Cancer Stories

Male breast cancer

January 25th, 2006

Definition
Male breast cancer is a malignant tumor that forms in a man’s breast.

Description

Breast cancer is rare in men, but can be serious and fatal. Many people believe
that only women can get breast cancer, but men have breast tissue that also
can develop cancer. When men and women are born, they have a small amount of
breast tissue with a few tubular passages called ducts located under the nipple
and the area around the nipple (areola). By puberty, female sex hormones cause
breast ducts to grow and milk glands to form at the ends of the ducts. But male
hormones eventually prevent further breast tissue growth. Although male breast
tissue still contains some ducts, it will have only a few –or no– lobules.
Near the breasts of men and women are axillary lymph nodes. These are underarm
small structures shaped like beans that collect cells from lymphatic vessels.
Lymphatic vessels carry lymph, a clear fluid that contains fluid from tissues,
cells from the immune system, and various waste products throughout the body.
The axillary lymph nodes are important to breast cancer patients, as they play
a role in the spread and staging of breast cancer.

Breast cancer is much more common in women, mostly because women have many
more breast cells that can undergo cancerous changes and because women are exposed
to the effects of female hormones.

Infiltrating ductal carcinoma is the most common type of breast cancer in men.
It is a type of adenocarcinoma, or a type of cancer that occurs in glandular
tissue. Infiltrating ductal carcinoma starts in a breast duct and spreads beyond
the cells lining the ducts to other tissues in the breast. Once the cancer begins
spreading into the breast, it can spread to other parts of the body. This distant
spread is called metastasis. When breast cancer metastasizes to other areas
of the body, it can cause serious, life-threatening consequences. For example,
breast cancer might spread to the liver or lungs. About 80% to 90% of all male
breast cancers are infiltrating ductal carcinomas.

Ductal carcinoma in situ (DCIS) is not common; it accounts for about 10% of
all male breast cancers. It also is an adenocarcinoma. In situ cancers remain
in the immediate area where they began, so DCIS remains confined to the breast
ducts and does not spread to the fatty tissues of the breast. This means it
is likely found early. DCIS also may be called intraductal carcinoma.

Other types of breast cancer are very rare in men. Adenocarcinomas that are
lobular (forming in the milk glands or lobules) only occur in about 2% of male
breast cancer cases because men normally do not have milk gland tissues. Inflammatory
breast cancer, a serious form of breast cancer in which the breast looks red
and swollen and feels warm, also occurs rarely. Paget’s disease of the nipple,
a type of breast cancer that grows from the ducts beneath the nipple onto the
nipple’s surface, only accounts for about 1% of female breast cancers. However,
slightly more men have this form of breast cancer than women. Sometimes, Paget’s
disease is associated with another form of breast cancer.

Although not a form of cancer, but a benign condition, gynecomastia is important
to mention. It is the most common of all male breast disorders and can be associated
with male breast cancer in a rare condition called Klilnefelter’s syndrome.
Gynecomastia most often occurs in teenage boys when their hormones change during
puberty. Older men also may experience the condition when their hormone balance
changes as they age. Gynecomastia is an increase in the amount of breast tissue,
or breast tissue enlargement. If a man has Klinefelter’s syndrome, he can develop
gynecomastia and increased risk of breast cancer.

Demographics

Breast cancer in men is rare, accounting for less than 1% of all breast cancers.
Still, about 1,450 American men were diagnosed with the disease and 470 men
died from it in 2004. Although studies show the number of breast cancer cases
in women has decreased in the United States and Europe since the 1960s, the
number of breast cancer cases in men have not decreased, but remained stable
or slightly increased.

The rate of increase in cases begins and steadily rises at age 50 for men.
However, the average age for male breast cancer is between 60 and 70 years old,
with a median age of 67 years. Men often are diagnosed at a later stage than
women.

Causes and symptoms

Scientists do not know what causes most cases of male breast cancer. However,
excellent progress is being made in genetic research and in understanding how
genes instruct cells to grow, divide, and die. For example, researchers have
now mapped all of the genes in the human body. Genes are part of the body’s
DNA, which is the chemical that instructs the cells. When DNA or genes carry
defects (mutations), they activate changes in the cells, such as rapid cell
division, that lead to cancer. Some genes, called tumor suppression genes, cause
cells to die. Scientists have identified some genetic mutations that are risk
factors for breast cancer. In other cases, environmental, or outside, factors
are thought to increase a man’s risk for breast cancer.

Mutations of at least two versions of a tumor suppressor gene (BRCA1 and BRCA2)
have been identified as causes of breast cancer in women. In men, the BRCA2
mutation is considered responsible for about 15% of breast cancers. Men can
inherit genes from either parent. Studies have shown that BRCA1 also may increase
a man’s risk for breast cancer, but its role is less certain. These mutations
have been shown to increase other cancers in men, including prostate cancer.
Klinefelter’s syndrome is a rare genetic cause of breast cancer in men. It results
from inheriting an additional X chromosome.

Several other factors also may cause male breast cancer. Some conditions, such
as the liver disease cirrhosis, can cause an imbalance in a man’s hormones,
producing high levels of the female hormone estrogen, which can lead to breast
cancer. Exposure to some substances such as high amounts of radiation may contribute
to male breast cancer. A 2004 report studied why a cluster of breast cancer
cases occurred among a small group of men who worked in the basement office
of a multi-story office building. The study linked their breast cancer to exposure
to high magnetic fields from a nearby electrical switchgear room in their work
space.

Many men do not realize they can develop breast cancer; they ignore the symptoms.
The most common symptom is a mass, or lump in the chest area, particularly around
the nipple. The lump will be firm, not tender or painful. Other signs that may
warn of male breast cancer include:

Skin dimpling or puckering

Changes in the nipple, such as drawing inward (retraction)

Nipple discharge of any kind

Redness or scaling of the nipple or breast skin

Abnormal swelling (or lump) of the breast, nipple, or chest muscle

Prolonged rash or irritation of the nipple, which may indicate Paget’s disease

Diagnosis

Physicians follow the same steps for diagnosing breast cancer in men as in women,
except that routine screening of breast cancer is not done in men. Once symptoms
are noticed, however, physicians will proceed in the same way. The physician
will conduct a thorough medical history and examination, including questions
that may identify risk factors for breast cancer, such as male or female relatives
with the disease. The medical history also helps gather details on possible
symptoms for breast cancer.

The physician also performs a clinical breast examination. This helps locate
and study a lump or suspicious area. The physician will feel (palpate) a mass
to get an idea of its size, texture, likely location and relation to surrounding
skin, muscles and tissues. At this point, the physician already will begin to
look for signs that the cancer may have spread to other organs and to the lymph
nodes. The physician will palpate lymph nodes and the liver, for instance, to
see if they are enlarged.

The next step in diagnosis usually is a diagnostic mammogram. Mammography is
an x ray of the breast. Mammograms are performed by radiologic technologists
who take special training in the procedure. Mammograms are evaluated by radiologists,
physicians who receive medical training specifically in interpreting x rays.
If the initial mammogram shows suspicious findings, the radiologist may order
magnification views to more closely look at the suspicious area. Mammograms
can accurately show the tissue in the breast, even more so in men than women,
because men do not have dense breasts or benign cysts in their breasts that
interfere with the diagnosis.

The radiologist also might recommend an ultrasound to follow up on suspicious
findings. Ultrasound often is used to image the breasts. Also known as sonography,
the technique uses high-frequency sound waves to take pictures of organs and
functions in the body. Sound wave echoes can be converted by computer to an
image and displayed on a computer screen. Ultrasound does not use radiation.
A technologist will perform the ultrasound; it will be evaluated by the radiologist.

Biopsies, which involve removing a sample of tissue, are the only definite
way to tell if a mass is cancerous. At one time, surgical biopsies were the
only option, requiring removal of all or a large portion of the lump in a more
complicated procedure. Today, fine-needle aspiration biopsy and core biopsies
can be performed. In fine-needle aspiration biopsy, a thin needle is inserted
to withdraw fluid from the mass. The physician may use ultrasound or other imaging
guidance to locate the mass if necessary. The fluid is tested in a laboratory
under a special microscope to determine if it is cancerous.

A core biopsy is similar, but involves removing a small cylinder of tissue
from the mass through a slightly larger needle. Core biopsy may require local
anesthesia. These biopsy techniques usually can be performed in a physician
office or outpatient facility. The cells in biopsy samples help physicians determine
if the lump is cancerous and the type of breast cancer. A tissue sample also
may be used for assigning a grade to the cancer and to test for certain proteins
and receptors that aid in treatment and prognosis decisions.

If there is discharge from the nipple, the fluid also may be collected and
analyzed in a laboratory to see if cancer cells are present in the fluid.

Diagnosis of breast cancer spread may require additional tests. For example,
a computed tomography (CT) scan may be ordered to check organs such as the liver
or kidney for possible metastasized cancer. A chest x ray can initially check
for cancer spread to the lungs. Bone scans are nuclear medicine procedures that
look for areas of diseased bone. Magnetic resonance imaging (MRI) has been increasingly
used in recent years as a follow-up study to mammograms when findings are not
clear. However, for metastatic breast cancer, they are more likely to be ordered
to check for cancer in the brain and spinal cord. Positron emission tomography
(PET) scans also have become more common in recent years.

Treatment team

The treatment team for male breast cancer normally consists of a primary care
physician, a medical oncologist (cancer specialist) and if radiation therapy
is used, a radiation oncologist. Many other staff also are involved. For instance,
special oncology nurses help guide patients through their care and recovery.
Radiation therapists are specially trained technologists who deliver the radiation
therapy treatments prescribed by the radiation oncologist.

Clinical staging, treatments, and prognosis

A technique called sentinel lymph node biopsy may be the first step in staging.
The sentinel node is the first one the cancer cells are likely to reach, so
it is the first one checked for cancerous cells. Using a radioactive substance
and blue dye injected into the area around the tumor, physicians can track the
path of the cells and stage the cancer. The technique has been used for many
years on women with breast cancer; research in 2004 showed it worked well for
predicting lymph node status in men as well.

Staging

Cancer staging systems help physicians compare treatments and research and identify
patients for clinical trials. Most of all, they help physicians determine treatment
and prognosis for individual patients by describing how severe a patient’s cancer
is in relation to the primary tumor. The most common system used for cancer
is the American Join Committee on Cancer (AJCC) TNM system, which bases staging
largely on the spread of the cancer. T stands for tumor and describes the tumor’s
size and spread locally, or within the breast and to nearby organs. The letter
N stands for lymph nodes and describes the cancer’s possible spread to and within
the lymph node system. In some descriptions below, the cancer may have been
found by sentinel node biopsy as microscopic disease in nodes that are in the
breasts (rather than the armpits). For simplification, these findings have been
grouped with the axillary lymph nodes. M stands for metastasis to note if the
cancer has spread to distant organs. Further letters and numbers may follow
these three letters to describe number of lymph nodes involved, approximate
tumor sizes, or other information. The following is a summary of breast cancer
stages:

Stage 0: Tis, N0, M0: Ductal carcinoma in situ (DCIS). This is the earliest
and least invasive form of breast cancer; the cancer cells are located within
a duct and have not invaded surrounding fatty tissue.

Stage I: T1, N0, M0: The tumor is less than 1 in. in diameter (2 cm or less)
and has not spread to lymph nodes or distant organs.

Stage IIA: T0, N1, M0/T2, NO, MO: No tumor is found or the tumor is smaller
than 2 cm and cancer is found in one to three axillary lymph nodes (even if
no tumor is found), or the tumor is between 2 and 5 cm in diameter but has not
spread to the axillary lymph nodes. The cancer has not spread to distant organs.

Stage IIIB: T2, N1, M0/T3, NO, MO: The tumor is between 2 and 5 cm in diameter
and has spread to one to three axillary lymph nodes or the tumor is larger than
5 cm, has not grown into the chest wall or spread to the lymph nodes or distant
organs.

Stage IIIA: T0-2, N2, M0/T3, N1, MO: The tumor is smaller than 5 cm in diameter
and has spread to four to nine axillary lymph nodes or the tumor is larger than
5 cm and has spread to one to nine axillary lymph nodes. The cancer has not
spread to distant organs.

Stage IIIB: T4, N0-2, M0: The tumor has grown into the chest wall or the skin
and may have spread to no lymph nodes or as many as nine lymph nodes. Cancer
has not spread to distant sites.

Stage IIIC: T0-4, N3, MO: The tumor is any size, has spread to 10 or more axillary
lymph nodes or to one or more lymph nodes under or above the collarbone (clavicle)
on the same side as the breast tumor. The cancer has not spread to distant organs.

Inflammatory breast cancer: Classified as stage III, unless it has spread to
distant organs or lymph nodes not near the breast (which would classify it as
Stage IV).

Stage IV: T0-4, N0-3, M1: Regardless of the tumor’s size, the cancer has spread
to distant organs, such as the liver, bones, or lung, or to lymph nodes far
from the breast.

Treatment

If the axillary lymph nodes were identified as containing cancer at the time
of the sentinel lymph node biopsy, they will be removed in an axillary dissection.
Sometimes, this is done at the time of the biopsy.

For Stage I, surgery often is the only treatment needed for men. Women often
have lumpectomies, which remove as little surrounding breast tissue as possible,
to preserve some of their breast shape. For men, this is less of a concern,
and mastectomy, or surgical removal of the breast, is performed in 80% of all
male breast cancers. Men with Stage I tumors larger than 1 cm may receive additional
(adjuvant) chemotherapy.

Men with Stage II breast cancer also usually receive a mastectomy. If they
have cancer in the lymph nodes, they probably will receive adjuvant therapy.
Those with estrogen receptor-positive tumors may receive hormone therapy with
tamoxifen. The treatment team may recommend adjuvant radiation therapy if the
cancer has spread to nearby lymph nodes and/or to the skin.

Stage III breast cancer requires mastectomy followed by adjuvant therapy with
tamoxifen when hormones are involved. Most patients with Stage III disease also
will require chemotherapy and radiation therapy to the chest wall.

Men with Stage IV breast cancer will require systemic therapy, or chemotherapy
and perhaps hormonal therapy that works throughout the body to fight the cancer
in the breast, as well as the cancer cells that have spread. Patients also may
receive immunotherapy to help patients fight infection following chemotherapy.
Radiation and surgery also may be used to relieve symptoms of the primary cancer
and areas where the cancer may have spread. The treatment team also may have
to diagnose specific treatments for the metastatic cancers, depending on their
sites.

If male breast cancer recurs in the breast or chest wall, it can be treated
with surgical removal and followed by radiation therapy. An exception is recurrence
in the same area, where additional radiation therapy can damage normal tissue.
Recurrence of the cancer in distant sites is treated the same as metasteses
found at the time of diagnosis.

Prognosis

Prognosis for male breast cancer varies, depending on stage. Generally, prognosis
is poorer for men than for women, because men tend to show up for diagnosis
when their breast cancer has reached a later stage. The average five-year survival
rate for Stage I cancers is 96%. For Stage II, it is 84%. Stage III cancers
carry an average five-year survival rate of 52%, and by Stage IV, the rate drops
to 24%.

Alternative and complementary therapies

Many alternative and complementary therapies can help cancer patients relax
and deal with pain, though none to date have been shown to treat or prevent
male breast cancer. For example, traditional Chinese medicine offers therapies
that stress the importance of balancing energy forces. Many studies also show
that guided imagery, prayer, meditation, laughter, and a positive approach to
cancer can help promote healing. Early studies have shown that soy and flaxseed
may have some preventive properties for breast cancer. However, these trials
have been conducted in women. When looking for these therapies, cancer support
groups suggest asking for credible referrals and working with the medical treatment
team to coordinate alternative and complementary care.

cancer treatment

Coping with cancer treatment

It is difficult for some men to accept and cope with a breast cancer diagnosis,
since it is a relatively rare and unexpected disease among men. It is important
that men work closely with their treatment team to talk about the their concerns
and to carefully follow all instructions for care. Support groups and family
support are critical in coping with a breast cancer diagnosis.

Eating a nutritious diet, stopping use of tobacco, and limiting use of alcohol,
can help in recovery from breast cancer. Beginning a regular exercise program
when the treatment team recommends also helps.

Clinical trials

Research currently is underway to test various chemotherapy combinations for
male breast cancer at different stages. A clinical trial also is underway to
investigate a vaccine for treating patients with metastatic breast cancer. The
National Institutes of Health list clinical trials by disease type, including
those for which they are recruiting patients. Choosing to participate in a clinical
trial is a decision that involves the patient, family, and treatment team.

Prevention

Some forms of male breast cancer cannot be prevented. But detecting the cancer
at an early stage can prevent serious complications, such as spread to distant
organs. Men who have a history of breast cancer in their family should pay particular
attention to the symptoms of breast cancer and seek immediate medical evaluation.
Physicians may be able to test the blood of men with family history for presence
of the BRCA2 gene so they may more carefully watch for early signs of breast
cancer. Avoiding exposure to radiation also may help present some male breast
cancers.

Special concerns

Men should remember that there are important difference between male and female
breast cancers. Some experts say that specific guidelines and instructions for
men with breast cancer are noticeably lacking, so men should not be afraid to
ask questions or to push a physician for more information when he suspects he
might have a suspicious lump or finding in his breast.

Entry Filed under: Survival Stories