Breast Cancer in Men

Overview

Male breast cancer is a rare cancer that forms in the breast tissue of men. Though breast cancer is most commonly thought of as a woman’s disease, male breast cancer does occur. Male breast cancer is most common in older men, though it can occur at any age. Men diagnosed with male breast cancer at an early stage have a good chance for a cure. Still, many men delay seeing their doctors if they notice one of the usual signs or symptoms, such as a breast lump. For this reason, many male breast cancers are diagnosed when the disease is more advanced.

Male breast cancer is a relatively rare cancer in men that originates from the breast. Most cases of male breast cancer develop in men who are 65 or over, although cases have been recorded in men aged anywhere from 5 to 93. The estimated 5-year survival rate for early-stage male breast cancer is almost 100 percent. For mid-stage male breast cancer, it is 72-91 percent, and for advanced-stage male breast cancer, there is 20 percent chance of survival after 5 years from detection. A man’s lifetime risk of developing breast cancer is about 1 in 1,000 thousand.

Men possess a small amount of nonfunctioning breast tissue (breast tissue that cannot produce milk) that is concentrated in the area directly behind the nipple on the chest wall. Like breast cancer in women, cancer of the male breast is the uncontrolled growth of some of the cells of this breast tissue that have the potential to spread elsewhere in the body. These cells become so abnormal in appearance and behavior that they are then called cancer cells.

Breast tissue in healthy young boys and girls consists of tubular structures known as ducts. At puberty, a girl’s ovaries produce female hormones (estrogen) that cause the ducts to grow and milk glands (lobules) to develop at the ends of the ducts. The amount of fat and connective tissue in the breast also increases as girls go through puberty. On the other hand, male hormones (such as testosterone) secreted by the testes suppress the growth of breast tissue and the development of lobules. The male breast, therefore, is made up of predominantly small, undeveloped ducts and a small amount of fat and connective tissue.

Symptoms

The most common symptom of male breast cancer is the appearance of a lump in the breast. In most cases, the lump will be painless. Less common symptoms of male breast cancer usually affect the nipple. Such symptoms include nipple retraction, ulceration, and discharge, where fluid begins to leak from the nipple. If the cancer spreads, additional symptoms may include breast pain, bone pain, and swelling of the lymph nodes (glands) near the breast, usually in or around, the armpit.

Symptoms of breast cancer in men are similar to those in women. Most male breast cancers are diagnosed when a man discovers a lump on his chest. But unlike women, men tend to delay going to the doctor until they have more severe symptoms, like bleeding from the nipple. At that point, the cancer may have already spread.

• A painless lump or thickening in your breast tissue
• Changes to the skin covering your breast, such as dimpling, puckering, redness or scaling
• Changes to your nipple, such as redness or scaling, or a nipple that begins to turn inward
• Discharge from your nipple

Diagnosis  

The same techniques that are used to diagnose breast cancer in women are used in men: physical exams, mammography, and biopsies (examining small samples of tissue under a microscope).

Likewise, the same treatments that are used in treating breast cancer in women — surgery, radiation, chemotherapy, biological therapy, and hormone therapy — are also used to treat breast cancer in men. The one major difference is that men with breast cancer respond much better to hormone therapy than women do. About 90% of male breast cancers have hormone receptors, meaning that hormone therapy can work in most men to treat the cancer.

Diagnostic mammography

A mammogram is an x-ray exam of the breast. It is called a diagnostic mammogram when it is done because problems are present.

For a mammogram, the breast is pressed between 2 plates to flatten and spread the tissue. This may be uncomfortable for a moment, but it is necessary to produce a good, readable mammogram. The compression only lasts a few seconds. This procedure produces a black and white image of the breast tissue either on a large sheet of film or as a digital computer image that is read, or interpreted, by a radiologist (a doctor trained to interpret images from x-rays and other imaging tests). In some cases, special images known as cone or spot views with magnification are used to make a small area of abnormal breast tissue easier to evaluate.

The results of this test might suggest that a biopsy is needed to tell if the abnormal area is cancer. Mammography is often more accurate in men than women, since men do not have dense breasts or other common breast changes that might interfere with the test.

Breast ultrasound

Ultrasound, also known as sonography, uses high-frequency sound waves to outline a part of the body. Most often, a small, microphone-like instrument called a transducer is placed on the skin (which is first lubricated with gel). It emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image on a computer screen. A newer ultrasound machine that was designed to look at the breast uses a much larger transducer that can examine the entire breast at once.

This test is painless and does not expose you to radiation.

Breast ultrasound is often used to evaluate breast abnormalities that are found during mammography or a physical exam. It can be useful to see if a breast lump or mass is a cyst or a tumor. A cyst is a non-cancerous, fluid-filled sac that can feel the same as a tumor on a physical exam. A mass that is not a simple cyst will often need to be biopsied.

In someone with a breast tumor, ultrasound can also be used to look at the lymph nodes under the arm to see if they are enlarged. If they are, ultrasound can be used to guide a needle to take a sample (a biopsy) to look for cancer cells.

Magnetic resonance imaging (MRI) of the breast

MRI machines are quite common, but they need to be specially adapted to look at the breast. It’s important that MRI scans of the breast be done on one of these specially adapted machines and that the MRI facility can also do a MRI-guided biopsy if it is needed. MRI can be used to better examine suspicious areas found by a mammogram. MRI is also sometimes used in someone who has been diagnosed with breast cancer to better determine the actual size of the cancer and to look for any other cancers in the breast.

Nipple discharge exam

Fluid leaking from the nipple is called nipple discharge. If you have a nipple discharge, you should have it checked by your doctor. If there is blood in this fluid, you might need more tests. One test collects some of the fluid to look at under a microscope to see if cancer cells are present. This test is often not helpful, since a breast cancer can still be there even when no cancer cells are found in the nipple discharge. Other tests may be more helpful, such as a mammogram or breast ultrasound. If you have a breast mass, you will probably need a biopsy, even if the nipple discharge does not contain cancer cells or blood.

Biopsy

A biopsy removes a body tissue sample to be looked at under a microscope. A biopsy is the only way to tell if a breast abnormality is cancerous. Unless the doctor is sure the lump is not cancer, this should always be done. There are several types of biopsies. Your doctor will choose the type of biopsy based on your situation.

Fine needle aspiration biopsy: Fine needle aspiration (FNA) biopsy is the easiest and quickest biopsy technique. The doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area. The doctor can guide the needle into the area of the breast abnormality while feeling the lump. A local anesthetic (numbing medicine) may or may not be used. Because such a thin needle is used for the biopsy, the process of getting the anesthetic might actually be more uncomfortable than the biopsy itself.

Core needle biopsy: For a core biopsy, the doctor removes a small cylinder of tissue from a breast abnormality to be looked at under a microscope. The needle used in this technique is larger than that used for FNA. The biopsy is done with local anesthesia and can be done in a clinic or doctor’s office.

Surgical (open) biopsy: Most breast cancer can be diagnosed with a needle biopsy. Rarely, though, surgery is needed to remove all or part of the lump to know for certain if cancer is present. Most often, the surgeon removes the entire mass or abnormal area, as well as a surrounding margin of normal-appearing breast tissue. This is called an excisional biopsy. If the mass is too large to be removed easily, only part of it may be removed. This is called an incisional biopsy.

Lymph node biopsy: Cancer in the breast can spread to lymph nodes under the arm and around the collar bone (clavicle). If any of these lymph nodes are enlarged, they may be biopsied. Often, this is done with a needle biopsy during the same procedure as the breast biopsy.

Lymph node dissection and sentinel lymph node biopsy: These procedures are done specifically to look for breast cancer spread to lymph nodes. They are described in more detail under “Types of breast surgery” in the “ Surgery for breast cancer in men” section.

Treatment

Surgery – this is usually the first treatment option for male breast cancer, and usually involves an operation called a modified radical mastectomy.

The surgeon removes the entire breast and the lymph nodes in the armpit.

Estrogen hormone therapy – in some cancers, estrogen receptors are present on the walls of the cancerous cells.

In these cases, estrogen helps the cells to divide and grow. Hormone therapy blocks the effects of estrogen and slows the growth.

Tamoxifen – a widely used medication in hormone therapy. It prevents estrogen from entering the cancerous cells.

Aromatase inhibitors – these block the effects of the aromatase protein that, in turn, lowers the amount of estrogen in the body.

Chemotherapy – if there are no estrogen receptors on the cancerous cells, hormone therapy does not work. In these cases, chemotherapy is used. Chemotherapy is usually given after surgery in order to prevent the cancer returning, or it is used to treat the symptoms of incurable cancer.

Risk Factors

A risk factor is anything that affects your chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx (voice box), bladder, kidney, and several other organs.

But risk factors don’t tell us everything. Having a risk factor, or even several, does not mean that you will get the disease. Some men with one or more breast cancer risk factors never develop the disease, while most men with breast cancer have no apparent risk factors. Even when someone has a risk factor, there is no way to prove that it actually caused the cancer.

We don’t yet completely understand the causes of breast cancer in men, but researchers have found several factors that may increase the risk of getting it. As with female breast cancer, many of these factors are related to your body’s sex hormone levels.

Aging

Aging is an important risk factor for the development of breast cancer in men. The risk of breast cancer goes up as a man ages. On average, men with breast cancer are about 68 years old when they are diagnosed.

Family history of breast cancer

Breast cancer risk is increased if other members of the family (blood relatives) have had breast cancer. About 1 out of 5 men with breast cancer have a close relative, male or female, with the disease.

Inherited gene mutations

Men with a mutation (defect) in the BRCA2 gene have an increased risk of breast cancer, with a lifetime risk of about 6 in 100. BRCA1 mutations can also cause breast cancer in men, but the risk is lower, about 1 in 100.

Although mutations in these genes most often are found in members of families with many cases of breast and/or ovarian cancer, they have also been found in men with breast cancer who did not have a strong family history.

Mutations in CHEK2 and PTEN genes also may be responsible for some breast cancers in men.

Klinefelter syndrome

Klinefelter syndrome is a congenital condition (present at birth) that affects about 1 in 1,000 men. Normally the cells in men’s bodies have a single X chromosome along with a Y chromosome, while women’s cells have 2 X chromosomes. Men with this condition have cells with a Y chromosome plus at least 2 X chromosomes (but sometimes more).

Men with Klinefelter syndrome also have small testicles (smaller than usual). Often, they are infertile because they are unable to produce functioning sperm cells. Compared with other men, they have lower levels of androgens (male hormones) and more estrogens (female hormones). For this reason, they often develop gynecomastia (benign male breast growth).

Some studies have found that men with Klinefelter syndrome are more likely to get breast cancer than other men. One study of men with this syndrome found that the risk of getting breast cancer was about 1% (1 in 100). But this is a hard area to study because these are both uncommon problems, and it is hard to collect enough cases to be sure. The risk seems to be increased, but overall it is still low because this is such an uncommon cancer, even for men with Klinefelter syndrome.

Radiation exposure

A man whose chest area has been treated with radiation (such as for the treatment of a cancer in the chest, such as lymphoma) has an increased risk of developing breast cancer.

Alcohol

Heavy drinking (of alcoholic beverages) increases the risk of breast cancer in men. This may be because of its effects on the liver (see next paragraph).

Liver disease

The liver plays an important role in sex hormone metabolism by making binding proteins that carry the hormones in the blood. These binding proteins affect the hormones’ activity. Men with severe liver disease such as cirrhosis have relatively low levels of androgens and higher estrogen levels. They have a higher rate of benign male breast growth (gynecomastia) and also have an increased risk of developing breast cancer.

Estrogen treatment

Estrogen-related drugs were once used in hormonal therapy for men with prostate cancer. This treatment may slightly increase breast cancer risk.

There is concern that transgender/transsexual individuals who take high doses of estrogens as part of a sex reassignment could also have a higher breast cancer risk. Still, there haven’t been any studies of breast cancer risk in transgendered individuals, so it isn’t clear what their breast cancer risk is.

Obesity

Studies have shown that women’s breast cancer risk is increased by obesity (being extremely overweight) after menopause. Obesity is probably a risk factor for male breast cancer as well. The reason is that fat cells in the body convert male hormones (androgens) into female hormones (estrogens). This means that obese men have higher levels of estrogens in their body. Some obese men may notice that they don’t have to shave as frequently as other men. They might also have trouble fathering children. Regular exercise and maintaining a healthy weight may help reduce the risk of breast cancer, as well as that of many other diseases and cancers.

Testicular conditions

Some studies have suggested that certain conditions, such as having an undescended testicle, having mumps as an adult, or having one or both testicles surgically removed (orchiectomy) may increase male breast cancer risk. Although the risk seems to be increased, overall it is still low.

Certain occupations

Some reports have suggested an increased risk in men who work in hot environments such as steel mills. This could be because being exposed to higher temperatures for long periods of time can affect testicles, which in turn would affect hormone levels. Men heavily exposed to gasoline fumes might also have a higher risk. More research is needed to confirm these findings.

Causes

Hormone levels

Breast cells normally grow and divide in response to female hormones such as estrogen. The more cells divide, the more chances there are for mistakes to be made when they are copying their DNA. These DNA changes can eventually lead to cancer (see below).

Factors that change the ratio of female and male hormones in the body can therefore have an effect on breast cancer risk. Many of these were described in the section ” What are the risk factors for breast cancer in men?”

 Gene changes (mutations)

Researchers are making great progress in understanding how certain changes in DNA can cause normal cells to become cancerous. DNA is the chemical in our cells that makes up our genes, the instructions for how our cells function. We usually look like our parents because they are the source of our DNA. However, DNA affects more than how we look.

 Some genes contain instructions for controlling when our cells grow, divide, and die. Certain genes that speed up cell division are called oncogenes. Others that slow down cell division or cause cells to die at the appropriate time are called tumor suppressor genes. Cancers can be caused by DNA mutations (defects) that turn on oncogenes or turn off tumor suppressor genes.

 Acquired gene mutations

Most DNA mutations related to male breast cancer occur during life rather than having been inherited before birth. It’s not clear what causes most of these mutations. Radiation to the breast area is a factor in a small number of cases. Some acquired mutations of oncogenes and/or tumor suppressor genes may be the result of cancer-causing chemicals in our environment or diet, but so far studies have not identified any chemicals that are responsible for these mutations in male breast cancers.

Inherited gene mutations

Certain inherited DNA changes can cause a high risk of developing certain cancers and are responsible for cancers that run in some families.

Some breast cancers are linked to inherited mutations of the BRCA1 or BRCA2 tumor suppressor genes. Normally, these genes make proteins that help cells recognize and/or repair DNA damage and prevent them from growing abnormally. But if a person has inherited a mutated gene from either parent, the chances of developing breast cancer are higher.

In women, mutations of BRCA1 and BRCA2 are responsible for a small fraction of breast cancers. Women with either of these altered genes have a very high risk of breast cancer.

In men, changes in the BRCA2 gene seem to be responsible for some breast cancer cases, but different studies have different estimates for how many.

Staging

Doctors carry out staging to determine the extent to which a cancer has spread within the body. Staging of breast cancer in men is carried out identically to the staging of breast cancer in women. Imaging studies such as X-rays, CT scans, magnetic resonance imaging (MRI), ultrasound, and bone scans may be performed to evaluate the presence and extent of metastatic disease once the initial diagnosis of breast cancer had been made. The American Joint Committee on Cancer (AJCC) TNM staging system takes into account the tumor size, lymph node involvement by cancer, and presence of metastasis. For 2018, a new edition of the AJCC staging system also takes into account biologic characteristics of the tumor including estrogen receptor (ER) and progesterone receptor (PR) status, tumor grade (the appearance of the cells under a microscope and their similarity to normal cells), and the presence of the HER-2 protein on the cancer cells.

• T: tumor size and extent of local spread
• N: extent of tumor involvement of lymph nodesin the axillary (underarm) region. Since the nipple area is rich in lymphatic vessels, male breast cancer commonly spreads via the lymphatic channels to the axillary lymph nodes. (When the tumor has spread to the lymph nodes, doctors sometimes use the term “lymph node-positive” cancer.)
• M: presence of distant metastases (spread to other parts of the body through the bloodstream or lymphatic vessels).

Stage 0

Stage 0 refers to intraductal carcinoma or ductal cancer in situ, in which the cancer cells have not spread beyond the boundaries of the ducts themselves.

Stage I

In Stage I breast cancer, the tumor is 2 cm or less in greatest diameter and has not spread to the lymph nodes or to other sites in the body.

Stage II

Stage II cancers are divided into two groups. Stage IIA cancer is either less than 2 cm in diameter with spread to the axillary lymph nodes, or the tumor is between 2 cm-5 cm but has not spread to the axillary lymph nodes. Stage IIB tumors are either larger than 5 cm without spread to the lymph nodes or are between 2 cm-5 cm in size and have spread to the axillary lymph nodes.

Stage III

Stage III is considered to be locally advanced cancer. Stage IIIA means the tumor is smaller than 5 cm but has spread to the axillary lymph nodes, and the axillary lymph nodes are attached to each other or to other structures; or the tumor is greater than 5 cm in diameter with spread to the axillary lymph nodes, which may be attached to each other or to other structures. Stage IIIB tumors have spread to surrounding tissues such as skin, chest wall, or to the lymph nodes inside the chest wall.

Stage IV

Stage IV cancer refers to metastatic cancer, meaning it has spread to other parts of the body. With breast cancer, metastases (sites of tumor elsewhere in the body) are most often found in the bones, lungs, liver, or brain. It may also reoccur in and spread to involve areas of the chest wall, skin, and muscles, as well as more distant lymph nodes.

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