It is often with surprise that I get asked, “Can men get breast cancer?” If you have breasts, you can get breast cancer! So, do men have breasts? Yes, they do have breasts – boobs – sometimes called Moobs… Therefore men can get breast cancer. It is extremely uncommon, but does nevertheless occur. Hence, when I hear ridiculous stories such as lights and water causing breast cancer, I always ask why we have not seen an increase in male breast cancer rates.
Before I deal with breast cancer in men, let’s look at what kind of breast problems men can get and why these occur.
Up until puberty when hormones result in an increase in size of the female breast, male and female breasts consist of the nipple areolar complex and an underlying breast bud. The physiological changes at puberty result in higher levels of estrogen in females, resulting in deposition of fat in the breast and the increase in breast ducts and lobules, allowing women to be able to breastfeed.
Many have questioned the function of the male breast and why the trait has not been lost in evolution. Many a scientist and philosopher has postulated and debated why the gene coding for the male breast has not been coded out.
Personally, I am quite particular to a good-looking male chest and think that the nipple areolar complex is a nice focal point, without which it would be looking at the Mona Lisa sans smile. So, I don’t have an answer, but feel we should just appreciate the beauty, as men do with regards to the female chest.
Moob problems/Gynaecomastia
Gynaecomastia is an abnormal enlargement of the breast in the male. Gynaecomastia is the most common condition affecting the male breast. About one third of normal adult males will have mild gynaecomastia rising to approximately two thirds of normal boys at puberty. It may be physiological (it just happens due to normal variations in hormones) as seen in baby boys’ pubertal and senescent hypertrophy (polite way of saying in older men). This is due to relative changes in the ratio of estrogen in relation to circulating levels of testosterone (the absolute values when we pull the blood tests are normal). The most common cause is an enlargement of ductal and stromal tissues of the breast, which is structurally different from the surrounding subcutaneous fat and can be seen on a sonar.
The following are rare causes of gynaecomastia and should not be top of the list of what one looks for on Google doc:
- Low testosterone (male sex hormone) levels seen following mumps orchitis (this is when mumps affects the testes, testicular destruction by tumours and many years ago syphilis.
- Elevated levels of estrogen seen when the liver does not metabolise estrogen efficiently (e.g. alcohol or hepatitis), or where the liver is damaged.
- Medications such as HAART (HIV medication), diuretics (water tablets), digoxin, anti-hypertensive medication, dagga and psychiatric medication and anabolic steroids. There is such abuse of anabolic steroids amongst sporty and gym dudes wanting to build beautiful bodies… At a cost of moobs and small testes, DON’T DO IT! The long-term damage is so hard to correct.
- Repetitive trauma to the breast from running, rowing and other sports or wearing braces.
- True gynaecomastia is always central in the breast (under the nipple) whereas breast cancer may not be directly under the nipple.
Gynaecomastia may be bilateral or unilateral (both moobs or just one). The presentation is usually a tender enlargement of the breast. Patients may be concerned about the cosmetic appearance, tenderness, pain or the fear of an underlying cancer. A sonar can determine if there is gynaecomastia, a mass or simply obesity related subcutaneous fat. We seldom need to do a core needle biopsy of gynaecomastia and one should never do a FNA (as the results often say inconclusive or atypical and then there is a rush for an often unnecessary surgery).
Investigations required are assessment of hormonal profiles, liver function tests, thyroid function tests, breast ultrasound and testicular ultrasound.
An HIV test should be requested…please let’s always be condom-wise.
Physiological gynaecomastia of a mild nature can be observed and the patient reassured. If there is a drug-related cause, discontinuation of the causative drugs or improvement of the medical condition causing the gynaecomastia often leads to breast regression.
Moderate gynaecomastia can be managed with the use of low dose SERMs (Tamoxifen or Fareston) for at least six months. Tamoxifen is such a clever medicine and not an anti-estrogen; 10mg (half the cancer dose works wonders for gynacomastia). If there is significant breast enlargement (I have seen some young men with breasts bigger than a B cup), or after failure of medical treatment (Tamoxifen doesn’t decrease the size in some, particularly the steroid abusers), surgical management can be considered.
A subcutaneous mastectomy is performed through elevation of periareolar (around the nipple areola area), with careful attention paid to removing enlarged tissue but allowing sufficient tissue to remain under the nipple to prevent a doughnut deformity post-op (the nipple sticks to the muscle).
Male breast cancer
The occurrence of male breast cancer varies throughout the world. In the UK the incidence is approximately 0.7% of all breast cancers. In North America there seems to be an increasing incidence especially amongst black males and approximately 2190 men were diagnosed in the USA in 2010; 410 men will die from breast cancer. It is most commonly found in men over sixty, although men of all ages can be affected. It appears from studies in other parts of Africa, as well as South Africa, that it is more common amongst African males (incidence of 1-3%).
It is difficult to establish definite risk factors for breast cancer in males (remember that 60% of women getting breast cancer have no risk factors). There is often a discussion as to its relationship with gynaecomastia, due to the association with possible higher levels of estrogen. There is a proven relationship between obesity and male breast cancer, which is thought to increase the risk from one to five times. This is due to the elevated levels of circulating estrogen associated with obesity. A link has also been found among males with a previous history of prostate cancer due to the type of medication used, as well as those undergoing gender re-assignment (not well substantiated data). The link to patients with prostate cancer may be due to a common underlying genetic mutation (BRCA 2).
There does appear to be a genetic component in male breast cancer in about 4-40% of cases. Male breast cancer is three to five times more common in men who have had at least one first-degree female relative with breast cancer. A number of genes have been associated in its prevalence including BRCA2, AR gene, cytochrome P45017 (CYP17), the XXY karyotype (Klinefelter’s syndrome), the PTEN tumour suppressor gene associated with Cowden’s syndrome, and the CHEK2 gene.
The most conclusive of these is BRCA 2, XXY (Klinefelter’s syndrome) and Cowden’s syndrome.
Male carriers of the BRCA2 mutation have an estimated 6.3% cumulative lifetime risk of breast cancer by 70 years. It is most commonly found in Ashkanazi Jews and some Eastern European populations. Patients with Klinefelter’s syndrome have a specific body shape (tall and skinny, little hair, poor coordination and reading difficulties… and VERY RARE), high estrogen to androgen ration despite low to normal estrogen levels. There is an increase in breast cancer with a risk of 20 times a normal male.
The personality of male breast cancers (see the article in the Autumn 2015 issue on personality not size) is the same as for female breast cancers. They are most commonly ductal carcinomas and whilst lobular carcinoma is rarely seen in men, they can be associated with Kleinfelter’s syndrome. Any variation of ductal carcinoma can be seen in male breast cancers including Paget’s disease (cancerous eczema of the nipple). Most male breast cancers (80% to 90%) are estrogen and progesterone receptor positive and usually with a Ki above 15%…
Like female breast cancer, most male breast cancers present as a painless lump. Because of the lack of knowledge and screening of male patients, maybe because men think they can’t get breast cancer, and maybe because they or we don’t examine male breasts that often, they usually present late. Another reason is because men do not have lots of breast tissue (unless they have big Moobs), the ratio of the male breast cancer to the male breast means that more often the breast cancer is involving the skin or underlying muscle. This commonly means that more T4 (tumours involving skin or muscle) are seen. This is relevant to the need for radiation, but remember personality not size!
Male patients may also have a nipple discharge or nipple changes, and a very few present with a painful swelling. Any one-sided breast mass that is firm, fixed or ulcerated in a man should raise suspicion. All potential breast cancers are investigated the same way, whether in men or women, the triple assessment followed by an examination and then a mammogram and sonar (yes, you can mammogram a male moob) followed by an image guided core needle biopsy to provide the diagnosis. (No surgical biopsies please!) A sonar is particularly useful in males because of the little breast tissue and to check axillary lymph nodes.
Treatment
The treatment for male breast cancer is the same as in female breast cancer and always based around multi-disciplinary care. Clearly in men, breast saving surgery is more difficult, near impossible, however is determined by the size of the moob. Most men get a mastectomy and sentinel lymph node biopsy or axillary sampling depending on whether glands are involved.
Chemotherapy and radiation treatment are given depending on stage and cancer biology, but as most male breast cancer presents in a locally advanced condition, they almost always require radiation and sometimes chemotherapy.
Chemotherapy today is often given based on the behavior and personality of the cancer and not size, so each patient will be discussed in a multi-disciplinary unit. In fact some studies say that unlike in female breast cancer where radiation is required if the tumour size is greater than 5cm, in men tumour size greater than 2cm requires radiation. Risk of local recurrence may be high, due to the small size of the male breast and the often lack of radiation given risk of systemic recurrence (cancer coming back elsewhere in the body) can be significantly decreased by the use of hormonal therapy if the tumour is hormone sensitive. In the past chemical castration (or orchidectomy – not done today!) was used. There is a perception of worse prognosis in male breast cancer. This is not due to inherently aggressive disease but may rather be due to the later stage of presentation at diagnosis. Typically 5-10% of patients will have metastatic disease (cancer elsewhere in the body) at first presentation. A study in Scandinavia found that men had poorer survival due to later onset and advanced stage, however, when age, stage and treatment were controlled for, men actually had an inherent survival advantage.
A lovely study in our unit showed that men do not like to walk around with mastectomy scars and feel shy with their tops off if they have had a breast cancer operation…Please guys, we can reconstruct male nipple areolas too!
So, please guys and girls let’s be moob aware! Let’s educate our men to check their own breasts, or have a feel of your partner’s manly chest. Men don’t be shy and seek medical attention – be assessed appropriately by a breast specialist.
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