When you talk about breast cancer, the first thing that comes to your mind is probably a disease that affects women. However, breast cancer does occur in men and, though rare, healthcare professionals are witnessing a slow rise in the number of such cases.
Nipples, stroma, ducts (tubes that deliver milk to the nipples) and lobules are the components of breasts in both men and women (milk-producing glands). Girls’ breast tissue grows as a result of the hormones in their bodies throughout puberty. Boys’ bodies include hormones that prevent the development of their breasts, resulting in less breast tissue.
“Ductal carcinomas, which start in the milk ducts, are the most common kind of breast cancer in men. About one in 1,000 men will develop breast cancer in their lifetime (compared to one in eight for woman),” says Dr (Col) Ranga Rao, chairman, oncology, Paras Hospitals, Gurugram.
The unique thing about men’s connection with breast cancer is that it’s a reality, says Dr Sajjan Rajpurohit, director-medical oncology, Max Super Speciality Hospital, Shalimar Bagh, New Delhi. “Many of these cases are being reported in the familial pattern, which means that the patient is likely to have a family history of breast cancer or ovarian cancer. Also, 50-60% of these will have some form of hereditary cause, which is known as hereditary breast ovarian cancer syndrome, and will include genes like brca1, brca 2 and rad52 and palb2. All these genes can be involved in patients with male breast cancers,” he adds.
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Breast cancer in men forms only about 1% of the total number of breast cancer cases but the percentage of occurrence has risen over time. “Female breast cancer is the most commonly diagnosed cancer in India (26.3%). Male breast cancer forms only about 1% of the breast cancers and, even though over the decades the percentage has risen, it still remains around 1%,” says Dr Nikhilesh Borkar, consultant surgical oncologist at Sir HN Reliance Foundation Hospital in Mumbai.
“One must see absolute rather than relative numbers. One study said that the incidence (of breast cancer in men) increased by 26%, from 0.86 to 1.08 per lakh people. The lifetime risk of developing breast cancer remains around 1 in 833 (0.12%) in males compared to 1 in 8 (12%) in females. The incidence in India is even lesser compared to the west,” Borkar explains, adding: “The problem is that awareness is less among men and no routine screening method leads to detection in advanced stages. Also, non-compliance to hormonal therapy can cause sexual dysfunction, leading to poorer prognosis.”
Dr Boman Dhabhar, senior consultant medical oncologist, Masina Hospital, Byculla, Mumbai, holds lifestyle changes like alcohol, obesity and smoking responsible for this slow rise. “Breast cancer in men is a well-known phenomenon and the cases are gradually increasing over the years. Once considered an extremely rare disease, it is now not so much. Of all breast cancers, 1-1.5% occur in men,” he adds.
The age group of breast cancer in men is quite similar to that in women, which normally happens beyond the age of 50 to 60 years. However, some men can have an early cancer of the breast, especially patients who have mutation in the brca1 gene.
“So, brca1 gene dependent breast cancer cases are more likely to happen in patients less than 40 years of age, otherwise all other mutations or sporadic cases or the cases which are not responsible because of the genetic or inherited cases usually happen beyond the age of 60 years,” says Dr Rajpurohit of Max Super Speciality Hospital.
Men tend to be 5 to 10 years older than women at the time of diagnosis, and the prevalence of breast cancer increases with age in both sexes, adds Dr Borkar of Sir HN Reliance Foundation Hospital. “The median age as per the study of around 1,500 male breast cancers in the US is around 68 years. In India, too, it is around 60 -70 years. But beware, it can also occur at an earlier age. It’s due to the altered estrogen-to-androgen ratio with age. It can also happen due to hormonal therapies, hepatic dysfunction, obesity, or testicular conditions like orchitis, undescended testes, and testicular injury,” he adds.
So, what are the initial signs to look out for? Like their female counterparts, as per Dr Dhabhar of Masina Hospital, breast cancer in men can also be present with a palpable chest lump or swelling. “Nipple involvement is rare and usually not more than 1% have this. Screening has not played a major role for male breast cancers but males with a strong family history and who are known carriers of a defective gene should perform regular self-examinations or get examined by a doctor on a timely basis,” he adds.
Dr Rajpurohit of Max Super Speciality Hospital agrees that the symptoms of breast cancer in men are quite similar to in women. There will be a painless lump in the breast in the male and it might appear as if the breast is getting enlarged or there is an abnormal lump which is being felt. “Initially, it might just appear as if it is because of some trauma, or you could spontaneously notice it accidentally. But later on, people can also have swelling in the axillary area or the armpit area. These are the initial symptoms. Later symptoms could be bone pain, cough, breathlessness, and liver dysfunction,” he adds.
“With respect to screening, normally it is not advised for male breast cancer. There is no screening to confirm any males undergoing mammograms. So, it is only based upon the symptoms and no screening for men,” explains Rajpurohit, adding: “However, if a man has got a family history and the mother or grandmother suffering from breast cancer then they should undergo a genetic testing just to understand the situation because these men can also have cancer of the prostate with a higher probability or a male breast cancer or if they are affected with mutation in the genes brca1 or brca2.”
So, what kind of treatment can a patient go for if he is diagnosed with breast cancer and what is the survival rate? “Early-stage disease undergoes a simple mastectomy. Limited data suggest that breast-conserving surgery is a reasonable alternative, provided there is enough breast tissue to ensure adequate surgical margins. For advanced stages, the disease may require chemotherapy first, followed by surgery, which is usually mastectomy,” says Dr Borkar of Sir HN Reliance Foundation Hospital, adding: “Surgery may be followed by chemotherapy, radiation-therapy, and hormonal therapy (tamoxifen).”
According to Dr Dhabhar of Masina Hospital, consulting a medical oncologist is of utmost importance and the treatment depends entirely on the molecular profile of the tumour. “Hence, a biopsy with an IHC is mandatory for all patients. Male breast cancers more commonly express hormone receptors like ER & PR which makes them susceptible to hormonal treatment. Other treatment modalities include chemotherapy, targeted therapies, and immunotherapy,” he adds.
What kind of treatment can one go for?
Genetic studies (blood test) for brca mutations would be helpful. Making choices regarding treatment options will depend in large part on the stage (extent) of breast cancer. In general, you will probably require more therapy if the cancer has spread more. However, there are additional elements, such as:
- If hormone receptors are present in the cancer cells (that is, if the cancer is ER-positive or PR-positive)
- If the HER2 protein is present in significant concentrations in the cancer cells
- Your general well-being and preferences
- How quickly the cancer is expanding
— Dr (Col) Ranga Rao, chairman, oncology, Paras Hospitals, Gurugram