Male Breast Cancer: A Rare But Real Disease

"If a man notices a lump or bump in the breast, he will likely dismiss breast cancer as a possible cause," says William J. Gradishar, M.D. (Feinberg School of Medicine and the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL). "Although such an abnormality could be totally benign, it needs to be evaluated, and that goes for men, as well as for women."

Male breast cancer is rare, accounting for less than 1 percent of all breast carcinomas. In the United States, approximately 1,300 men are diagnosed with breast cancer each year and about 400 men die annually of the disease. But, unlike the observed increase in female breast cancer in the U.S. and Europe since the 1960s, the incidence of male breast cancer has remained stable during the same period.

Gradishar explains that male breast cancer usually presents as a firm painless mass in the subareolar region of the breast. The second most common presentation, he says, is a mass in the upper outer breast quadrant. Other early findings may include nipple retraction; skin dimpling or puckering; redness or scaling of the nipple or breast; and abnormal swelling or lumps in the breast, nipple, or chest muscle. Although nipple discharge is not a common presenting feature of male breast cancer, it may represent an underlying malignancy, Gradishar says.

Risk factors for male breast cancer include Klinefelter's syndrome (a condition that results from the inheritance of an additional X chromosome), estrogen excess, radiation exposure, liver disease, and mutations in the BRCA2 gene. Family history also plays a strong role: about 20 percent of men with breast cancer have a close female relative who has had the disease. Diagnosis occurs most often between 60 and 70 years of age.

Women have long been encouraged to perform self-breast examination and to undergo periodic clinical breast examination. How-to instructional pamphlets and literature stressing the importance of early detection are widely distributed by healthcare groups and breast cancer support organizations, including Network of Strength (Y-ME), which provides brochures in English, Spanish, Chinese, Korean and Vietnamese. Many physicians provide waiting room videos to educate women about breast health and disease, and demonstrations of proper breast-check techniques are commonly offered to women awaiting mammography.

In contrast, specific recommendations, guidelines and instructions for men are noticeably lacking, yet, Gradishar says, routine breast examination is important in this population. "Self examination in men is quickly and easily performed because of the relatively small amount of breast tissue involved, and an internist could perform a clinical exam while the patient is already in the office for a routine annual check-up," he says. The latter would work well, he quips, because "men are notorious for not going to physicians."

Gradishar does not recommend screening mammography in men because of the low incidence of the disease, but notes its effectiveness in distinguishing malignancy from gynecomastia (excessive development of the male breast) during differential diagnosis of a breast mass.

If a breast mass is identified, a biopsy will be performed to establish a definitive diagnosis of male breast cancer. Suspicious tissue will be removed using fine-needle aspiration, core biopsy, or excisional biopsy and analyzed for cancer cells; hormone receptor status is also usually determined at the time of biopsy.

The most common type of male breast cancer is invasive ductal carcinoma. Other cancers like ductal carcinoma in situ , inflammatory breast cancer, and Paget's disease can also occur in men, but are rare. Lobular carcinoma in situ is not typically found in men.

Treatment depends on the type and stage of the cancer and may include surgery, radiation, chemotherapy or hormone therapy. Modified radical mastectomy is the standard surgical treatment for localized disease in men, and either axillary node dissection or sentinel node biopsy can be performed to determine whether metastasis has occurred. Because most male breast cancers are estrogen receptor positive, adjuvant hormone therapy using the antiestrogen tamoxifen (Nolvadex ® ) commonly is prescribed.

Although breast reconstruction following surgery is an option, Gradishar says that it is rarely performed. "With clothes on, many men look exactly the same after mastectomy as they did before it, and scarring is usually minimal. Reconstruction is unnecessary in most cases," he says.

As in females, outcome in males is influenced by tumor size, extent of metastasis, and lymph node involvement. If treatment begins in the same stage, male breast cancer survival rates are similar to those of females.

An Update on Senator Brooke

In the summer of 2003, Network of Strength brought you the story of former Republican Senator Edward W. Brooke's courageous battle with breast cancer.

Brooke, the first African-American elected to the United States Senate by popular vote and a decorated World War II captain, was diagnosed with breast cancer in September 2002. The Massachusetts senator underwent a right modified radical mastectomy and the removal of his left breast for symmetry and as a precautionary measure. Chemotherapy and radiation were not recommended, but treatment with tamoxifen for five years was prescribed because of his positive estrogen receptor status.

Now, about two years later, Brooke says of his condition, "So far, so good. I've had no indication that there is anything going on in my breasts or other organs and have seen no evidence at all of a return or a spread of the cancer."

Brooke encourages doctors to routinely examine men's breasts and advises men to perform self-examination to enable early detection. "In all my years, I had never really examined my own breasts or had a doctor examine my breasts, because I was thinking that men wouldn't get breast cancer. I think all men should realize that if you have breast tissue-and men do-you can get breast cancer," he says.

The senator acknowledges and appreciates the continued strong support of Breast Cancer Network of Strength and the Susan G. Komen Breast Cancer Foundation.

This article was first printed in the winter 2005 issue of Lifeline.

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