Aside from prostate cancer, did you know that men can also have breast cancer? Know the early warning signs and symptoms.
What is breast cancer in men?
A breast cancer is a malignant tumor that starts from cells of the breast. A malignant tumor is a group of cancer cells that may grow into (invade) surrounding tissues or spread (metastasize) to distant areas of the body. Breast cancer occurs mainly in women, but men can get it, too. Many people do not realize that men have breast tissue and that they can develop breast cancer.
Normal breast structure
To understand breast cancer, it helps to have some basic knowledge about the normal structure of the breasts.
The breast is made up mainly of lobules (milk-producing glands in women), ducts (tiny tubes that carry the milk from the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic vessels).
Until puberty (usually around 13 or 14), young boys and girls have a small amount of breast tissue consisting of a few ducts located under the nipple and areola (area around the nipple). At puberty, a girl's ovaries make female hormones, causing breast ducts to grow, lobules to form at the ends of ducts, and the amount of stroma to increase. In boys, hormones made by the testicles keep breast tissue from growing much. Men's breast tissue has ducts, but only a few if any lobules.
Like all cells of the body, a man's breast duct cells can undergo cancerous changes. But breast cancer is less common in men because their breast duct cells are less developed than those of women and because their breast cells are not constantly exposed to the growth-promoting effects of female hormones.
The lymph (lymphatic) system of the breast
The lymph system is important to understand because it is one of the ways that breast cancers can spread. This system has several parts.
Lymph nodes are small, bean-shaped collections of immune system cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.
Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Some lymphatic vessels connect to lymph nodes near the breast bone (internal mammary nodes) and either above or below the collarbone (supraclavicular or infraclavicular nodes).
It's important to know if the cancer cells have spread to lymph nodes. If they have, there is a higher chance that the cells could have gotten into the bloodstream and spread (metastasized) to other sites in the body. This is important to know when you are choosing a treatment. The more lymph nodes with breast cancer cells (positive lymph nodes), the more likely it is that the cancer might be found in other organs as well. Still, not all men who have positive lymph nodes develop metastases, and in some cases a man can have negative lymph nodes and later develop metastases.
Benign breast conditions
Men can also have some benign (not cancerous) breast disorders.
Benign breast tumors
There are many types of benign breast tumors (abnormal lumps or masses of tissue), such as papillomas and fibroadenomas. Benign breast tumors do not spread outside the breast and are not life threatening. Benign tumors are common in women but are very rare in men.
Gynecomastia
Gynecomastia is the most common male breast disorder. It is not a tumor but rather an increase in the amount of a man's breast tissue. Usually, men have too little breast tissue to be felt or noticed. A man with gynecomastia has a button-like or disk-like growth under his nipple and areola, which can be felt and sometimes seen. Although gynecomastia is much more common than breast cancer in men, both can be felt as a growth under the nipple, which is why it's important to have any such lumps checked by your doctor.
Gynecomastia is common among teenage boys because the balance of hormones in the body changes during adolescence. It is also common in older men due to changes in their hormone balance.
In rare cases, gynecomastia occurs because tumors or diseases of certain endocrine (hormone-producing) glands cause a man's body to make more estrogen (the main female hormone). Men's glands normally make some estrogen, but it is not enough to cause breast growth. Diseases of the liver, which is an important organ in male and female hormone metabolism, can change a man's hormone balance and lead to gynecomastia. Obesity (being extremely overweight) can also cause higher levels of estrogens in men.
Some medicines can cause gynecomastia. These include some drugs used to treat ulcers and heartburn, high blood pressure, and heart failure. Men with gynecomastia should ask their doctors if any medicines they are taking might be causing this condition.
Breast cancer general terms
Here are some of the key words used to describe breast cancer.
Carcinoma
This is a term used to describe a cancer that begins in the lining layer (epithelial cells) of organs such as the breast. Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas).
Adenocarcinoma
An adenocarcinoma is a type of carcinoma that starts in glandular tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are glandular tissue (they make breast milk in women), so cancers starting in these areas are sometimes called adenocarcinomas.
Carcinoma in situ
This term is used for an early stage of cancer, when it is confined to the layer of cells where it began. In breast cancer, in situmeans that the abnormal cells remain confined to ducts (ductal carcinoma in situ, or DCIS). These cells have not grown into (invaded) deeper tissues in the breast or spread to other organs in the body. Ductal carcinoma in situ of the breast is sometimes referred to as non-invasive or pre-invasive breast cancer because it may develop into an invasive breast cancer if left untreated.
When cancer cells are confined to the lobules it is called lobular carcinoma in situ. This is not actually a true pre-invasive cancer because it does not turn into an invasive cancer if left untreated.
Invasive (infiltrating) carcinoma
An invasive cancer is one that has already grown beyond the layer of cells where it started (as opposed to carcinoma in situ). Most breast cancers are invasive carcinomas, either invasive ductal carcinoma or invasive lobular carcinoma.
Types of breast cancer in men
Ductal carcinoma in situ (DCIS)
In DCIS (also known as intraductal carcinoma), cancer cells form in the breast ducts but do not grow through the walls of the ducts into the fatty tissue of the breast or spread outside the breast. DCIS accounts for about 1 in 10 cases of breast cancer in men. It is almost always curable with surgery.
Infiltrating (or invasive) ductal carcinoma (IDC)
This type of breast cancer breaks through the wall of the duct and grows through the fatty tissue of the breast. At this point, it can spread (metastasize) to other parts of the body. At least 8 out of 10 male breast cancers are IDCs (alone or mixed with other types of invasive or in situ breast cancer). Because the male breast is much smaller than the female breast, all male breast cancers start relatively close to the nipple, so they are more likely to spread to the nipple. This is different from Paget disease as described below.
Infiltrating (or invasive) lobular carcinoma (ILC)
This type of breast cancer starts in the breast lobules (collections of cells that, in women, produce breast milk) and grows into the fatty tissue of the breast. ILC is very rare in men, accounting for only about 2% of male breast cancers. This is because men do not usually have much lobular tissue.
Lobular carcinoma in situ (LCIS)
In LCIS, abnormal cells form in the lobules, but they do not grow into the fatty tissue of the breast or spread outside the breast. Although LCIS is sometimes grouped with DCIS as a type of non-invasive breast cancer, most breast specialists think it is a risk factor for developing breast cancer rather than a true non-invasive cancer. As with invasive lobular carcinoma, LCIS is very rare in men.
Paget disease of the nipple
This type of breast cancer starts in the breast ducts and spreads to the nipple. It may also spread to the areola (the dark circle around the nipple). The skin of the nipple usually appears crusted, scaly, and red, with areas of itching, oozing, burning, or bleeding. The fingertips can be used to detect a possible lump within the breast.
Paget disease may be associated with DCIS or with infiltrating ductal carcinoma. It accounts for about 1% of female breast cancers and a higher percentage of male breast cancers.
Inflammatory breast cancer
Inflammatory breast cancer is an aggressive, but rare type of breast cancer. It causes the breast to be swollen, red, warm and tender rather than forming a lump. It can be mistaken for an infection of the breast. This is very rare in men.
Breast Cancer in Men
Although it is a rare form of cancer, breast cancer does occur in men. It is estimated that 1,970 new cases in males will develop in 2010, with 390 deaths. It tends to occur at a later age in men than in women, with the male peak age being 71 years old as opposed to peaks at 51 and 71 years old in women.(1)(2)
Symptoms(1) (2)
- Painless lump in the breast (over 75% of cases)
- Nipple retraction, discharge, or ulceration
- Painful lump in the breast
- Paget's Disease (only about 1% of cases): This is a rare type of cancer that can appear as a skin rash (dermatitis) around the nipple. Note that this is NOT related to Paget's disease of the bone.
Detection and Diagnosis
Diagnosis of breast cancer in men is generally delayed 6 - 10 months (the time from the onset of symptoms until the patient seeks treatment). This delay is partially due to a) the rarity of the disease and b) a lack of awareness of (suspicion of) the disease by patients and their doctors. Because of this delay, men present with the disease at a later stage than women:
- Stage I - ~40%
- Stage II - ~20%
- Stage III/IV - Over 40%
When symptoms are present, doctors generally use the Triple Test (TT) method to determine stage and treatment plan. The TT is the use of clinical exam, mammography or ultrasound, and fine needle aspiration (FNA) or core needle biopsy (CNB). (2)(1) Watch a video about mammography, ultrasound, and/or biopsy.
Mammography has been shown to have a sensitivity of 92% and a specificity of 90% in male breast cancer, but is not used as a screening tool.
Pathology
Male breast tissue is mostly fat and the lobules needed to form milk are undeveloped. Over 90% of male breast tumors are invasive (infiltrating) ductal carcinoma and ER positive.(1) (2)
Risk Factors(2)(1)
- Obesity
- Alcohol consumption
- Liver damage or dysfunction
- Testicular abnormality or damage
- Radiotherapy, especially to the chest
- Family history of breast cancer (especially with a BRCA2 mutation)
- Klinefelter's Syndrome
Treatment
Surgery
Simple or modified radical mastectomy and surgical assessment of the lymph nodes are used when cancer is found in its early stages. Assessment of the lymph nodes is accomplished using either axillary dissection or sentinel lymph node biopsy.
Radiotherapy
Males are more likely to receive radiotherapy than females, probably due to the fact that males present with breast cancer at a later stage than females. Radiation dosages used to treat men are generally the standard amounts used to treat women. Radiotherapy has been shown effective in preventing local recurrence in men with breast cancer.(3)(4)
Systemic Therapy
Because about 90% of men with breast cancer are hormone receptor positive (HR+), treatment with tamoxifen is standard in HR+ men. Men treated with tamoxifen have shown higher overall survival rates. Men may also receive systemic chemotherapy.(3) (2)
Quality of Life
Men with breast cancer face a different environment than women coping with breast cancer. There is a large amount of information and public support for women. On the other hand there is a lack of information and added stressors for men. Men deal with issues of masculinity and stigmatism in addition to the other physical and emotional concerns that come along with having breast cancer.(5)(6)
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