8 August 2012

Male Breast Cancer and Gynaecomastia

Breast Cancer in men is a rare disease. Less than 1% of all breast cancers occur in men. For men, the lifetime risk of being diagnosed with breast cancer is about 1 in 1,000.

You may be thinking, men don’t have breasts, so how can they get breast cancer? Men do have breast tissue which usually stays flat and small, due to very little hormone stimulation of their breast tissue.

Sometimes men can develop enlarged breast tissue (gynaecomastia- breast tissue growth that is non cancerous/benign) if they take certain medicines or have abnormal hormone levels.

It’s important to understand the risk factors for male Breast Cancer — particularly because men are not routinely screened for this disease and don’t think about the possibility of getting Breast Cancer. As a result, Breast Cancer tends to be more advanced in men than in women when it is first detected.

A number of factors can increase a man’s risk of getting Breast Cancer:

• Growing older: This is the biggest factor. Just as is the case for women, risk increases as age increases. The median age of men diagnosed with breast cancer is about 67. This means that half the men who are diagnosed are over 67 and half are under.
• High estrogen levels:Breast cell growth — both normal and abnormal — is stimulated by the presence of estrogen. Men can have high estrogen levels as a result of:
  • taking hormonal medicines
  • being overweight, which increases the production of estrogen
  • having been exposed to estrogens in the environment (such as estrogen and other hormones fed to fatten up beef cattle, or the breakdown products of the pesticide DDT, which can mimic the effects of estrogen in the body)
  • being heavy users of alcohol, which can limit the liver’s ability to regulate blood estrogen levels
  • having liver disease, which usually leads to lower levels of androgens (male hormones) and higher levels of estrogen (female hormones). This increases the risk of developing gynaecomastia (breast tissue growth that is non-cancerous/benign) as well as  Breast Cancer.
• Klinefelter syndrome: Men with Klinefelter syndrome have lower levels of androgens (male hormones) and higher levels of estrogen (female hormones). Therefore, they have a higher risk of developing gynaecomastia (breast tissue growth that is non-cancerous) and breast cancer. Klinefelter syndrome is a condition present at birth that affects about 1 in 1,000 men. Normally men have a single X and single Y chromosome. Men with Klinefelter syndrome have more than one X chromosome (sometimes as many as four). Symptoms of Klinefelter syndrome include having longer legs, a higher voice, and a thinner beard than average men; having smaller than normal testicles; and being infertile (unable to produce sperm).
• A strong family history of breast cancer or genetic alterations/mutations: Family history can increase the risk of breast cancer in men — particularly if other men in the family have had breast cancer. The risk is also higher if there is a proven breast cancer gene abnormality in the family. Men who inherit abnormal BRCA1 or BRCA2 genes (BR stands for BReast, and CA stands for CAncer) have an increased risk for male breast cancer. This risk of developing breast cancer by age 70 is approximately 1% with the BRCA1 gene and 6% with the BRCA2 gene. Overall, that’s about 80 times greater than the lifetime risk of men without BRCA1 or BRCA2 abnormalities. Also, a family in which male breast cancer has occurred has a 60% to 76% risk of having an abnormal BRCA2 gene. An abnormal BRCA2 gene accounts for up to 40% of male breast cancers. Because of this strong association between male breast cancer and an abnormal BRCA2 gene, first-degree relatives (siblings, parents, and children) of a man diagnosed with breast cancer may want to ask their doctors about genetic testing for abnormal breast cancer genes. Still, the majority of male breast cancers happen in men who have no family history of breast cancer and no inherited gene abnormality.
• Radiation exposure: Having radiation therapy to the chest before age 30, and particularly during adolescence, may increase the risk of developing breast cancer. This has been seen in young people receiving radiation to treat Hodgkin’s disease. (This does NOT include radiation therapy to treat breast cancer.)

One study found that male breast cancer is on the rise, with a 25% increase over the 25 years from 1973 to 1988. But it’s still rare. It’s unclear whether the reported rise means the disease is slowly becoming more common, or whether men better understand the symptoms and report their symptoms, leading to diagnoses that might have been missed in the past.

If you notice any persistent changes in your breasts, you should consult your doctor. 

Here are some signs to look out for:

• a lump felt in the breast
• nipple pain
• an inverted nipple
• nipple discharge (clear or bloody)
• sores on the nipple and areola (the small ring of color around the center of the nipple)
• enlarged lymph nodes under the arm
• It’s important to note that enlargement of both breasts (not just on one side) is usually NOT cancer. The medical term for this is gynaecomastia. Sometimes the breasts can become quite large. Non-cancer-related enlargement of the breasts can be caused by medications and steroids, heavy alcohol use, weight gain, or marijuana use.

A small study about male Breast Cancer found that the average time between the first symptom and diagnosis was 19 months, or over a year and a half. That’s a very long time! This is probably because people don’t expect Breast Cancer to happen to men, so there is little to no early detection.

Earlier diagnosis could make a life-saving difference. With more research and more public awareness, men will learn that — just like women — they need to go to their doctor right away if they detect any persistent changes in their breasts.

After an abnormality of the breast is found, tests are performed to rule out the possibility of Breast Cancer. 

• Mammogram: A mammogram is an X-ray picture of the breast. A radiologist will look at the pictures and determine if anything looks abnormal. He or she may then decide to get other pictures of a certain area. These are called spot or magnification views.
• Ultrasound: Ultrasound sends high-frequency sound waves through your breast and the images generated are viewed and interpreted by the radiologist. Ultrasound complements other tests. If an abnormality is seen on mammography or felt by physical exam, ultrasound is the best way to find out if the abnormality is solid or fluid-filled (such as a benign cyst). Ultrasound cannot definitely determine whether a solid lump is cancerous.
• Nipple discharge examination: If you have nipple discharge, some of the fluid may be collected and examined under a microscope to see if any cancer cells are present.
• Biopsy: A biopsy is necessary to distinguish normal tissue from abnormal tissue. The purpose of this procedure is to make a diagnosis.

Biopsies are performed on any kind of abnormality that your doctor can feel or that the radiologist sees on a mammogram or ultrasound. Various techniques are used to biopsy tissue, and your radiologist will use the least invasive procedure possible while making sure that enough tissue is removed to make a clear diagnosis.

• Fine needle biopsy of palpable lesions (lesions that can be felt) is least invasive. A long, thin, hollow needle is placed in the palpable abnormality. Cells are extracted through the center of the needle. The tissue is then sent off to pathology for analysis. This biopsy technique has the highest risk of a “false negative” — a biopsy result that says “normal,” even though a cancer is present. The reason for this is probably that the needle doesn’t always pick up the cancer cells.
• Ultasound needle biopsy (core biopsy) removes multiple tissue samples of the lesion. A core biopsy removes a bigger piece of tissue than a fine needle biopsy and is done when a lesion is seen on ultrasound, whether palpable or not.
• Stereotactic needle biopsy (core biopsy) removes multiple tissue samples of a lesion. If the lesion can’t be felt, the needle is guided to the area of concern with the help of mammography. A small metal clip may be inserted into the breast to mark the site of biopsy in case the biopsy proves cancerous and additional surgery is required. But since most men diagnosed with breast cancer have mastectomy, a clip is usually unnecessary since the whole breast is removed.

If a cancer diagnosis is made other tests, such as blood tests, chest X-ray, and bone scan, might be done to see if the cancer has spread to other parts of the body.

Most breast cancers in men are ductal carcinomas. Ductal means the cancer started in the milk ducts of the breast. These cancers are usually invasive because they start inside the duct and then break through the wall of the duct, growing into the normal surrounding breast tissue. Non-invasive breast cancers, called DCIS (ductal carcinoma in situ), are uncommon in men. These cancers start and stay inside the milk ducts. Men rarely get lobular breast cancer (the kind of cancer that starts in the lobules where milk is made) because lobules are not fully formed in male breast tissue.

Some breast cancers spread to the lymph nodes under the arm. When the lymph nodes are involved in the cancer, they are called positive. When lymph nodes are free or “clear” of cancer, they are called negative. If the lymph nodes are abnormal and have been sampled, the pathology report will indicate whether the lymph nodes have any cancer cells in them. In addition, the report will say whether the cancer is contained within the lymph node or if there is any cancer extension from the lymph node, through the node’s outer capsule and into the tissue outside the node (when this happens, it’s called extracapsular extension).

In both men and women, the more extensive the lymph node involvement, the more aggressive the cancer usually is. But the extent of disease within a particular lymph node is less important than the total number of lymph nodes affected. The more lymph nodes involved, the more serious the cancer diagnosis can be.

A hormone receptor test is done on the cancer tissue to see if they are sensitive to the hormones estrogen and progesterone. Most breast cancers in men have estrogen and progesterone receptors. If the receptors are present, the test will read “positive,” and if the receptors are absent, the report will say “negative.” Positive hormone receptors can mean a better prognosis and a potential role for anti-estrogen hormonal therapy.

The cancer tissue that is removed is tested for high levels of the HER2 gene or protein. HER2 is a gene that helps control how cells grow, divide, and repair themselves. The HER2 gene directs the production of special proteins, called HER2 receptors, in cancer cells. When levels of the HER2 gene or protein are high, the cancer is called HER2-positive (less than 25% of breast cancers are HER2-positive). Cancers that are HER2-positive tend to be more aggressive. But a targeted therapy called Herceptin (chemical name: trastuzumab) works well against these kinds of cancers.