Male breast cancer

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Male breast cancer
By Mayo Clinic staff

Definition
Breast cancer isn't just a woman's disease. Men also have breast tissue that can undergo cancerous changes. While women are about 100 times more likely to get breast cancer, any man can develop breast cancer. Male breast cancer is most common between the ages of 60 and 70.

The prognosis for male breast cancer is the same as for breast cancer in women. In the past, male breast cancer was often diagnosed at a more advanced stage, which may have led people to believe it had a worse prognosis. Although male breast cancer and breast cancer in women are similar, important distinctions such as breast size and awareness affect early diagnosis and survival in cases of male breast cancer.

Symptoms
Knowing the signs and symptoms of breast cancer may help save your life. The earlier the disease is discovered, the more treatment options and the better chance of recovery you have.

The most common sign of breast cancer for both men and women is a lump or thickening in the breast. Often the lump is painless. Other male breast cancer symptoms include:

Skin dimpling or puckering
Development of a new retraction or indentation of the nipple
Changes in the nipple or breast skin, such as scaling or redness
Nipple discharge
Causes
Cancer is a group of abnormal cells that grow more rapidly than do normal cells. Cancer cells also have the ability to invade and destroy normal tissues, either by growing directly into surrounding structures or after traveling to another part of your body through your bloodstream or lymphatic system. Microscopic cancer cells form small clusters that continue to grow, becoming more densely packed and hard.

In most cases it isn't clear what triggers abnormal cell growth in breast tissue in men. But doctors do know that about one in six cases of breast cancers in men are inherited, compared with about 5 percent to 10 percent of breast cancers in women. Defects in breast cancer gene 1 or 2 (BRCA 1 or BCRA 2) put you at greater risk of developing breast cancer. Other inherited genes also may increase your risk of developing breast cancer. Knowing your family history is important to determine your chance of inheriting an abnormal gene.

Most genetic mutations related to breast cancer aren't inherited, but instead develop during your lifetime. These acquired mutations may result from radiation exposure, such as receiving chest radiation therapy in childhood, or from other, as yet unknown, factors.

Risk factors
A risk factor is anything that makes it more likely you'll get a particular disease. But not all risk factors are created equal. Some, such as your age, sex and family history, can't be changed. Others, including smoking and a poor diet, are personal choices over which you have some control.

Having one or even several risk factors doesn't necessarily mean you'll become sick — some men with more than one risk factor never get breast cancer, whereas others with no identifiable risk factors do.

Factors that may make you more susceptible to breast cancer include:

Age. Breast cancer is most commonly diagnosed in men between the ages of 60 and 70, with an average age range of 65 to 67.
Family history. If you have a close relative, such as a mother or sister, with breast cancer, you have a greater chance of also developing the disease. About one in five men with breast cancer have a relative who's had it, too. Just because you have a family history of breast cancer doesn't mean it's hereditary, though.
Genetic predisposition. In men, nearly 20 percent of breast cancers are inherited. Defects in one of several genes, especially BRCA1 or BRCA2 put you at greater risk of developing breast and prostate cancers. Usually these genes help prevent cancer by making proteins that keep cells from growing abnormally. But if they have a mutation, the genes aren't as effective at protecting you from cancer.

Men with a BRCA2 mutation have a 6 percent lifetime risk of breast cancer — about 100 times more than other men's risk. Inherited mutations in the cell-cycle checkpoint kinase 2 (CHEK-2) gene and the p53 tumor suppressor gene also make it more likely that you'll develop breast cancer.

Radiation exposure. If you received radiation treatments to your chest as a child or young adult, you're more likely to develop breast cancer later in life.
Klinefelter's syndrome. This condition results from an abnormality of the sex chromosomes, X and Y, present at birth (congenital). A male normally has only one X and one Y chromosome. In Klinefelter's syndrome, two or more X chromosomes are present in addition to one Y chromosome. The Y chromosome contains the genetic material that determines the sex of a child and related development.

The extra X chromosome that occurs in Klinefelter's syndrome causes abnormal development of the testicles. As a result, men with this syndrome produce lower levels of certain male hormones — androgens — and more female hormones — estrogens, which can cause noncancerous breast growth (gynecomastia). Men with this condition may be at greater risk of breast cancer, though this connection is still unclear.

Exposure to estrogen. If you take estrogen-related drugs, such as those used as part of a sex change procedure, you have a much higher risk of breast cancer. Estrogen drugs may also be used in hormone therapy for prostate cancer. Such drugs may slightly increase your risk of breast cancer, though not enough to outweigh the benefit of treating prostate cancer.
Liver disease. If you have liver disease, such as cirrhosis of the liver, your body's androgen activity may be reduced and its estrogen activity greater. This can increase your risk of gynecomastia and breast cancer.
Excess weight. Obesity may be a risk factor for breast cancer in men, because it increases the number of fat cells in the body. Fat cells convert androgens into estrogen, increasing the amount of estrogen in your body and, therefore, your risk of breast cancer.
Excessive use of alcohol. If you drink heavy amounts of alcohol, you have a greater risk of breast cancer.
When to seek medical advice
Most breast lumps in men are a result of enlarged breasts (gynecomastia), not breast cancer. However, it's important to have lumps evaluated promptly. If a problem exists, you can have it identified and treated as soon as possible. See your doctor if you discover a lump or any of the other warning signs of breast cancer.

Tests and diagnosis
Because male breast cancer is rare, routine screening mammograms (mammography) generally aren't recommended for men. If, however, you have a strong family history of breast cancer, consider talking to your doctor about developing a breast-screening program.

If your doctor suspects breast cancer, to diagnose your condition he or she may conduct a number of tests including breast examination (clinical breast exam), mammograms (mammography) or other tests:

Clinical breast exam. During this exam, your doctor examines your breasts for lumps or other changes. He or she may be able to feel lumps you missed and will assess how large the lumps are, how they feel, and how close they are to your skin and muscles. Your doctor will also examine the rest of your body for signs that the cancer has spread, such as an enlarged liver or lymph nodes.
Mammogram. A mammogram uses a series of X-rays to show images of your breast tissue. This test may be even more accurate in men than in women, because men don't have dense breast tissue that can make it difficult to distinguish abnormal from normal tissue or breast cysts. During a mammogram, your breasts are compressed between plastic plates while a radiology technician takes the X-rays. If you find the compression too uncomfortable, tell the technician.
Breast ultrasound (ultrasonography). Your doctor may use this technique to evaluate an abnormality seen on a mammogram or found during a clinical exam. Ultrasound uses sound waves to form images of structures within the body.
Nipple discharge examination. Your doctor may collect nipple discharge if you're experiencing it. The discharge is then examined for cancerous cells.
Biopsy. A biopsy is the only way for your doctor to know whether a lump or abnormality is cancer. Biopsies can provide important information about an unusual breast change and help determine whether treatment is needed and, if so, the type of treatment required. To obtain a tissue sample, your doctor may use one of several procedures.

Fine-needle aspiration biopsy is used for lumps you or your doctor can feel. During the procedure your doctor uses a thin, hollow needle to withdraw cells from the lump. He or she then sends the cells to a lab for analysis.

In core needle biopsy, a radiologist or surgeon uses a hollow needle to remove tissue samples from a breast lump. A number of samples, each about the size of a grain of rice, may be taken, and a pathologist then analyzes them for malignant cells. The advantage of a core needle biopsy is that it removes tissue, rather than just cells, for analysis.

In surgical biopsy, your surgeon removes all or part of a breast lump. In general, a small lump will be completely removed (excisional biopsy). If the lump is larger, only a sample will be taken (incisional biopsy). The biopsy is generally performed on an outpatient basis in a clinic or hospital.

Estrogen and progesterone receptor tests. If a biopsy reveals malignant cells, your doctor will recommend additional tests — such as estrogen and progesterone receptor tests — on the malignant cells. These tests help determine whether female hormones affect the way the cancer grows. About 90 percent of male breast cancers have estrogen receptors, and more than 80 percent have progesterone receptors. If the cancer cells have receptors for estrogen or progesterone or both, your doctor may recommend treatment with a drug such as tamoxifen, which prevents estrogen from binding to these cells and stimulating growth.
HER2 testing. If the biopsy shows malignant cells, your doctor may also test the sample for the presence of a protein called human epidermal growth factor receptor-2 (HER2), which promotes the growth of cancer cells. About 30 percent of male breast cancers have too much of this protein. Such cancers are usually more aggressive, growing and spreading more quickly than do other breast cancers. Once identified, this type of cancer is treated with a drug called trastuzumab (Herceptin). This medication keeps the protein from stimulating the growth of breast cancer cells.
Staging tests
If your doctor finds cancer, he or she will examine you further to determine if and how far the cancer has spread. Staging tests help determine the size and location of your cancer and whether it has spread. They also help your doctor determine the best treatment for you. Cancer is staged using the numbers 0 through IV:

Stage 0 cancers are also called noninvasive or in situ (in one place) cancers. Although they haven't spread to other parts of your body or invaded normal breast tissue, it's important to have them removed, because they eventually can become invasive cancers. Finding and treating a cancerous lump at this stage offers the best chance for a full recovery.
Stage I to IV cancers are invasive tumors that have the ability to spread to other areas. A stage I cancer is small and well localized and has a very successful treatment rate. But the higher the stage number, the lower the chances of cure. By stage IV, the cancer has spread beyond your breast to other organs, such as your bones, lungs or liver. Although it may not be possible to eliminate the cancer at this stage, its spread and some symptoms may be controlled with radiation, hormonal therapy, chemotherapy or all three.
Tests to determine a cancer's spread may include:

Chest X-ray. Your doctor may take a chest X-ray to see whether the cancer has spread to your lungs.
Computerized tomography. A CT scan is an X-ray technique that produces more-detailed images of your internal organs than do conventional X-ray exams. Conventional X-ray exams produce 2-D images. But CT uses an X-ray-sensing unit that rotates around your body and a large computer to create cross-sectional images (like slices) of the inside of your body. A CT scan can help your doctor see if cancer has spread to your liver or other organs. Some CT scans require you to ingest a contrast medium before the scan. A contrast medium blocks X-rays and appears white on images, which can help emphasize some structures in your body.
Magnetic resonance imaging (MRI). This test uses a magnetic field and radio waves to create cross-sectional images. Most MRI machines are large, cylindrical-shaped magnets. The strong magnetic field is produced by passing an electric current through wire loops or coils, which are located inside a protective housing. Other coils in the housing send and receive radio waves. When you're in the machine, your body produces very faint signals in response to the radio waves. These signals are detected by coils within the machine, or by additional coils designed to surround a specific body part needing examination. A computer then processes the signals and generates an image. The collected signals create a composite, 3-D representation of your body.
Positron emission tomography (PET) scan. Unlike other scanning techniques, a PET scan doesn't produce clear structural images of organs. Instead, it shows images containing areas of more or less intense color to provide information about chemical activity within certain organs and tissues. Tumors often use more energy than healthy tissues do and may absorb more of a radioactive tracer, which allows the tumors to appear on the scan.
Genetic testing
The discovery of BRCA2 and other genes that may increase breast cancer risk has raised a number of emotional and legal questions about genetic testing. A simple blood test can help identify defective BRCA genes, but it's not 100 percent accurate. And it's important to know that having a defective BRCA gene doesn't mean you'll get breast cancer. In addition, test results can't determine at what age you might develop cancer, how aggressively the cancer might progress or what your risk of death might be.

In general, testing is most beneficial if the results will help you make a decision about how you might best reduce your chance of developing breast cancer, such as modifying your lifestyle or closer screening. It may also help family members decide if they should be tested or evaluated for the presence of an abnormal gene. Be sure to thoroughly discuss all your options with a genetic counselor before any testing is done, so that you can understand the risks and the benefits of such testing.

Treatments and drugs
Breast cancer in men is generally treated the same as it is in women. In most cases no one right treatment exists. Instead, you'll want to find the approach that's best for you. To do that, you'll need to consider many different factors, including the stage of your cancer and your age.

Before making any decisions, learn as much as you can about the many treatment options. Talk extensively with your health care team. Consider a second opinion. Don't be afraid to ask questions. In addition, look for breast cancer books, Web sites, and information from organizations such as the American Cancer Society and Susan G. Komen for the Cure. Talking to others who have faced the same decision also may help. This may be the most important decision you ever make.

Treatments exist for every type and stage of breast cancer. Some men may need only surgery. Others will need surgery and an additional (adjuvant) therapy such as radiation, chemotherapy or hormone therapy.

Surgery
Breast-sparing procedures are often an option for women, but are not typically feasible for men. This is because a man's breast doesn't contain much tissue, so removing the cancer usually means removing all of the breast. Breast cancer operations include the following:

Simple mastectomy. During a simple mastectomy, your surgeon removes all of your breast tissue — the lobules, ducts, fatty tissue, and a strip of skin with the nipple and areola. Depending on the results of the operation and follow-up tests, you may also need treatment with radiation to the chest wall, chemotherapy or hormone therapy.
Modified radical mastectomy. Most men with breast cancer require a modified radical mastectomy. In this procedure, a surgeon removes your entire breast and some underarm (axillary) lymph nodes, but leaves your chest muscles intact. If the cancer has spread into the chest wall, your doctor may need to do a radical mastectomy that removes the chest wall muscles. Serious arm swelling (lymphedema) is more likely to occur in modified radical mastectomy than in simple mastectomy with sentinel node biopsy. Your lymph nodes will be tested to see if the cancer has spread. Depending on those results, you may need further treatment.
Sentinel lymph node biopsy. Breast cancer first spreads to the lymph nodes under the arm. That's why you need to have these nodes examined. If your surgeon doesn't plan to do this, be sure you understand the reason. Until recently surgeons would remove as many lymph nodes as possible. But this greatly increased the risk of numbness, recurrent infections and serious swelling of the arm. That's why a procedure has been developed that focuses on finding the sentinel nodes — the first nodes to receive the drainage from breast tumors and therefore the first to develop cancer. If a sentinel node is removed, examined and found to be healthy, the chance of finding cancer in any of the remaining nodes is very small, and no other nodes need to be removed. This spares the need for a more extensive operation and decreases the risk of complications. It's important that the procedure be performed by an experienced team.
Radiation therapy
Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. It's administered by a radiation oncologist at a radiation center. It may be used to shrink the tumor before surgery or to eliminate any remaining cancer cells in the breast, chest muscles or armpit after surgery.

Most men who undergo radiation therapy for breast cancer receive external beam radiation. In this procedure you receive radiation directed at the cancerous area from a machine outside your body. Radiation is usually started three to four weeks after surgery, to allow some time for your body to heal.

If your doctor recommends chemotherapy, the radiation will be delayed until all of the chemotherapy treatments are completed. You'll typically receive treatment five days a week for about six consecutive weeks. The treatments are painless, and each treatment takes just a few minutes. The effects are cumulative, however, and you may become quite tired toward the end of the series. Your breast may be pink, puffy and somewhat tender, as if it had been sunburned.

Chemotherapy
Chemotherapy uses drugs to destroy cancer cells. Your doctor may recommend chemotherapy after surgery to kill any cancer cells that may have spread outside your breast. Treatment often involves receiving two or more drugs in different combinations. These may be administered intravenously, in pill form or both. You may have treatments every two or three weeks for three to six months.

For many people, chemotherapy can feel like another illness. The side effects may include hair loss, nausea, vomiting and fatigue. These effects occur because chemotherapy affects healthy cells — especially fast-growing cells in your digestive tract, hair and bone marrow — as well as cancerous ones. Not everyone has side effects, however, and there are now better ways to control some of them.

New drugs can help prevent or reduce nausea. Relaxation techniques, including guided imagery, meditation and deep breathing, also may help. In addition, exercise has been shown to be effective in reducing fatigue caused by chemotherapy.

One side effect of chemotherapy that has only recently been described is called "chemobrain." This refers to the difficulties some patients have with thinking or concentrating while receiving chemotherapy or after. It's uncertain how commonly this occurs, or if this is even due to the chemotherapy. Many people who receive chemotherapy don't experience this side effect. Those who do may have difficulty with word finding, memory, multitasking and learning new things. Studies suggest it may effect between 20 percent and 30 percent of people undergoing chemotherapy. There's no way to predict who will experience this mild cognitive impairment, and it's not clear whether the treatment or the cancer is the actual cause of chemobrain.

In rare cases, certain chemotherapy medications may lead to cancer of the white blood cells (acute myeloid leukemia) — usually within one to two years after treatment ends. Some chemotherapy medications have the potential to damage the heart.

Hormone therapy
Estrogen receptor positive cancer means that estrogen might encourage the growth of breast cancer cells in your body. Estrogen is present in men, though in smaller amounts than in women. But 90 percent of breast cancers in men have estrogen receptors. Normally estrogen binds to certain cells in your breast and in other parts of your body. Hormone-blocking agents such as tamoxifen block this binding of estrogen to those receptors. This may help destroy cancer cells that have spread or reduce the chances that your cancer will recur.

The primary medication used to reduce the effect of estrogen in your body is tamoxifen (Nolvadex). This synthetic hormone belongs to a class of drugs known as selective estrogen receptor modulators (SERMs). It's used as a treatment for men with hormone-sensitive metastatic breast cancer and as an adjuvant therapy for men with early-stage estrogen receptor positive breast cancer. You take tamoxifen daily, in pill form, for five years.

The male hormones — androgens — also play a role in the growth of breast cancer in men, although the role is unclear. Limiting androgens through the use of certain drugs does appear to effectively reduce the spread of the cancer. These drugs include:

Luteinizing hormone-releasing hormone analogues. These drugs cause the testicles to reduce their androgen production.
Anti-androgen drugs. Anti-androgens block the effect of male hormones on breast cancer cells.
Side effects of hormonal therapies may include hot flashes, decreased sexual desire, loss of erection, weight gain and mood swings.

A new group of hormonal therapy medications called aromatase inhibitors (anastrozole, exemestane and letrozole) are used to treat hormone-sensitive breast cancer in postmenopausal women. At this time, no data exist as to the usefulness of these medications in the treatment of male breast cancer.

Herceptin therapy
One new medication, trastuzumab (Herceptin), is a monoclonal antibody that attacks and blocks the activity of a certain protein made by some breast cancers. Only about one-third of breast cancers make too much of this protein called HER-2-neu. This protein stimulates the cancer cells to grow. Trastuzumab binds onto this protein and blocks its effect and kills the cancer cells. This treatment only works in those breast cancers that make too much HER-2-neu. Side effects of trastuzumab are uncommon, but may include heart problems, fever, chills, nausea and vomiting, weakness, diarrhea and headache.

Biological therapy
Sometimes called biological response modifier or immunotherapy, this treatment tries to stimulate your body's immune system to fight cancer. Using substances produced by the body or similar substances made in a laboratory, biological therapy seeks to enhance your body's natural defenses against specific diseases. Many of these therapies are experimental and available only in clinical trials.

Prevention
To help reduce your risk of breast cancer, maintain a healthy body weight and avoid heavy alcohol use. Early detection also increases your chances of surviving the disease. So if you develop a breast lump or other abnormality, seek prompt care.

Coping and support
After a diagnosis of breast cancer, it may take some time to sort through all your emotions. But you can still feel in charge of your life. One of the best ways to regain control is to educate yourself about breast cancer and its treatment. You'll have many decisions to make in the weeks and months ahead. The more you know, the better prepared you'll be to make the best choices.

In addition to talking to your medical team — your surgeon, a specialist in chemotherapy and hormone therapy (medical oncologist) and a specialist who administers radiation therapy (radiation oncologist) — you may also want to talk to a counselor or medical social worker. Or you may find it helpful and encouraging to talk to other men with cancer.

There are also excellent books about breast cancer and many reputable resources on the Internet. Be sure to look for the most current information, however. Breast cancer treatments are changing rapidly, and information quickly becomes dated. It's important not to rely on just one source. There are many different approaches to breast cancer treatment.

Telling others
Unfortunately, treatment decisions aren't the only decisions you'll face. Every day may present new challenges. One of the first will likely be how and when to tell those closest to you. If you have children, telling them — no matter what their ages — can be difficult. Yet it's best to be as honest as you can. You don't have to give all the details. How much and what you say will depend on each child's age and ability to understand. But trying to hide your illness isn't a good idea. Instead, tell your children you're doing everything possible to get well.

The decision to tell friends and co-workers isn't easy either. Especially in the beginning, you may not want anyone outside your family to know. But over time you may find it helpful to confide in a few close friends or co-workers. Still, how much and whom to tell is up to you.

Keep in mind that people may not always react as you expect. Some may have many of the same feelings you do — anger, fear, grief. Others may be incredibly supportive. And some may not say much at all or may even avoid you. That's not because they don't care, but because they may not know what to say. Let them know that there are no right words and that their concern is enough.

Maintaining a strong support system
More and more studies show that strong relationships are crucial in dealing with life-threatening illnesses. In fact, friends and family are often an integral part of your treatment. Sometimes, though, you may want or need different kinds of support. If so, you may find the concern and understanding of other men with cancer especially helpful. Your doctor or a medical social worker may be able to put you in touch with a group near you. Or contact one of the many cancer organizations.

Taking care of yourself
During your treatment, you'll need to plan your schedule carefully. Allow yourself time to rest. And don't be afraid to ask for help. Your friends and family want to help, but they may not always know what to do. Be specific about your needs.

At the same time, you'll likely want to stay as independent as possible. Sometimes in their desire to help, other people may try to take over your life. Or they may act as if you're terribly fragile. Both can be detrimental to your recovery. Don't hesitate to tell friends and loved ones how you want to be treated.

If you haven't done so before, now is a good time to start eating a healthy diet, getting regular exercise and reducing stress. In fact, stress-reduction techniques and exercise may help relieve some of the side effects associated with radiation and chemotherapy.

Take time to examine what's most important to you. Think about the things you want to accomplish and how you can achieve your goals. And make it a priority to live your life to the fullest.

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