Breast cancer in men

Everyone has breast tissue, whatever their sex: in men there is only a little of it, it sits under the nipple and never develops beyond a rudimentary state. But where there is tissue, a tumour can start. Men account for fewer than one in a hundred cases of breast cancer, and that rarity is the central problem — nobody thinks of the disease, so the diagnosis is often made later than it could have been. And this despite the fact that in men a tumour lies close to the surface and can be felt early, if you know what to look for.

Why a tumour arises in a man's chest at all

The cells lining the breast ducts are sensitive to sex hormones: the longer oestrogen acts on them without testosterone to balance it, the higher the chance of an error during cell division. That is where the whole range of causes comes from — conditions that shift the hormonal balance, and inherited faults in the genes responsible for repairing DNA.

Almost all breast tumours in men turn out to be hormone-dependent. As a cause that is bad news; as a starting point for treatment it is good news, because there are tablets that work against such tumours.

How it usually begins

The first sign is nearly always a lump. Pay attention if it is:

• hard and uneven to the touch, sitting to one side of the nipple rather than directly beneath it;
• on one side only;
• fixed under your fingers, as though stuck to the skin or the chest wall;
• painless — the absence of pain is not reassuring, rather the opposite.

Other things matter too: the nipple pulling inwards or changing direction; a crust or sore on it that will not heal and looks like eczema; skin over the lump dimpling inwards; fluid coming from the nipple, especially if bloodstained; a lump felt in the armpit.

Any of these signs means seeing a doctor without delay. Most lumps in a man's chest are benign, and the examination usually ends with a reassuring answer. But the two cannot be told apart by eye, and how soon you come forward directly affects what the treatment will be.

The condition most often mistaken for a tumour

Far more often, a man's chest enlarges not because of cancer but because of gynaecomastia — growth of that same glandular tissue beneath the nipple. It happens in adolescents, in older men, with obesity, with liver and thyroid disease and with certain medicines. The differences a doctor looks for are these:

• gynaecomastia is usually on both sides, a tumour on one;
• in gynaecomastia the tissue is soft and elastic, evenly surrounds the nipple and is often tender when pressed;
• a tumour is hard, off-centre, painless and gradually loses its mobility;
• gynaecomastia does not pull the nipple in, produces no discharge and does not break down the skin.

All of this consists of clues, not proof: at the slightest atypical feature the doctor will arrange imaging, and that is good practice rather than over-caution.

What raises the likelihood

• age: most cases appear after sixty;
• breast or ovarian cancer in close relatives, particularly at a young age;
• an inherited fault in a DNA repair gene, above all the type 2 one: in men its contribution is considerably greater than that of type 1;
• Klinefelter syndrome, a condition present from birth with an extra female sex chromosome;
• radiotherapy given to the chest, especially at a young age;
• cirrhosis and other severe liver damage: the liver stops breaking oestrogens down;
• diseases and injuries of the testicles, an undescended testicle, orchitis after mumps in adulthood, removal of the testicles;
• a substantial excess of weight: fatty tissue produces oestrogens of its own;
• long-term use of oestrogens, including feminising hormone therapy.

Older studies linked work in very hot environments with risk, through overheating of the testicles, but the evidence is weak. Not everything can be changed, though some things are within reach: keeping weight down, cutting alcohol (no dose has been established as safe where cancer risk is concerned), not smoking, and treating liver disease.

What the assessment involves

The doctor will ask when the lump appeared and how it has changed, what medicines you take, and whether anyone in the family has had breast, ovarian, prostate or pancreatic cancer. Then both sides of the chest and the armpits are examined; you will need to undress to the waist, and asking for someone you trust or a member of staff to be present is an entirely normal request.

After that everything is usually arranged in a single visit: mammography (men have it too), ultrasound of the chest and armpits, and a needle biopsy. Only examination of the cells gives an answer; imaging on its own does not make the diagnosis. The same sample is tested for hormone receptors and for the protein associated with aggressive growth, and the choice of treatment follows from that.

Results arrive unevenly: the examination and the scans are discussed the same day, while the tissue report takes anything from a few days to a couple of weeks. If the diagnosis is confirmed, tests of spread are added: a chest X-ray, a CT scan, a bone scan and blood tests.

What treatment consists of

The approach depends on the size and type of the tumour, on whether the lymph nodes are involved, on whether there are deposits in other organs, and on general condition. As a rule several methods are combined.

• Surgery. The main step. The gland is usually removed in its entirety along with the nipple, because there is so little tissue that the tumour takes up almost all of it. The lymph nodes in the armpit are checked at the same time: first the sentinel node, and only if it is involved are the rest removed.
• Radiotherapy. Given after surgery to lower the chance of the cancer returning, and also where there are deposits in other organs, to relieve symptoms.
• Hormone therapy. In men this is the mainstay. Anti-oestrogen tablets are taken for years; the side effects — hot flushes, reduced desire, mood swings — are worth discussing with your doctor rather than enduring in silence.
• Chemotherapy and targeted drugs. Added when the tumour is of an aggressive type, is large, or the nodes are involved.

Where there are deposits in other organs a cure is usually out of reach, but treatment remains both possible and worthwhile: the aim shifts to holding the growth back, removing pain and keeping ordinary life going for years. Specialists in symptom control become involved at that stage, and turning to them does not mean everything is over.

And one thing men tend not to talk about: the scar, the missing nipple and remarks about a supposed "women's disease" are hard to live with. A nipple can be rebuilt surgically or tattooed, stick-on versions exist, and the psychological side is the work of a separate professional — asking for that help is entirely reasonable.

Heredity and what it means for the family

When breast cancer in a man is confirmed, genetic testing is almost always discussed: the proportion of inherited cases here is higher than in women. Another reason to test is breast, ovarian, prostate or pancreatic cancer in several blood relatives.

Finding a fault changes a great deal. For the patient it affects the extent of surgery and the choice of drugs, and it means a raised risk of prostate and pancreatic cancer, both worth keeping an eye on. For children, brothers and sisters it is a reason to see a genetic counsellor: the fault passes on with a probability of one in two, and knowing about it allows monitoring to start long before any symptoms. For a family, this part of the work often turns out to be the most valuable of all.

Online consultation

In an online consultation the doctor will go through exactly what you have felt and how it has changed, judge whether it resembles gynaecomastia or calls for urgent checking, explain which tests are arranged and in what order, help you read the reports you already have, and say whether genetic testing is worth raising for you and your relatives.

This material is for information only and does not replace medical advice.