Four months back, a 65-year-old man consulted me for a swelling in the region of his chest, it was difficult for him to understand and, then, to accept that he had the cancer of the breast. A majority of people is unaware that breast cancer can afflict men too.
Breast cancer in males is an infrequent problem; for every 100 cases of breast cancer, 99 are seen in females and only 1 in males. Statistics in the US reveal that breast cancer constitutes only 0.2 per cent of all malignancies seen in males whereas breast cancer is the commonest cancer in females—about 26 per cent.
In India, the incidence is still lower. Because of its rarity, clinicians and researchers have not been able to collect substantial data on the subject and ignorance persists both in the minds of the doctors and the public.
The breast tissue is the same in males and females, and till puberty, boys and girls have a small amount of breast tissue (mainly ducts) under the nipple. At puberty, the hormonal status is vastly changed. An increase in female hormones gives rise to development of secondary sexual characters, the breasts start enlarging in size, whereas in males the male hormones give rise to development of male secondary characters, the breasts hardly increase in size and thus the differentiation takes place.
Males also have a small quantity of oestrogen, the main female sex hormones. The small quantity normally does not give rise to enlargement of breast tissue. Over production of oestrogen, as seen in some diseases ( liver cirrhosis, cancer of the testes or adrenal glands, Klinefelter’s syndrome (a syndrome in which males have an extra X chromosome) chronic renal failure patients on dialysis ), can give rise to enlargement of breasts in the same fashion as seen in females and this enlargement is known as gynaecomastia.
This is also known to occur after the use of certain medicines. The well-documented ones are the drugs used for ulcers, blood pressure, heart failure, migraine, seizures, and also the use of oestrogen commonly prescribed for cancer of prostate. Forty per cent of adolescent boys do experience gynaecomastia but it soon disappears. During old age, when the hormonal balance changes, the breast size may enlarge. The accumulation of fat in obese men (a classical example is Sumo wrestlers) can make the breasts appear enlarged but this is not true gynaecomastia.
Gynaecomastia is not cancer. It is a benign condition; and there is no evidence that it can chance into cancer except for tha onas that have been produced by ” “oestrogen. Cancerous changes, like alseshera, can take place in”the breast tissue.
Male and female breast cancer patients have common features. A swelling or nodule in the breast (commonly under the nipple and areola), without any pain (one must remember this) is the common presenting complaint. Bloody discharge from the nipple, retraction of the nipple, ulceration of the overlying skin or presence of nodules in the armpit (palpable lymph nodes) are the other presenting features.
The male breast cancer patients are diagnosed at an advanced stage of the disease, even in developed countries; this delay results in bad prognosis of the male breast cancer patients as compared to females. The small size of the male breast also contributes. The tumour quickly goes beyond the confines of the breast and spreads into the overlying skin and the underlying muscles.
The diagnosis and investigations in a male breast cancer patient is carried out in the same way as in a female. Mammography is not of much help because the small-sized breast can not be satisfactorily examined by mammography machine. MRI, CT scan, Ultrasound are useful.
The line of treatment is multi-modality—comprising of surgery, radiotherapy, chemotherapy and hormone therapy. Mastectomy or surgical removal of breast is the standard treatment and unlike in females where breast conservation (removal of the tumour only) is feasible, because of the small size of the male breast, total removal of the breast is the procedure of choice. In an advanced stage, the surgeon may have to perform a more radical procedure, taking away the underlying muscles and may have to also use skin grafting to cover the resultant defect. Use of multiple chemotherapeutic agents, either before or after surgery, is widely used and gives better results.
Breast tumour tissue contains hormone receptors in a high proportion of men—over 80 per cent as compared to 65 per cent in women but because of the paucity of vast experience on the subject, it is not yet known if positive hormone receptor status indicates a better prognosis as seen in women. Similarly the role of antioestrogen agents has not been well established although it is considered to be beneficial. Surgical castration has been also credited to give beneficial results – regression of the size of the tumour, relief of symptoms and clearance of metastasis in a few patients but the experience is scanty. A patient of male breast cancer may go into a state of depression particularly if he considers himself to be harbouring a disease that is predominantly for females, and one that involves hormone imbalances, this might be perceived as a threat to his masculinity. He definitely requires support and sympathy from his dear and near ones.
Dr Sameer Kaul