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Breast cancer

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Breast cancer in men

Breast cancer starts in the breast tissue. Men have breast tissue just like women, but their breasts are less developed.

Breast cancer in men is rare. Less than 1% of all breast cancers occur in men. It is estimated that 220 new cases of breast cancer in men will be diagnosed in Canada in 2015, and that 60 men will die from the disease.

While breast cancer in men is similar to the disease in women, there are some differences. For the most part, breast cancer in men is treated like breast cancer in women after menopause (when the ovaries stop producing estrogen).

Risks

Any substance or condition that increases cancer risk is referred to as a risk factor. There isn’t a known, single cause of breast cancer in men. Most cancers are the result of many risk factors. However, some men with breast cancer do not have any identifiable risk factors.

The risk of a man developing breast cancer increases with age. Most men diagnosed with the disease are over the age of 60.

The following factors increase the risk of breast cancer in men.

Family history of breast cancer

Men who have a close relative (male or female) diagnosed with breast cancer have a greater risk of developing the disease. The risk increases with the number of relatives diagnosed.

Certain genetic mutations

Genetic mutations are changes to a gene, which can increase the risk of developing cancer. Inherited gene mutations are passed on from a parent to a child. Only a small portion of breast cancer in men is caused by inheriting a gene mutation.

  • Men who have a BRCA2 gene mutation are at an increased risk of developing breast cancer.
    • Mutations in the BRCA1 gene also increase risk, though it is not as high as with the BRCA2 gene mutation.
  • Men who carry these gene mutations may pass them along to their children. Children of men with breast cancer are at an increased risk of developing breast cancer.

Klinefelter syndrome

Klinefelter syndromeKlinefelter syndromeAn inherited sex chromosome disorder in which men have at least one extra X chromosome. Signs include small testicles, enlarged breasts and lack of facial and body hair. is a very rare inherited (genetic) disorder. Men with this disorder have lower levels of androgens and higher levels of estrogen, which are associated with an increased risk of developing breast cancer.

Radiation exposure

Previous exposure to radiation, especially to the chest, increases the risk of breast cancer in men.

Cirrhosis of the liver

Cirrhosis is scarring of the liver. It occurs when scar tissue replaces healthy tissue in the liver. Hormones are carried into the blood by proteins made by the liver. A liver damaged by cirrhosis causes high estrogen levels and low androgen levels in the body, which are associated with a greater risk of developing breast cancer.

Possible risk factors

The following factors have some association with breast cancer in men, but there is not enough evidence to say they are known risk factors. Further study is needed to clarify the role of these factors for breast cancer in men.

  • gynecomastia (enlarged male breasts)
    • Men with gynecomastia may have a higher risk of developing breast cancer, although whether or not this is a risk factor is unclear. Abnormal estrogen or androgen levels are often associated with gynecomastia.
  • being obese
    • Obesity increases the risk of breast cancer in women, and may increase the risk of breast cancer in men. Fat cells in the body convert androgens into estrogen, so men with more fat cells have higher levels of estrogen in their body.
  • drinking alcohol
    • Alcohol increases the risk of breast cancer in women. It may also increase the risk in men because of the effect it has on the liver, which may affect the level of estrogen in the body.
  • estrogen treatment
    • Men with prostate cancer may be treated with estrogen, which can slightly increase the risk of developing breast cancer. However, the risk is small when compared to the benefit of the treatment.
    • Men taking estrogens during a sex change procedure may also have a higher risk of developing breast cancer.
  • taking finasteride (Proscar or Propecia)
    • Finasteride is a drug used to treat an enlarged prostate (Proscar) or male pattern hair loss (Propecia). A recent study suggested that there may be a very small increase of breast cancer in men who took this drug.
  • problems with the testicles
    • Some studies have suggested that the risk of breast cancer is increased in men who have:
      • an undescended testicle (cryptorchidism)
      • had one or both testicles removed (orchiectomy)
      • had mumps as an adult
  • occupational exposure
    • Some research studies suggest that men who work in hot environments may be at an increased risk of breast cancer. High temperatures in the following types of environments may affect the testicles and hormone levels:
      • steel mills
      • blast furnaces
      • rolling mills
    • Other studies have shown a link between breast cancer in men and exposures to gas and exhaust fumes.

See a list of questions to ask your doctor about risks.

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Signs and symptoms

A sign is something that can be observed and recognized by a doctor or healthcare professional (for example, a rash). A symptom is something that only the person experiencing it can feel and know (for example, pain or tiredness).

Most breast problems are not breast cancer. The signs and symptoms of breast cancer can also be caused by other health conditions. It is important to have any unusual symptoms checked by a doctor.

  • a hard, painless lump in the breast – most common sign
    • in men, the lump is often around or under the nipple
  • a lump in the armpit
  • breast swelling or tenderness
  • changes to the skin
    • redness
    • scaling
    • puckering or dimpling
    • itching
  • changes to the nipple
    • discharge
    • crusting or ulcers
    • nipples that suddenly point inward (inverted)

Many men do not report symptoms of breast cancer to their doctors. This may be because they are not aware that men can get breast cancer or they are embarrassed. For this reason, men are often diagnosed at a later stage than women. Men should know what is normal for their breasts and report any changes to a doctor.

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Diagnosis

Diagnosis is the process of finding the cause of a health problem. Diagnostic tests will be done if the signs and symptoms of breast cancer are present or if the doctor suspects breast cancer. Many of the same tests used to initially diagnose cancer are used to determine the stage (how far the cancer has progressed). The doctor may also order other tests to check a man’s general health and to help plan treatment. Tests may include the following.

See a list of questions to ask your doctor about diagnostic tests.

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Pathology and staging of breast cancer in men

Malignant tumours are cancerous growths that have the potential to metastasize (spread to other parts of the body):

Staging

Breast cancer in men is staged using the same staging system for breast cancer in women.

  • Stage is based on the size of the tumour and whether or not the cancer is in any lymph nodes or has spread to other areas of the body.
  • Breast cancer in men is often diagnosed at a later stage than in women, when the cancer has started to spread to other parts of the body.

Grading

Grading for breast cancer in men is the same as grading for breast cancer in women.

Prognosis and survival for breast cancer in men

Men with breast cancer may have questions about their prognosis and survival. Prognosis and survival depend on many factors. Only a doctor familiar with a person’s medical history, type of cancer, stage, characteristics of the cancer, treatments chosen and response to treatment can put all of this information together with survival statistics to arrive at a prognosis.

A man’s prognosis depends on the:

  • stage of the cancer
    • Lower stages have less risk of the cancer recurring and a more favourable prognosis. Higher stages have more risk of recurrence and a less favourable prognosis.
  • type of breast cancer
  • hormone receptor status of the tumour
    • Hormone receptor–positive tumours have a more favourable prognosis.

See a list of questions to ask your doctor about pathology and staging.

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Treatment

Treatment plans are designed to meet the unique needs of each person with cancer. Treatment decisions for breast cancer in men are based on the:

  • stage of the breast cancer
  • hormone receptor status of the cancer
  • HER2 status of the cancer
  • risk for recurrence (with early stage breast cancer)
  • overall health of the man

Men with breast cancer often receive the same type of treatment as post-menopausal women with breast cancer. A treatment plan for men with breast cancer may include one or more of the following:

Surgery

Surgery is the most common treatment for breast cancer in men. The types of surgery are:

  • mastectomy – usually a modified radical mastectomy
  • lymph node surgery
    • axillary lymph node dissection
    • sentinel lymph node biopsy – in certain situations

Breast-conserving surgery is not usually done in men because most tumours are found around the nipple, which makes this type of surgery difficult.

Adjuvant therapy

Adjuvanttherapy is additional treatment that may be given after breast cancer surgery to reduce the risk of the cancer recurring. As with women, the decision to offer a man adjuvant therapy is based on the risk of breast cancer recurrence. The benefit of using adjuvant therapy is weighed against the risks associated with receiving treatment.

Chemotherapy

Chemotherapy may be used to treat breast cancer in men with cancer that has spread to the lymph nodes or cancer that is considered high risk.

The drugs used are the same as those given to post-menopausal women with breast cancer. The most common chemotherapy combinations used to treat breast cancer in men are:

  • CMF – IV
    • cyclophosphamide (Cytoxan, Procytox), methotrexate and 5-fluorouracil (Adrucil, 5-FU)
  • FAC (or CAF)
    • cyclophosphamide , doxorubicin (Adriamycin) and 5-fluorouracil

In men who have breast cancer tumours that are HER2 positive, trastuzumab (Herceptin) may be used in combination with chemotherapy.

For more detailed information on specific drugs, go to sources of drug information.

Hormonal therapy

Hormonal therapy may be used to treat breast cancer in men that is hormone receptor positive. Most male breast tumours are hormone receptor positive.

The most common types of hormonal therapy used to treat breast cancer in men are:

  • anti-estrogens
    • Tamoxifen (Nolvadex, Tamofen) is the hormonal therapy used for breast cancer in men. It is often given as adjuvant therapy.

For more detailed information on specific drugs, go to sources of drug information.

Radiation therapy

External beam radiation therapy may be used as adjuvant therapy after surgery to treat breast cancer in men. It may be given after mastectomy to remove large tumours if:

  • the cancer had spread to the muscles in the chest
  • cancer is found in a large number of lymph nodes removed during surgery
  • Radiation therapy is also given to men after they have breast-conserving surgery.

Treatment of metastatic breast cancer in men

Treatment for breast cancer that has spread to other parts of the body (metastatic breast cancer) may include hormonal therapy, chemotherapy or a combination of both.

Hormonal therapy

The types of hormonal therapy used for metastatic breast cancer in men may include:

  • tamoxifen
    • This drug is used for estrogen receptor–positive tumours.
  • aromatase inhibitors
    • Researchers are studying the role of aromatase inhibitors in treating breast cancer in men. They are a standard treatment given to post-menopausal women and may be offered to men with breast cancer in some situations.
      • anastrozole (Arimidex)
      • letrozole (Femara)
  • luteinizing hormone–releasing hormone (LHRH) agonists
    • LHRH agonists may be given to decrease the production of sex hormones.
      • goserelin (Zoladex)
      • leuprolide (Lupron, Lupron Depot, Eligard)
      • buserelin (Suprefact)
  • anti-androgens
    • These drugs may be given along with LHRH agonists to help reduce side effects.
      • flutamide (Euflex)
      • bicalutamide (Casodex)
  • orchiectomy
    • The testicles are surgically removed to lower hormone production. The testicles produce androgens that may be changed into estrogen by other tissues.

For more detailed information on specific drugs, go to sources of drug information.

Chemotherapy

Chemotherapy may be used for metastatic breast cancer in men when it no longer responds to hormonal therapy. The drug combinations that may be offered are:

  • CMF – IV
  • FAC (or CAF)

Other drug combinations that are also used to treat post-menopausal women with metastatic breast cancer may be offered, but there is little research on the best chemotherapy for metastatic breast cancer in men.

  • AC
    • doxorubicin and cyclophosphamide
  • AC ? Taxol
    • doxorubicin and cyclophosphamide, followed by paclitaxel (Taxol)
  • CEF
    • cyclophosphamide (by mouth), epirubicin (Pharmorubicin) and 5-fluorouracil
  • FEC
    •  cyclophosphamide (intravenous), epirubicin and 5-fluorouracil
  • FEC ? T
    • cyclophosphamide, epirubicin and 5-fluorouracil, followed by docetaxel (Taxotere)
  • TC
    • docetaxel and cyclophosphamide
  • TAC (or DAC)
    • docetaxel, doxorubicin and cyclophosphamide

For more detailed information on specific drugs, go to sources of drug information.

See a list of questions to ask your doctor about treatment.

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Follow-up after treatment for breast cancer in men

Breast cancer behaves differently in each man, and a standard follow-up schedule would not work for everyone. Men with breast cancer should talk to their doctor about a follow-up plan that suits their individual situation. Follow-up care is often shared among the surgeon, cancer specialists (oncologists) and the family doctor.

After treatment has ended, new symptoms and symptoms that don’t go away should be reported to the doctor without waiting for the next scheduled appointment. These may include:

  • pain, especially pain in the legs, back or hips
  • persistent cough or difficulty breathing
  • a lump in either breast, the neck, armpits or groin

The chance of breast cancer recurring is greatest within 5 years, so close follow-up is needed during this time. Follow-up after breast cancer treatment varies. Follow-up visits are usually scheduled:

  • every 3–6 months for the first 3 years after treatment
  • every 6–12 months for the next 2 years
  • then once a year

Tests may be ordered if there are symptoms or if the doctor suspects the cancer has come back (has recurred).

  • mammography
  • blood chemistry tests
    • Blood tests may be done to see if the breast cancer has spread to the liver or bones.
  • bone scan
    • Bone scans are done to check for cancer that has spread to the bones.
  • other imaging tests

If a recurrence is found during follow-up, the oncology team will assess the man with cancer to determine the best treatment options.

See a list of questions to ask your doctor about follow-up after treatment.

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Supportive care

A cancer diagnosis can lead to many challenges for the man with cancer and his family. Each man’s experience will be different because his cancer, treatment and recovery are different. A man with breast cancer may have concerns about:

  • lymphedema
    • A man may develop swelling of the arm when lymph nodes in the armpit are removed during an axillary lymph node dissection.
  • hot flashes
    • A man may have hot flashes due to the side effects of some hormonal therapies.
  • erectile dysfunction (impotence)
    • Some hormonal therapies for breast cancer in men can cause erectile dysfunction.
  • problems with fertility
  • body image and self-esteem
    • Many men find it difficult to talk about their breast cancer diagnosis because it is often seen as a cancer that only women get.

See a list of questions to ask your doctor about supportive care after treatment.

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Clinical trials

Canada is an international leader in conducting research studies called clinical trials. A man with breast cancer may want to consider taking part in a clinical trial. There are very few clinical trials looking at breast cancer in men because this type of cancer is so rare.

Find out more about clinical trials.

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