Breast cancer in men

What is male breast cancer?

Cancerous cells can develop in the small amount of breast tissue that men have behind their nipples. Breast cancer occurs much more commonly in women and only 1% of breast cancers occur in men.

What causes male breast cancer?

The cause of breast cancer in men is not completely understood, but some men seem to be at higher than average risk of developing the disease.

This rare cancer most commonly occurs in men over the age of 60. It is more common in men who have:

* several close members of their family (male or female) who have had breast cancer, or
* a close relative diagnosed with breast cancer in both breasts, or
* a relative diagnosed with breast cancer under the age of 40. Having several members of the family with cancer of the ovary or colon may also increase a man's risk of developing breast cancer.

There are special clinics for people who are concerned that they may have an increased risk of developing cancer because of a history of cancer in their family. These are known as family cancer genetic clinics. Your GP (family doctor) can refer you to one of these clinics if they think you may be at an increased risk of developing male breast cancer.

CancerBACUP has further information about genetics and cancer.

In rare circumstances men with high oestrogen levels or men who have been exposed to repeated doses of radiation (particularly at a young age) may be at an increased risk of developing breast cancer. Men who have a rare genetic condition called Klinefelter's syndrome, where an extra female chromosome is present, have a higher than normal risk of developing breast cancer.

Types of breast cancer in men
Different types of breast cancer can affect men. The most common type is called invasive ductal carcinoma, which is also the most common type of breast cancer to affect women. Other, rarer types are inflammatory breast cancer, Paget's disease of the breast and a pre-cancerous condition known as ductal carcinoma in situ (DCIS).

Signs and symptoms

The most common symptom is a lump in the breast. However, other signs may occur such as a change in the size or shape of the breast, an ulcer on the skin, fluid coming out of the nipple (discharge) or turning-in of the nipple (inversion). Another possible symptom is a rash on the nipple or surrounding area.

How is it diagnosed?

Your doctor will do a physical examination of the affected breast. Tests will be needed to confirm the diagnosis and to find out whether the cancer has spread. You may have some, or all, of the tests described below.

Ultrasound scan A scan using sound waves is used to see whether a lump is solid or contains fluid. A small amount of clear gel is applied to the breast area. Then a small microphone-like device is rubbed over the area to show a picture of the breast on a monitor screen.

Needle aspiration A thin needle is inserted into the breast in the area of the lump and some cells are drawn out. This may be done at the same time as the ultrasound so that the doctor can be sure that the cells are from the affected area of the breast. The cells are examined in the laboratory to see if any are cancerous (malignant).

Needle biopsy A small piece of tissue is taken from the breast with a needle and sent for examination under a microscope to check for cancer cells. An injection of local anaesthetic is given to numb the area before the biopsy is taken.

Blood tests These are done to check your general health before any operation.

Mammogram (breast x-ray) Mammograms may be used to look for changes in the breast, but ultrasound is more helpful for diagnosing breast cancer in men.

Staging and grading

Staging of breast cancer

The stage of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment.

In some people cancer can spread to other parts of the body, either in the blood stream or through the lymphatic system. The lymphatic system is part of the body's defences against infection and disease. The system is made up of a network of lymph glands or nodes that are linked by fine ducts containing lymph fluid. Your doctors will usually look at the nearby lymph nodes when staging your cancer.

Generally breast cancer is divided into four stages, from stage 1, which is small and localised to stage 4, where the disease has spread to other parts of the body. If the cancer has spread to distant parts of the body this is known as secondary or metastatic cancer.

A commonly used staging system is described below:

Stage 1 tumours These measure less than 2 centimetres across. The lymph glands in the armpit are not affected and there are no signs that the cancer has spread elsewhere in the body.

Stage 2 tumours These measure 2? centimetres across, or the lymph glands in the armpit are affected, or both. However, there are no signs that the cancer has spread further.

Stage 3 tumours These are larger than 5 centimetres across and may be attached to surrounding structures such as the muscle or skin. The lymph glands are usually affected, but there are no signs that the cancer has spread beyond the breast or the lymph glands in the armpit.

Stage 4 tumours These are of any size, but the lymph glands are usually affected and the cancer has spread to other parts of the body. This is secondary breast cancer.

Grading of breast cancer

Grading refers to the appearance of the cancer cells under the microscope. The grade gives an idea of how quickly the cancer may develop. There are three grades: grade 1 (low grade), grade 2 (moderate grade) and grade 3 (high grade). Low-grade means that the cancer cells look very like the normal cells of the breast. These cancer cells are usually slow-growing and less likely to spread. In high-grade tumours the cells look very abnormal. They are likely to grow more quickly and are more likely to spread.

Treatment

As breast cancer in men is so rare, there have been very few research studies looking at the treatments for this condition. It behaves in a similar way to breast cancer in women, and so is usually treated in much the same way. A combination of treatments is often used.

Surgery

For most men surgery is the first choice of treatment. However, men cannot usually have just the lump removed (lumpectomy). This is because the amount of breast tissue is small, and because the tumour is often near or under the nipple. Most men having surgery need to have a mastectomy (removal of all of the breast tissue and the nipple). Some or all of the lymph nodes under the arm are likely to be removed as well.

Hormonal therapy

Most breast cancers need the hormone oestrogen in order to grow. Oestrogen is the female sex hormone, but men have a small amount circulating in their bloodstream. Hormonal therapy is very effective in reducing the amount of oestrogen in the body and is used to try to prevent the cancer returning following surgery. Hormonal therapy may also be used to shrink the cancer if it returns after initial surgery.

Tamoxifen Tamoxifen is the hormonal therapy that is commonly used to treat breast cancer. It works by attaching itself to the oestrogen receptors on the surface of the cancer cells. This prevents oestrogen from entering the cells and can stop them from growing or dividing. Men usually have similar side effects to women who take tamoxifen (such as hot flushes or loss of sex drive). However, they may also experience difficulty in achieving erections.

Aromatase inhibitors such as letrozole, anastrozole, and exemestane. In men, oestrogen is made by the conversion of the male sex hormones (androgens). This conversion is carried out by the enzyme aromatase. Aromatase inhibitors are drugs that work by blocking aromatase and so blocking the formation of oestrogen. If aromatase inhibitors are used, they usually need to be given with drugs such as goserelin (Zoladex) that decrease the production of androgens.

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. Chemotherapy may be used after surgery if your doctors feel that there is a high risk of cancer cells having escaped from the breast to other parts of the body before the cancer was removed. Chemotherapy is usually given if there are cancer cells found in the lymph nodes under the arm, or if the cancer has spread beyond the breast. The chemotherapy drugs used to treat breast cancer in men are the same as those used to treat women with breast cancer. Your doctor will discuss with you whether chemotherapy is necessary in your situation.

Radiotherapy

Radiotherapy treats cancer by using high-energy rays to destroy the cancer cells. It may be used to reduce the chance of the cancer returning at the site of the scar after surgery. Radiotherapy may also be used to relieve pain or discomfort caused by a cancer that has spread to other parts of the body ?for example, the bone.

Research trials

Research into treatments for breast cancer in men is ongoing. Cancer doctors use clinical trials to assess new treatments. Before any trial is allowed to take place, an ethics committee must have approved it, to ensure that the trial is in the interest of patients.

You may be asked to take part in a clinical trial. Your doctor must discuss the treatment with you so that you have a full understanding of the trial and what it means to take part. You may decide not to take part or withdraw from a trial at any stage. You will then receive the best standard treatment available.

Your feelings

It is often very difficult to find information and support when you are diagnosed with a rare cancer. Men find that they experience many different emotions including anger, resentment, guilt, anxiety and fear. Some men find it difficult or embarrassing to talk about their breast cancer, especially as it more commonly affects women. These are all normal reactions and are part of the process many people go through in trying to come to terms with their illness. CancerBACUP has a section that discusses the emotional effects of cancer and how to deal with them.