Male breast cancer is extremely rare. There are only about 2,500 cases diagnosed in the United States each year (compared to the 300,000 women who are diagnosed with breast cancer during the same period). As a result, there’s very little awareness among the general public about this issue. And when a man is diagnosed with breast cancer, it’s generally true to say he’s caught completely off guard.
I can remember one patient, Rob, who came to me on his doctor’s recommendation after finding a lump under his right nipple. We did a mammogram and ultrasound, then two needle biopsies that confirmed breast cancer both in the lump behind the nipple and under his armpit in a lymph node. Rob was in his fifties, but unlike many women the same age, he hadn’t been thinking about breast cancer—and he’d certainly never had a mammogram before! The word “shock” can’t begin to describe Rob’s reaction when he learned that this was his diagnosis. Not surprisingly, he had a barrage of questions, the first of which was “Why have I gotten a female cancer? I didn’t even know this could happen to men!” I reassured him that male breast cancer is not a female cancer. The disease is different in men and has completely different ramifications physically, mentally, and emotionally.
MYTH: “Male breast cancer is more life-threatening than female breast cancer because it’s rarer.”
Breast cancer is absolutely as treatable and curable in men, and survival rates are basically the same as with women at comparable stages of disease. So we have plenty of room for optimism. But male breast cancer is usually detected later in men than it is with women because they aren’t usually screened with mammograms, and because of decreased awareness.
Rob had initially assumed that the lump under his nipple was a skin cyst, and he had simply waited for it to disappear. Because he had delayed for many months before seeing a doctor, his cancer had already spread to the lymph nodes.
For his part, Rob handled his diagnosis and treatment beautifully. He did say it was hard for many of his male friends, who, while trying to be supportive, had not known other men with breast cancer before and often didn’t know what to say. He once darkly joked with me that most of his male friends were reaching the age where they were starting to worry and talk about prostate cancer so much that his diagnosis with breast cancer had actually become an interesting diversion. Rob didn’t seem to experience the same level of information overload and bombardment with suggestions and recommendations from others that many female patients do, perhaps because male breast cancer is so rare. This has its advantages, but also has its disadvantages: few to bond and commiserate with, and support groups filled exclusively with women. As with many individuals who are diagnosed with a rare cancer, Rob made his own way, with the support of his doctors and his family and close friends.
Causes
We don’t know nearly as much about breast cancer in men as we do about breast cancer in women, but there are risk factors that have been identified for male breast cancer. These include a variety of rare chromosomal abnormalities, as well as increased estrogen exposure and genetic predisposition, especially with the BRCA-2 gene, which is associated with an increased breast cancer risk to around 10 percent for men (for more on BRCA-2, go to chapter 15). Gynecomastia, or the male breast enlargement that is typical in older or heavier men, is not a risk factor for developing breast cancer.
Detection and diagnosis
Most cases of male breast cancer are found after the patient himself detects some kind of abnormality, usually a lump directly under the nipple. The reason for this is that almost all male breast cancers originate in the ducts of the breast, and most of the ducts in the male breast are directly behind the nipple. Because the cancer is often so close in proximity to the nipple it can be associated with visible nipple changes such as inversion, bleeding, or discharge, any of which may be the first sign that something is wrong. Oftentimes men will first notice a lump under their arm because the cancer has already spread to the lymph nodes, and the patient hasn’t realized that there was a lump or change in the breast in the first place.
As with female breast cancer, a needle biopsy is the best way to make a diagnosis. Most commonly, an ultrasound can identify the mass and then a needle is directed to the center of the suspicious area. The snippets of tissue that are removed can be analyzed under the microscope to make a definitive diagnosis. Surgical biopsies, which involve a trip to the operating room to make an incision so that a portion of the mass can be removed, should be reserved for cases where the needle biopsy could not be done but where there is still a concern (see chapter 2 for more on needle biopsies versus surgical biopsies).
Treatment
With so few cases of male breast cancer each year, it’s impossible to perform randomized trials to know specifically which treatments work best for male breast cancer, and so treatment options are essentially extrapolated from those that work for women. Like the treatment of breast cancer in women, most male breast cancer treatment starts with surgery and progresses through medical treatment (chemotherapy and hormonal treatment) if needed. Radiation is also given if needed.
Surgery
Breast cancer surgery and decision making for men are very different than they are for women.
Most male breasts are relatively small, and therefore lumpectomy—where only the lump and the surrounding tissue are removed—is not an option. Instead, mastectomy is the standard surgery recommended for male breast cancer. For men, as with women, mastectomy means removing all the breast tissue up to the clavicle, down to the abdomen, to the sternum in the center and across to the latissimus dorsi muscle under the arm. A standard male mastectomy includes removal of the nipple and areolar complex (surrounding darker-colored skin), since in most male breast cancer cases, the cancer is near or virtually inseparable from the nipple.
We don’t tend to perform breast reconstruction for men, as in most cases—especially for patients with hairy chests—the minimal asymmetry from the slightly flatter chest wall, the mastectomy scar, and the lack of nipple is barely visible. Occasionally a tattoo of the nipple can re-create it over the mastectomy scar, but this isn’t very commonly done or requested.
NEED TO KNOW
Even among specialists, there are very few surgeons, medical oncologists, or radiation oncologists and very few centers treating more than a few cases of breast cancer in men per year—which is why it’s essential for men to be treated at a center known for excellence. If you don’t live near one of these, you should definitely consider traveling for your treatment. As an additional benefit, most advanced breast centers are well set up to accommodate male patients in a private, gender-neutral way so men can get through their experience without the pink examination robes and ribbons, and with their dignity intact.
Lymph nodes
As with female breast cancer, when male breast cancer spreads it most commonly goes first to the lymph nodes under the arm. (See chapter 5 for a full explanation of the lymph nodes and their function.) Determining lymph node status in male breast cancer is as critically important for management as it is in women. Even when lymph nodes feel normal on exam and there is no obvious spread, we need to check them at surgery to find out for sure. Sentinel node biopsy—which involves injecting dye into the breast tissue that then travels to a few select nodes under the arm—is the standard procedure for checking lymph node status in women, and is definitely recommended in men. I am proud to say that along with my colleagues at the time at Memorial Sloan-Kettering, I was one of the first to demonstrate that sentinel node biopsy is just as accurate for checking lymph nodes in male breast cancer patients as it is for females. Sentinel node biopsy is performed in surgery at the same time as mastectomy, usually through the same incision. And when sentinel nodes are tested and found to be normal (negative), additional node removal—a much larger procedure associated with greater risk of complications—is not necessary.
For many cases of male breast cancer, however, the cancer has already spread to the lymph nodes by the time we find it. Sometimes the surgeon can feel an enlarged, suspicious node on examination, and sometimes an imaging study, either a mammogram or ultrasound, is an indicator. A needle biopsy done of the node or nodes that are suspicious can tell us about node spread before any surgery is done, and help to guide the operative procedure as a result. Specifically, if nodes are proven to have cancer before surgery, sentinel node biopsy is no longer necessary, as the node status has already been determined. For these cases where nodes are known to have cancer, removal of all the nodes, or axillary dissection, is the standard procedure. With axillary dissection the main risk is lymphedema, which is swelling of the arm due to lymph fluid, normally filtered by lymph nodes, accumulating in the arm due to severed outflow pathways. Early mobilization and strengthening can reduce this risk. Numbness, other side effects, and restrictions can also result from axillary dissection. (See chapter 5 for more information on axillary dissection and chapter 12 for more information on recovery from this operation.)
A WORD TO THE WISE
Surgery for male breast cancer is anatomically different from performing the same operation in women and can be more challenging. Males generally have much larger upper body musculature, and as a result, it can be much more effort to remove all the breast tissue, to find sentinel nodes wedged under the arm between larger muscles, and to clean out all the nodes if necessary. Finding a specialized breast surgeon with experience in operating on male breast cancer patients is important given these specific challenges and the rarity of the disease. Just having taken care of a large number of female breast cancer patients does not necessarily translate to doing a good job with the same operation in men.
TREATMENT AFTER SURGERY
Chemotherapy
As with women, chemotherapy is often recommended for men with larger tumors and positive nodes. In general, chemotherapy is given in treatment cycles, every two to three weeks, using the same agents that are recommended for women. Each cycle involves intravenous infusion of one or more drugs over a few hours. The side effects of chemotherapy can be the same in men as they are for women—although when it comes to hair loss, most of my male patients shave their heads and go bald; almost none get a wig. (See chapter 9 for more on chemotherapy treatment and its side effects.)
Endocrine therapy
Over 90 percent of male breast cancers are hormone receptor positive, meaning that estrogen and progesterone fuel the growth and spread of their cancer. This is in contrast to breast cancer in women, where approximately 60 to 70 percent of cases are hormonally responsive. As a result, most men are advised to take an anti-hormonal agent as part of their treatment. Tamoxifen, given as a pill, is usually recommended to be taken for at least five years. When it comes to aromatase inhibitors, which are now the treatment of choice for postmenopausal women, there is less overall experience in using them for treatment in men. Side effects from these endocrine therapy agents, which affect hormonal levels in the body, are different for men than for women and can include hot flashes and decreased libido. Studies have shown that men are less likely to adhere to hormonal treatment than their female counterparts, which may be because they don’t tolerate the side effects as well. However, most men do tolerate hormonal treatments well and complete treatment as recommended. (See chapter 9 for more on hormonal agents.)
Radiation
Because most men don’t have lumpectomies, most men don’t need radiation. But there are some criteria for giving radiation even after mastectomy. As with women, men with more advanced cancers, as indicated by a larger tumor or significant lymph node involvement, may be recommended for radiation as well. (See chapter 10 regarding indications for radiation after mastectomy.) Treatment involves receiving radiation beams to the chest wall and lymph node areas, usually for five minutes five days a week for six weeks. Side effects can be tanning and burning of the skin (similar to a bad sunburn), which is temporary; fatigue is common toward the end of the duration of treatment. The risk of lymphedema can be further increased when radiation is required on top of axillary dissection.
The BRCA factor
Most men diagnosed with male breast cancer should be tested for genetic predisposition, as the BRCA-2 mutation is found in approximately 10 percent of male breast cancer patients. And men who are known to carry the BRCA-2 mutation have a 10 percent risk of developing male breast cancer over their lifetimes. While a 10 percent risk does not seem high, it is about the same level of risk for developing breast cancer as the average woman over her lifetime, and as a result, screening with yearly mammogram is definitely recommended in this selected group of men. In addition, if you find out that you are BRCA-2 positive, this can also be helpful in screening for other cancers, and could be important for your children—both male and female—in determining whether they are at significantly higher risk for developing breast, ovarian, and other cancers. (See chapter 15 on BRCA mutations.)
The emotional impact
I always tell my male patients that there is no need to feel embarrassed or stigmatized in any way after a breast cancer diagnosis. However, it’s only natural for most men to feel isolated. There is so little awareness of male breast cancer in the general community that telling others can be challenging and is usually met with shock and disbelief. Many men diagnosed with this rare disease are inspired to raise awareness, and I have seen many male patients who use their diagnosis as a springboard to do much good for their communities.
Unlike my female patients, who usually benefit from the community of fellow patients and survivors, most of the men I see tend to avoid joining support groups, as these are predominantly women only. Many of the issues that affect women going through breast cancer treatment simply aren’t the same for men: rarely do men with breast cancer feel that the loss of a breast affects their attractiveness or self-image, and almost no men have to grapple with the process of reconstruction. However, it can still help to speak with others who have gone through treatment for cancer, whether it’s breast cancer or another cancer. After all, any human being diagnosed with cancer thinks about survival and mortality, and everyone has to deal with both the physical and emotional side effects of both the disease and the treatment. What I’ve seen is that most men with breast cancer carve their own path, using their doctors, family members, and close friends as support.
THE TAKEAWAY
• Male breast cancer is rare and so needs to be treated at a center of excellence if at all possible.
• Male breast cancer is usually diagnosed as a mass, and at a later stage, because most men are not regularly screened.
• Treatment is similar to that for women, although lumpectomy is not usually an option for men.
• Survival for male breast cancer is the same as that for women, stage for stage. The fact that it is rare does not make it any more dangerous in terms of mortality.