By Dr Justus Apffelstaedt, specialist surgeon with an interest in breast, thyroid and parathyroid health as well as soft tissue surgical oncology.
Although seen as a predominantly female disease, breast cancer affects men too. If you are worried about your breast health, it is important to remember the significance of early detection, even in these times when other ailments are a constant media focus.
Fear of the coronavirus should not lead to the delayed diagnosis and treatment of cancer with inevitable, unnecessary loss of life. The underlying principles of breast cancer diagnosis and treatment do not change due to the virus but can inform the management of diagnostic and therapeutic procedures. Breast practices outside of hospitals present a low risk environment for infection with the virus, provided basic precautions are taken.
What is the incidence of breast cancer in men?
For each 100 women that we see with breast cancer, we see one man. Therefore the risk is low, particularly in comparison to cancers such as lung, prostate or colon. The National Cancer Registry states that the life-time risk of suffering breast cancer in males is in between 1 in 500 to 1 in 1000, depending on race. Men at any age may develop breast cancer, but it is usually detected in men between 60 and 80 years of age (compared to women, usually detected from the age of 40).
Do men get the same types of breast cancer as women?
The most common type of breast cancer seen in men is infiltrating ductal carcinoma. This is cancer that has spread beyond the cells lining the ducts in the breast. It is the most common type of breast cancer in women as well as men. All other forms of breast cancer are exceedingly rare in men.
What are the possible causes in men and does this include a family history?
It is estimated that cancer-causing genetic abnormalities are at least 2 – 4 times more common in males with breast cancer than in females. Diagnosis of a disease-causing genetic mutation will greatly impact on the patient’s management and also has important consequences for other family members. Genetic testing has therefore become part of routine care in males with breast cancer.
Other risk factors include:
- Being exposed to radiation.
- Having a disease related to high levels of oestrogen in the body, such as cirrhosis (liver disease) or Klinefelter syndrome (a genetic disorder).
How would breast cancer be detected in a man?
Men with breast cancer usually have a lump that can be felt.
Men’s breasts are not usually as big as women’s and a mass is therefore more easily palpated by a man. On the other hand, in contrast to women, health care seeking behaviour in men is not well developed and most cases that we see are fairly advanced.
The following tests and procedures may be used:
- Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. This is usually done by taking a small core of tissue using a needle under local anaesthesia. Biopsies should be guided by ultrasound in a practice setting, i.e. outside of a hospital.
- As men often present with advanced breast cancer, they will have to undergo examinations to look for spread to other organs such as the lungs, liver and bone by appropriate examinations.
What is the normal treatment?
Treatments for breast cancer in men and women are generally the same. Many men benefit from a combination of different treatments. Here’s an overview of the various approaches:
- Surgery. The typical treatment for men is a mastectomy, in which the entire breast is removed. Breast-conserving surgery — in which just the tumour is taken out — isn’t usually possible for obvious reasons as men don’t have much breast tissue to begin with. The surgeon will also take out one or more of the lymph nodes for pathologic examination to assess if the cancer has spread.
- Radiation Therapy. Radiation is used commonly after surgery for breast cancer in men, as these tumours are often advanced and without radiotherapy, there is a high chance of recurrence.
- Chemotherapy. This is treatment with drugs — either taken by mouth or by injection — that attack cancer cells. Chemotherapy is often used after surgery to lower the risk of the cancer coming back. For men with advanced cancer orcancer thathas spread to other parts of the body (metastatic cancer), chemotherapy may be the primary treatment.
- Hormonal Therapy. Some kinds of breast cancer need certain hormones to grow. Hormonal therapy blocks the effects of these hormones, choking the cancer. Your doctor might use tamoxifen or other drugs. The effects of aromatase inhibitors like Arimidex, Femara and Aromasin haven’t been studied much in men. Sometimes, removal of the testes or suppression of their function by drugs is used to reduce the amount of certain male hormones in the system. Men with breast cancer should never take testosterone.
Hormonal therapy is often used after surgery to lower the risk of the cancer coming back. For men with locally advanced or metastatic cancer, it may be the primary treatment.
- Biological Therapy. This is a new approach. Some men have an excess of a protein that makes cancer spread quickly. Herceptin is a drug that’s been approved to treat metastatic breast cancer. It stops this protein from making the cancer cells grow. It may also boost your immune system, giving it more strength to fight the cancer itself.
What role do male hormones and/or estrogen play?
Evidently hormones play an important role, but because the incidence of the disease in men is so rare, there is no intensive research availableand the precise role of hormones is unknown.
Men that are treated with estrogen blockers – does this have an effect? E.g. mood swings, feeling irritated or angry.
Men have very limited side effects to estrogen blockers. We previously did orchiectomy (surgery in which one or more testicles are removed) as part of the hormonal treatment, however we found this not to be acceptable to the patients.
Are the chances of survival higher for men?
No – the chances for survival are lower than for women for a variety of reasons. The most important being that men are less likely to go to a doctor and therefore present with advanced cancers. Due to the anatomy of the male torso with very little breast tissue, small tumours infiltrate early into surrounding tissue and from there easily spread via the bloodstream to distant organs.
If a man is diagnosed with breast cancer, does this increase the chances of his daughters developing cancer?
Yes. Each man that is diagnosed with breast cancer should go for genetic testing. The chances are high that he is a carrier of the breast cancer gene mutations and therefore this can be inherited by his children.