen
is unclear. Studies in women with breast cancer suggest a five year course
of treatment is the most effective in preventing the return of cancer and
extending survival rates. However, it is unclear if this also applies to
men.
Tamoxifen can also cause unpleasant side effects, which will be
taken into consideration when your MDT is deciding what treatments to
recommend. You can discuss the pros and cons of long-term treatment with
tamoxifen with your MDT.
Side effects of tamoxifen can include:
- reduced interest in sex (loss of libido)
- headache
- inability to obtain or maintain an erection (erectile dysfunction)
- feeling sick (nauseus), although taking your medication with food may help to reduce this side effect
- changes in mood, such as feeling irritable or depressed.
You should inform your MDT if you experience side effects that become
particularly troublesome, as alternative medications are available.
Aromatase inhibitors are an alternative type of hormone
medication. They may be used if tamoxifen proves 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 taken daily
for two to five years. As with tamoxifen, there is little available
evidence (compared with female breast cancer) regarding what the most effective
length of dosage is.
Side effects of aromatase inhibitors can include:
- joint pain
- hot flushes
- feeling sick (nausea)
- lack of energy
- skin rashes
- being sick (vomiting)
- thinning of hair.
However, it is unlikely you will experience all of these side effects.
Chemotherapy is used to treat cases of breast cancer where hormone
therapy would be largely ineffective because the cancerous cells are not
oestrogen receptor positive (ER+). It's usually given after surgery to help
prevent the cancer returning or it's used to treat the symptoms of incurable
cancer.
Chemotherapy for breast cancer 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), chemotherapy
injections (intravenous chemotherapy) or a combination of both.
The side effects of chemotherapy can include:
- hair loss
- feeling sick (nausea)
- being sick (vomiting)
- tiredness
- diarrhoea
- loss of appetite
- mouth ulcers
- skin rashes
- infertility
However, the side effects should resolve once your treatment has
finished. Following treatment, your hair should grow back after about three to
six months. 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 your MDT 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 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 used, it may be several months after your
course of chemotherapy has ended before you can safely have children. Your MDT
will be able to give you a more detailed recommendation.
Biological therapy uses medication to block the effects of a protein
called human epidermal growth factor receptor 2 (HER2) in cases where HER2
is contributing to breast cancer. 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 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 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 directly in to a
vein (intravenously) through a drip. You will receive the treatment
in hospital. Each treatment session takes up to one hour and the number of
sessions you need 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 it is not causing any problems.
Other side effects of trastuzumab can include:
- an initial allergic reaction to the medication, which can cause nausea, wheezing, chills and fever
- diarrhoea
- tiredness
- aches and pains.
Source: NHS Choices.