Exploring Male Breast Cancer

Dr. Ian Lewis Shares Insights from a Career of Specialized Experience 

Last month marked breast cancer awareness month. Although the focus typically centers on women, it is important to recognize that men possess a small amount of breast tissue, giving them the potential to also develop breast cancer. But, because male breast cancer is rare, it frequently goes unnoticed until it is at an advanced stage. 

General Surgeon Dr. Ian Lewis, in an interview with Diabetes Today, spoke of the unique challenges men face with breast cancer, the importance of early detection, and the need for increased awareness to dispel misconceptions about this often-overlooked aspect of men’s health. While acknowledging that male breast cancer is not common, occurring at a ratio of about one man to every 135 women diagnosed, Dr. Lewis, who specializes in breast disease management, stressed the importance of awareness, vigilance, and understanding risk factors specific to men.

Understanding the risks

“Risk is a critical concept to understand,” Dr. Lewis said. “Cancer is not caused by one factor alone; it’s highly heterogeneous, meaning that multiple factors come into play that cause a cancer to occur. And the funny thing is, even when risks are at play, it doesn’t necessarily mean that you’re going to get cancer.” 

Dr. Lewis explained that in females, both genetic and environmental factors play a role. He noted that some environmental factors are lifestyle-related, such as alcohol consumption, cigarette smoking and exposure to exogenous estrogens, which include birth control pills and hormone replacement therapy.

He further stated, “Also, not having children can be a risk factor. If we agree that exposure to estrogen carries risks, then having a pregnancy or multiple pregnancies—especially before a certain age—means that for almost a year, there are no estrogen cycles during those nine months. Therefore, the more pregnancies a woman has, especially before the age of 30, the more that acts as a stabilizing factor in terms of exposure to estrogen. This, too, is connected to lifestyle choices, as women today can plan their families and pregnancies, knowing that being childless could be a risk factor.”

Dr. Lewis explained that for men, key risk factors include gynecomastia, a benign condition where men develop enlarged breast tissue due to hormonal fluctuations, which is very common. He explained that up to 90% of male newborn babies will have transient gynecomastia because of the maternal estrogens, and at early puberty, around 13 or 14, about 35% of boys will have gynecomastia that tends to be temporary. 

“If you go to dressing room during sports at school, you may notice some boys not taking off their T-shirts, and that’s exactly why, and it’s something not known to parents, and a lot of games teachers are not sensitive to it. The other age is what we call gynecomastia of old age, and that is around 50 to 69. They’re now saying that up to 90% of men will experience some kind of breast swelling around that phase in life, and these are all driven by hormone factors – the relative level of estrogen versus testosterone comes out of balance, and the relatively higher exposure to estrogen causes the male breast to develop,” he stated.

According to the general surgeon, not only does gynecomastia increase breast cancer risk among men, but it can also hide breast cancer, delaying detection. He revealed that while hormones play a part in this condition developing, some antihypertensive drugs, antacids, drugs used in the treatment of heart failure and prostate disease, alcohol, and marijuana are gynecomastia-inducing. Dr. Lewis added that alcohol consumption on its own is also a risk factor for male breast cancer. He said it is believed that alcohol prevents proper liver function, and this prevents estrogen from being broken down and secreted as it should; instead, it builds in the body, stimulates breast tissue, and causes cancer. He further explained that Klinefelters syndrome, a condition where a male is born with an extra copy of the X chromosome, also significantly increases the risk of breast cancer due to a hormone imbalance. This, too, is the case for men who have the breast cancer gene 1 or 2 (BRAC1 or BRAC2) mutations and men who have received radiation treatment for diseases of the chest.

Knowing the Signs

Like women, for men, the classic sign of breast cancer is a lump. However, Dr. Lewis lamented that men seldom consider breast cancer when they feel a lump, which he identifies as a significant misconception. 

“We think most men come in with an advanced diagnosis because they’ve kept the lesion so long that it’s had time to develop. Society, being society, believes men are not supposed to have breasts; the natural man has a flat chest. He’s not a “breasty” fellow. So, men tend to shy away because of the stigma attached to hearing that there’s a breast tissue-related issue,” he said.

The experienced surgeon advised, “The lump, usually painless, would tend to be close to the area around the nipple. They can have changes in the contour of the breast, whereby the breast becomes ulcerated or the nipple pulled in, what we call an in-drawn nipple, or nipple discharge, which could be clear, white, brown, or red. Anatomically speaking, these things happen, probably faster in men, because the breast tissue is smaller, so there’s not much room to play with, so any lump that forms will generally form close to the nipple and involve the nipple form early. We have a rule – any lump occurring in a male breast, especially if it is on one side, should be assessed by a surgeon.”

He added that internationally, most men diagnosed with breast cancer are 60 and up, but he noted that in his practice, of the 10 cases he has treated over the years, the majority have been younger men – between 30 and 50 years old.

Diagnosis and Treatment: Similar Approaches, Unique Challenges

To better understand the management of male breast cancer, Dr. Lewis explained it’s important to be aware of the diagnostic and treatment approaches, which he noted are similar to those used for women. “A biopsy is essential for diagnosis,” he stated, with mammograms and ultrasounds providing additional insights regarding spread within the breast or lymph nodes. However, due to limited breast tissue, most men require a mastectomy, if diagnosed with breast cancer, to remove all the best tissue, including the nipple and the areola and armpit dissection as well.

“It used to be said that male breast cancer does worse than female, but that is probably not true. The better statement to say is that men tend to present later. That’s a much different statement than to say that men have a more aggressive or much worse prognosis compared to women. So, a man who’s diagnosed at stage 2 should do equally well compared to a lady who’s at stage 2. But overall, because generally, men present later, you will probably find that cohort does a little worse compared to the overall collection of women”.

Interestingly, most male breast cancers are estrogen-dependent, which, according to Dr. Lewis, allows for treatment options using anti-estrogen therapies like Tamoxifen, which is commonly used in female breast cancer patients. The ten-year survival rate for early-stage male breast cancer is around 70%.

His remarks came as he said that as it relates to treatment, there are some subtle differences in how men with breast cancer are treated in comparison to women. But those differences, he maintained, are driven really by a lack of data and comprehensive studies to push the medical community in protocol directions.

Challenges in Awareness and Early Detection

While October’s breast cancer awareness initiatives have been fantastic and contributed significantly to public understanding about breast cancer among women, Dr. Lewis acknowledges that more needs to be done as it relates to awareness around male breast cancer. “How do we capture men?” he asks, reflecting on the challenges of educating a population that traditionally engages less with preventative health measures. “When you do breast cancer talks, you see a flood of women attending. When you do prostate cancer talks, you get a flood of women and men. So, women are the constant. So, how do we capture the men? Do we do it in a corporate setting where companies mandate little sit-down sessions through a company nurse, etc.? Do we try to capture them at school to say, look, this is something you may not hear about a lot, but as you get older, you need to know about it?”

Dr. Lewis encourages targeting awareness efforts in workplaces, community groups, and even schools to build foundational understanding among men. A comprehensive genetic screening program could also help, but given the rarity of male breast cancer cases, he noted that routine screening remains unlikely.

Proactive Health Management: Key Recommendations

Dr. Lewis’ advice to men and their families is simple yet powerful – focus on awareness, limit alcohol, self-examine regularly, especially if there’s a history of radiation treatment to the chest, and maintain proactive health check-ups. For healthcare providers, he stresses the importance of incorporating breast exams in routine health checks for men, ensuring patients receive a comprehensive assessment.

He maintains that routine examination and proactive management are key to improved outcomes. The experienced surgeon hopes that increased education will lead men to seek early intervention if symptoms arise.

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