The month of June welcomes Father’s Day. What a great time to discuss breast cancer and our men’s wellness. Breast cancer is typically thought of as a woman’s disease. But men develop the disease, too. And, due to a lack of awareness about male breast cancer, it’s often found at the later stages, when the disease is more challenging to treat.
How common is breast cancer in men?
The American Cancer Society estimates for breast cancer in men in the United States for 2023 are:
• About 2,800 new cases of invasive breast cancer will be diagnosed
• About 530 men will die from breast cancer
• Male breast cancer represents approximately 1% of all breast cancer cases.
Risk factors for breast cancer in men include:
• Getting older. The risk for breast cancer increases with age. However, most breast cancers are found after age 50.
• Heavy alcohol intake
• Liver disease. Cirrhosis (scarring) of the liver can lower androgen levels and raise estrogen levels in men, increasing the risk of breast cancer.
• Female relatives with breast cancer
• Genetic mutations. Inherited changes (mutations) in specific genes, such as BRCA1 and BRCA2, increase breast cancer risk.
• Radiation therapy treatment. Men with radiation therapy to the chest are more likely to get breast cancer.
• Hormone therapy treatment. Drugs containing estrogen (a hormone that helps develop and maintain female sex characteristics), used to treat prostate cancer in the past, increase men’s breast cancer risk.
• Klinefelter syndrome. Klinefelter syndrome is a rare genetic condition in which a male has an extra X chromosome. This can lead to the body making higher levels of estrogen and lower levels of androgens (hormones that help develop and maintain male sex characteristics).
• Certain conditions affect the testicles. Injury to, swelling in, or surgery to remove the testicles can increase breast cancer risk.
• Overweight and obesity. Older men who are overweight or have obesity have a higher risk of getting breast cancer than men at an average weight
Lumps and other signs may be caused by male breast cancer or other conditions. Check with your doctor if you have any of the following:
• Men with breast cancer usually have lumps that can be felt
• A lump or thickening in or near the breast or underarm area.
• A change in the size or shape of the breast.
• A dimple or puckering in the skin of the breast.
• A nipple turned inward into the breast.
• Fluid from the nipple, especially if it’s bloody.
• Scaly, red, or swollen skin on the breast, nipple, or areola (the dark area of skin around the nipple).
• Dimples in the breast that look like the skin of an orange, called peau d’orange
How is male breast cancer diagnosed?
Your healthcare provider will ask about your symptoms, family history of breast cancer, and other risk factors. Then, they’ll perform various tests or procedures to make a diagnosis, including:
• Breast exam: Your healthcare provider will examine your breast tissue, checking for skin changes, lumps, or other abnormalities.
• Imaging tests: Mammograms can detect the majority of male breast cancers. A mammogram is a low-dose X-ray that takes pictures of your breast tissue. Your provider may also perform an ultrasound. An ultrasound uses sound waves to take pictures of your breast tissue.
• Biopsy: Your healthcare provider will perform a biopsy to look for cancer cells in your breast tissue. For this procedure, your provider removes tissue from the tumor and sends it to a lab for testing. Testing the cancer cells in a lab allows healthcare providers to diagnose cancer and plan treatments that work best on specific cancer cells.
With breast cancer, providers look for proteins on cancer cells called receptors. These proteins include estrogen receptor (ER), progesterone receptor (PR), and HER2/neu receptor. These cell features provide essential information about what’s causing cancer cells to grow.
What are tests for male breast cancer?
After diagnosing breast cancer, providers classify it using a process called staging. Staging uses information like tumor size and cancer spread to determine how advanced the disease is.
You may need imaging tests such as a PET, bone, or CT scan to show where cancer cells are inside your body. In addition, your provider may perform a sentinel node biopsy as part of staging. For this procedure, your provider removes one or more lymph- nodes near a tumor and tests them for cancer cells.
After breast cancer has been diagnosed, tests to determine if cancer cells have spread within the breast or to other parts of the body. This process is called staging. The information gathered from the staging process determines the stage of the disease. It is essential to know the stage to plan treatment. Breast cancer in men is staged the same as it is in women. The spread of cancer from the breast to lymph nodes and other parts of the body appears to be similar in men and women.
The stages of male breast cancer are:
Stage 0: Cancer cells are only in the ducts. Stage 0 breast cancer is another name for ductal carcinoma in situ.
Stage I: The tumor is small and hasn’t spread to your lymph nodes.
Stage II: One of these is true:
• The tumor is smaller than 20 millimeters (mm) and has spread to a few lymph nodes in your armpit (axillary lymph nodes).
• The tumor is 20 mm to 50 mm across and hasn’t spread to the axillary lymph nodes (stage IIA), or the tumor is 20 mm to 50 mm and has spread to the axillary lymph nodes (stage IIB).
• The tumor is more significant than 50 mm and hasn’t spread to a few axillary lymph nodes.
Stage III: Cancer has spread to several lymph nodes. Cancer cells may also be in your chest wall or skin.
Stage IV: Cancer cells have spread to other parts of your body. Cancer can spread to all body areas, including your bones, lungs, liver, or brain.
After breast cancer is diagnosed, your health provider will order tests to determine if cancer cells have spread within the breast or to other body parts.
The following tests and procedures may be used in the staging process:
• Sentinel lymph node biopsy: The sentinel lymph node removal during surgery. The sentinel lymph node is the first in a group of lymph nodes to receive lymphatic drainage from the primary tumor. Therefore, the first lymph node cancer will likely spread from the primary tumor. A radioactive substance and blue dye are injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, removing more lymph nodes may not be necessary. Sometimes, a sentinel lymph node is found in more than one group of nodes.
• Chest X-ray: An X-ray of the organs and bones inside the chest. An X-ray is an energy beam that can go through the body and onto film, picturing areas inside the body.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body from different angles. The images are made by a computer linked to an X-ray machine. For example, a dye may be injected into a vein or swallowed to help the organs or tissues appear more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• Bone scan: A procedure to check if there are rapidly dividing cells in the bone, such as cancer cells. A minimal amount of radioactive material is injected into a vein and travels through the bloodstream. The radioactive material collects in the bones with cancer and is detected by a scanner.
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and shows where glucose is being used in the body. Malignant tumor cells appear brighter in the picture because they are more active and consume more glucose than normal cells.
Surgery for Male Breast Cancer
Surgery is the most common treatment for men with breast cancer. About 98 percent of male breast cancer patients are treated with mastectomy (surgical removal of the breast).
Your doctor may recommend a specific operation based on your breast cancer features and your medical history, or you may have a choice about which type to have. Knowing your options is essential so you can talk about them with your doctor and make the right choice.
There are two main types of surgery to remove breast cancer:
Mastectomy
The entire breast is removed in this surgery, including all breast tissue and sometimes other nearby tissues. Most men with breast cancer will undergo a mastectomy since men have a small amount of breast tissue.
There are several types of mastectomies:
In a simple or total mastectomy, the surgeon removes the entire breast, including the nipple, but does not remove underarm lymph nodes or muscle tissue from beneath the breast.
In a modified radical mastectomy, the surgeon extends the incision to remove the entire breast and lymph nodes under the arm. Suppose the tumor is large and growing into the chest muscles. In that case, the surgeon must do a radical mastectomy, a more extensive operation removing the entire breast, axillary lymph nodes, and the chest wall muscles under the breast. This is only needed if the cancer has grown into the pectoral muscles under the breast.
Breast-conserving surgery (BCS)
This surgery might also be called a lumpectomy, quadrantectomy, partial mastectomy, or segmental mastectomy. For this surgery, only the part of the breast containing the cancer is removed. The goal is to remove the cancer and some surrounding normal tissue. How much of the breast is removed depends on the size and location of the tumor and other factors.
BCS is commonly used to treat women with breast cancer. It is used much less often in men because most male breast cancers are located behind the nipple and have often grown into the nipple, requiring more extensive surgery such as a mastectomy. If BCS is done, it is typically followed by radiation therapy.
Possible side effects of breast surgery
Aside from post-surgical pain, temporary swelling, and a change in the appearance of the breast, possible side effects of surgery include bleeding and infection at the surgical site, hematoma (buildup of blood in the wound), and seroma (buildup of clear fluid in the wound).
How male breast cancer is treated
In cancer care, doctors specializing in different areas of cancer treatment work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. In addition, cancer care teams include a variety of other healthcare professionals, such as physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, genetic counselors, dietitians, and others.
The biology and behavior of breast cancer affect the treatment plan. Some tumors are small but grow fast, while others are large and grow slowly. Treatment options and recommendations are very personalized and depend on several factors. Even though the breast cancer care team will specifically tailor the treatment for each patient and the breast cancer, there are some general steps for treating breast cancer.
For ductal carcinoma in situ (DCIS) and stage 1 invasive breast cancer, doctors recommend surgery to remove the tumor as the first treatment. To ensure that the entire tumor is removed, the surgeon will also deduct a small area of healthy tissue around the tumor. Although surgery aims to remove all visible cancer, microscopic cells can remain after surgery, either in the breast or elsewhere. Therefore, in some situations, another surgery could be needed to remove the remaining cancer cells.
For larger or smaller cancers growing more quickly, doctors may recommend systemic treatment with chemotherapy or hormonal therapy before surgery, called neoadjuvant or preoperative therapy.
There may be several benefits to having other treatments before surgery:
• Surgery may be easier to perform afterward
• Your doctor may find out if specific treatments work well for the cancer
• You may be able to try a new treatment through a clinical trial
After surgery, the next step in managing early-stage breast cancer is to lower the risk of recurrence and eliminate any remaining cancer cells in the breast or elsewhere in the body. If present, these cancer cells are undetectable but are believed to be responsible for both local and distant recurrence of cancer.
Treatment given after surgery is called adjuvant therapy.
Adjuvant therapies may include:
• Radiation therapy
• Chemotherapy
• Targeted therapy
• Hormonal therapy
• Immunotherapy
Whether adjuvant therapy is needed depends on how likely any cancer cells could still be in the breast or body and how well a specific treatment is expected to work to treat the cancer. The choice of adjuvant therapy depends on the cancer’s stage, features, and a patient’s health and preferences. Although adjuvant therapy lowers the risk of recurrence, there will still be some risk of recurrence.
Along with staging, other tools can help estimate prognosis and help you and your doctor decide about adjuvant therapy. For example, some tests can predict the risk of recurrence for your specific tumor by testing the tumor tissue. These may also be used to understand better the cancer risks and whether chemotherapy will help reduce those risks.
Prevention
There is no clear way to prevent breast cancer in men. The best way to protect yourself is to:
• Know that men can develop breast cancer
• Know your risk factors and talk with your provider about screening and early detection with tests if needed
• Know the possible signs of breast cancer
• Tell your provider if you notice any changes in your breast
Take time to learn about your treatment options, and be sure to ask questions and unclear questions. Speak with your doctor about the goals of each treatment and what you can expect during and after treatment. These types of talks are called “shared decision-making.” Shared decision-making is when you and your doctors work together to choose treatments that fit your goals for your care. Shared decision-making is particularly important for breast cancer because multiple treatment options exist.
REFERENCES
CDC
Cleveland Clinic
John Hopkins Medicine
Mayo Clinic
MD Anderson Center
Memorial Sloan Kettering Cancer Center
