Breast Cancer in Men

Do not panic if you feel a lump around your breast - even if a lump is identified it is unlikely to be cancerous. It is more likely to be gynaecomastia or a fluid filled cyst. Further, there are some unique characteristics of MBC lumps:

• They are bumpy and not smooth 
• Get bigger with time
• Will not move around loosely in the breast when examined 
• Are usually in one breast (only 1% of cases are bilateral)
• Located under or around the nipple.

The other symptoms of MBC include:

• Dimpling, or rash around the nipple
• Fluid (sometimes bloody) from the nipple 
• Nipple that seems to be depressed or growing inward
• Area around the nipple sore, red, hard, or swollen 
• Lumps in the armpit 

Symptoms will become more widespread over time if the cancer spreads:

• Overall fatigue 
• Reluctance to eat 
• Weight loss
• Pain in the joints and bones 
• Shortness of breath

As mentioned above, MBC is likely to be diagnosed later in life when compared to female breast cancer (FBC) by around 5-10 years and is more likely to be in an advanced stage since it is often not detected early.

The exact causes of MBC are not fully understood yet. However, certain genetic mutations, genetic disorders, family history, previous treatment with hormonal therapy and exposure to radiation are known risk factors. Here is a more detailed look at these: 

• Klinefelter syndrome: Men with this condition are born with an extra X chromosome that causes changes in secondary sexual characteristics such as breast development, as well as lower levels of testosterone. Those with Klinefelter syndrome have a higher likelihood of getting MBC, however, compared to other cases, the disease occurs at a younger age.
• Family history: Those with family history of breast cancer are at a higher risk.
• Age: Studies have shown repeatedly that MBC is more likely to occur in older men.
• Genetic mutations: Genetic mutations in the BRCA2, and less commonly, BRCA1 genes increases the likelihood of MBC.
• Obesity: Obesity is harmful to overall health but also increases the amount of oestrogen in the blood, thereby increasing risk. Those with a BMI higher than 30 are more likely to get MBC.
• Liver disease: Liver disease can also increase the amount of oestrogen in the blood.
• Orchitis/epididymitis: Inflammation of the testicles due to conditions like orchitis or epididymitis can alter testosterone levels.
• Prostate cancer: Those given hormonal treatment for prostate cancer may be at an increased risk. Further, sometimes those who get checked for prostate cancer turn out to have breast cancer as the primary cancer.
• Lack of exercise: Studies have shown that those who exercise less may be at a higher risk. 
• Certain occupational hazards: It has not been established, but those exposed to certain hydrocarbons and electromagnetic fields at work may be at a higher risk of developing MBC. Exposure to radiation, on the other hand, is a definite risk factor.

There is not too much you can do to prevent MBC since it is linked to genetic factors. However, obesity and lack of exercise have been associated with it as well. Therefore, maintaining a healthy, balanced diet is key and getting at least 30 minutes of regular exercise a day is also important. If there is a family history of breast cancer, you should consider getting yourself routinely checked as well.

Also, if you have been treated in the past with hormone replacement therapy, or have been exposed to radiation either for treatment or because of work, consider getting regular checkups to catch a possible malignancy early.

The vast majority of lesions in male breast tissue are benign or caused by gynaecastomy. Less than 1% of lesions are caused by primary malignant tumours. 

Since MBC is rare, your doctor will probably check for differential diagnoses as well. Some of the more common causes for male breast lesions include: 

• Abscess
• Hematoma
• Lipoma
• Fat necrosis
• Ductal ectasia
• Intraductal papilloma
• Cyst
• Gynaecastomy

You will also be asked to provide a detailed medical history, and if you have genetic conditions, or have been on hormone replacement therapy in the past, this will be addressed as well.

A physical breast exam will be conducted to check the consistency of the growth and to see if the lesion is acting like a tumour. 

Imaging techniques such as ultrasound or mammography will be conducted. A solid lump, rather than a cyst filled with fluid, will be suspected of being cancerous and infected further. Mammographies are preferred since they have a higher degree of sensitivity and specificity. If there is discharge from the nipple, a smear test may be conducted as well. 

To confirm the diagnosis and determine what type of cancer is involved, a biopsy under local anaesthesia will be conducted as well. A part of the tissue is extracted and sent for laboratory analysis.

PET-CT scans, and other diagnostic exams such as pulmonary X-rays may be done as well to check for the spread of the disease. 

Other cancers metastasizing in male breast tissue are rare. Melanoma, lymphoma, prostate, lung and colon tumours are more likely to metastasize in the breast than other malignancies.

Treatment will depend on the stage at which the malignancy is detected. In the later stages where the cancer has spread to other parts of the body, the treatment will be more extensive and involve longer hospitalization. Generally, the following options are considered: 

• Surgery: The most commonly done procedure is mastectomy where the whole breast tissue is removed, including the nipple. This is done to physically remove the cancer from the body. A sentinel lymph node biopsy may be conducted during this procedure, wherein nearby lymph nodes are removed to check if the cancer is spread. If cancer is not detected in these nodes, it is unlikely that it has spread beyond the immediate tissue.
• Radiation therapy: This is required if a mastectomy is conducted. In this therapy, X-rays and protons are targeted using a machine to kill cancer cells. Radiation therapy usually lasts up to 6 weeks and can be done on an outpatient basis.
• Chemotherapy: Anti-cancer medications or infused drugs are given in this procedure. While it can kill cancer cells, there will be side effects and your life will be interrupted for some time at least.
• Hormone therapy: About 9 out of 10 MBC cases are ‘oestrogen receptor positive’, which means that they require oestrogen to develop and spread. Hormone drugs can block the effects of oestrogen and prevent the cancer from returning or lower the rate of the spread. Tamoxifen is the most commonly used drug for this. The drug will need to be taken for 5 years or even longer in some cases.

Getting a diagnosis of any kind of cancer is frightening and will likely provoke feelings of uncertainty, frustration and disorientation. Your doctor may recommend a counselor to manage this difficult time and will chart out an intervention plan that is best suited to you.

All the above mentioned treatments will have side effects and complications. Post surgery, there will be pain for up to 2 weeks - painkillers will make this tolerable. There may even be lymphedema in the arm which is a painful swelling. There will again be drugs to lessen the swelling and manage the pain.

Radiotherapy and chemotherapy will make you feel fatigued, sick or nauseous in some cases. You may also lose hair and weight and feel uncomfortable; chemotherapy may make you more susceptible to other diseases.

Hormone therapy can also make you feel sick, make you gain weight, suppress libido and trigger emotional changes. However, your doctor will go through all of these trade-offs with you in detail and having a plan will make it easier to manage the situation for you and your family.

Prognosis for MBC and FBC is quite similar - if disaggregated by stages. MBC is usually diagnosed late which means that prognosis is more grim. However, if detected and treated during stage 0 or stage 1, chances of a 5-year survival is up to 100%. For stage 3, 5 year survival rate drops to between 30 and 60%.

Those with oestrogen dependent cancers have a higher survival rate - this is good news since most cases are estrogen dependent. Unfortunately, if the cancer is advanced and metastasizes, median survival is 26.5 months with treatment. According to literature reviews, 10% of the time, a secondary cancer develops and is detected during routine checkups.