Male Breast Cancer: Coping and Finding Support

Overview and Psychological Impact of Male Breast Cancer

Nurse consoling older man
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We don’t have to look far to see evidence of support for women with breast cancer, but what about for men who have breast cancer? Many people, in fact, aren't even aware there is such as thing as male breast cancer. In some ways, breast cancer in men today is what breast cancer in women was four decades ago—something difficult to talk about with a huge psychological impact but very little support.

Let's begin by looking at an overview of male breast cancer, the statistics, the risk factors, and treatment options, and then focus on how you can best cope and find support both physically and emotionally as a man with breast cancer.

Male Breast Cancer—The Basics

Men do get breast cancer, though they are 100 times less likely to develop the disease than women. It’s estimated that in 2017 there will be 2,470 men diagnosed with breast cancer and 460 will die from the disease. Unfortunately, in one study, 80 percent of men with breast cancer had been unaware that men can get breast cancer.

At the current time, roughly 1 in 8 women will develop breast cancer, which accounts for almost 25 percent of cancers in women. For men, the average risk of breast cancer is 1 in 1000 and breast cancer accounts for only 0.1 percent of cancers in men. The number of men who are diagnosed with breast cancer has increased over the past few decades.

Men tend to be diagnosed at an older age than women with the average age at diagnosis is 68.

While there are some similarities between men and women with breast cancer, there are many important differences as well which we will discuss. It has been rumored that survival rates are lower for men with breast cancer, but it's important to talk about the reasons behind this.

Men—due to a lack of screening, lack of awareness (by both the public and health professionals), and perhaps more hesitancy to see a doctor for breast related symptoms—are often diagnosed when the cancer is at a more advanced stage of the disease. Survival rates for men and women when matched for the stage of the disease are very similar with survival being overall slightly higher in men.

Anatomy of the Breast in Men

Males have breast tissue just as women do, but the structure is slightly different. While men have breast ducts, they are less developed than in women. Unlike women, men do not usually have breast lobules.

Types of Breast Cancer in Men

The types of breast cancer in men and women differ, reflecting the different anatomy of the breasts. Around 80 percent of breast cancers in men are ductal carcinomasLobular carcinomas, cancers which arise in the breast lobules, account for only 2 percent of breast cancers in men. Paget's disease of the nipple is uncommon but accounts for a higher percent of breast cancers in men relative to women. Other forms of breast cancer such as inflammatory breast cancer and sarcomas are very uncommon.

Symptoms of Breast Cancer in Men

Symptoms of breast cancer in men are similar to those in women and may include:

  • A breast lump (with or without pain)
  • Nipple discharge
  • Skin thickening
  • Scaling or redness of the nipple (this is often seen earlier in men than in women)
  • Dimpling of the skin (an "orange peel" appearance)
  • Retraction or deformation of the nipple (when the nipple appears to be pulled inward)
  • A lump in your armpit or above your collarbone

As with women, men often learn they have breast cancer after finding a lump. Not all breast lumps in men are cancer.

Breast Lumps in Men

Not all breast lumps in men are cancer, but unlike women who may have a variety of benign breast lumps, a lump in a man is more likely to be cancer.

Gynecomastia is a condition in men that is not a lump but rather a uniform enlargement of fatty tissue in the breasts. Gynecomastia is common, occurring to some degree in around half of boys during adolescence. In adulthood, there are several causes of gynecomastia as well ranging from medications to liver disease to obesity.

Causes and Risk Factors for Male Breast Cancer

We don't really know what causes breast cancer in men, but several risk factors have been identified. These include:

  • Genetics: It's thought that genetics play a somewhat greater role in breast cancer in men than in women. Like women, men with BRCA mutations are at an increased risk, though this is different than in women. Around 55 to 65 percent of women with a BRCA1 mutation will develop breast cancer, but only around 1 in 100 men with the mutation. A BRCA2 mutation is associated with breast cancer in around 45 percent of women with the mutation but only 6 percent of men. Other mutations important in male breast cancer include CHEK2, PTEN, and PALB2 mutations.
  • Age: Breast cancer in men increases with age with the average age being 68 years.
  • Race: African American men have a greater incidence of breast cancer than Caucasian, Asian, or Hispanic men. African American men also tend to get breast cancer at a younger age (the opposite is true for women with breast cancer).
  • Klinefelter's syndrome (XXY): Men with Klinefelter's syndrome, a trisomy of the sex chromosomes such as XXY (and others) carries a risk of male breast cancer of 1 in 100 men.
  • Previous cancer treatments: Radiation therapy to the chest (for example, men who have been treated for Hodgkin's disease), estrogen therapy for prostate cancer, and orchiectomy for testicular cancer may be associated with an increased risk.
  • Alcohol use
  • Liver disease
  • Obesity: Alcohol abuse, liver disease, and obesity are all associated with elevated levels of estrogen and may increase risk.
  • Undescended testicles
  • Mumps orchitis
  • Environmental exposures: It's likely that certain environmental exposures increase risk, but with the exception of gasoline fumes this has been studied very little.
  • Early birth order: Being the first born is linked somewhat to breast cancer in both men and women.

Diagnosing Male Breast Cancer

Male breast cancer is diagnosed in a way similar to the diagnosis of breast cancer in women and may include a mammogram, breast ultrasound, or MRI. These imaging tests may suggest cancer, but the only conclusive way to make a diagnosis is through a biopsy.

There are several different types of breast biopsy procedures which may be done. A fine needle aspiration uses a very thin needle injected into a tumor to obtain a sample. With a core needle biopsy, as a slightly larger sample is removed. An open surgical biopsy can be done in two different ways, excisional or incisional. Most commonly an excisional biopsy will be done for a man which involves removing the entire mass as well as some surrounding tissue.

During an open biopsy (or during a mastectomy or breast conserving surgery discussed below) your doctor may also recommend a sentinel node biopsy. In this procedure, a radioactive dye is injected into your tumor where it makes its way into the lymphatic system. In this way, it can give your doctor a reading about which lymph node a cancer would travel to first, which can then be biopsied to see if there is any evidence of cancer in your lymph nodes.

A pathologist will look at your biopsy specimen under the microscope to determine if a mass is breast cancer, and if so, which type. In addition, she will report the tumor grade of the cancer, which is assigned a number of one to three depending on how aggressive the tumor appears to be. Tests are also done to assess hormone receptor status and to see if a cancer is positive for HER2/neu (see below).

Staging Breast Cancer in Men

In addition to evaluating your tumor with a biopsy, other tests may be done to see if your cancer has spread. Imaging tests such as a chest x-ray, CT scan, MRI, bone scan, or PET scan may be done depending on many factors. The regions of the body to which breast cancer most commonly spreads (sites of breast cancer metastases) are the lungs, the bones, the liver, and the brain.

Breast carcinomas may be either “in situ” or invasive. It’s important to note that all other stages, from I to IV are considered “invasive” breast carcinoma. This does not mean that they have “invaded” other tissues, have spread, or are more aggressive, though it can be frightening to see this word on a pathology report. An invasive breast cancer is one in which the cancer cells have spread past a region known as the basement membrane.

To determine the stage of invasive cancer, doctors look at three values:

  • T refers to the size of the tumor.
  • N refers to the presence of cancer in lymph nodes and is given a number based on how far these lymph nodes are from the original cancer.
  • M refers to the presence of distant metastases.

Breast cancers in men tend to spread more quickly than those in women, due to the smaller amount of breast tissue. These cancers don’t have to travel far to reach the skin and nipple or in the other direction, the muscles in the chest.

A simple description of the stages of breast cancer include:

  • Stage 0 or carcinoma in situ are cancers which are not invasive.
  • Stage I cancers are usually small cancers that have not spread to lymph nodes.
  • Stage II cancers may be larger or have spread to nearby lymph nodes.
  • Stage III cancers include those which are larger, are locally invasive, or have several lymph nodes near the tumor or lymph nodes farther away from the tumor.
  • Stage IV cancers are those which have spread to distant regions.

Treatment Options for Male Breast Cancer

There are many different treatment options available for breast cancer in men, with further treatments being evaluated in clinical trials. Treatments may include:

  • Surgery: In men, a mastectomy is done more often than breast-conserving surgery. For small cancers, surgery may be curative.
  • Hormone therapy: Roughly 90 percent of breast cancers in men are estrogen-receptor positive and can respond well to hormonal therapies. The most common drug used for male breast cancer is tamoxifen which is used to block the receptors on breast cancer cells so that estrogen cannot bind and cause them to grow. Male hormones may also cause breast cancer cells to grow.  Orchiectomy (removal of the testes) was once often performed, but medications such as Zoladex and Lupron are usually used instead to block the testes from making male hormones.
  • Chemotherapy: Chemotherapy for breast cancer may be done in a few different ways. It may be given after surgery (adjuvant chemotherapy) in order to treat any cancer cells which may have traveled away from the cancer site but are not yet detectable on scans. It may also be given prior to surgery (neoadjuvant chemotherapy) in order to reduce the size of a tumor before surgery.
  • Targeted therapy: For cancers which are HER2/neu positive, the drug Herceptin (or others) is often used. These drugs block the receptor so that growth factors cannot bind and signal the cells to grow.
  • Radiation therapy: There are a number of different ways in which radiation therapy may be used to treat male breast cancer.
  • Clinical trials: There are other targeted therapies and even immunotherapy drugs which are being studied for breast cancer which has not responded to other treatments.

Prognosis of Male Breast Cancer

Statistics regarding male breast cancer may be helpful in some ways, but it's important to keep in mind that these do not take into consideration newer treatments that are now available. For example, 5-year survival rates give us an idea of the prognosis of an "average" man diagnosed at least 5 years ago, but newer treatments have been approved since that time. The 5-year survival rates for men with breast cancer by stage (as of 2017) are:

  • Stage 0 - 100 percent
  • Stage I - 100 percent
  • Stage II - 91 percent
  • Stage III - 72 percent
  • Stage IV - 20 percent

It is rumored that survival rates for men with breast cancer are lower than those of women. When compared by stage, however, survival rates are very similar between the sexes and perhaps slightly better in men. That said, the improvement in survival over the last three decades is less for men than for women.

Genetic Testing

Since many breast cancers in men have a genetic component, many men are interested in genetic testing. If you are considering this, it's important to first talk to a genetic counselor. Genetic testing is in its infancy. A genetic counselor may see a pattern of risk while looking at your pedigree which provides more information than the tests we currently have.

What many people do not realize is that some of the mutations which predispose to breast cancer may also predispose to other cancers. For example, a BRCA2 mutation is associated with an increased risk of pancreatic cancer. A good genetic counselor can put all of these pieces together to help you understand your risk as well as that of your family.

Psychological Impact of Breast Cancer in Men

Breast cancer can have a tremendous impact on men from a psychological standpoint—something which has been neglected both in awareness and research. Men with breast cancer have reported feelings of anxiety, embarrassment, and even depression with regard to their diagnosis.

A diagnosis of breast cancer can also affect a man's masculinity and body image. Physically, a mastectomy causes changes in the appearance of a man's chest, and hormone therapy can result in a number of problems including sexual side effects. Emotionally, having a cancer which is most often considered a "female cancer" can have a negative effect on gender identity. Nearly half of men questioned in one study stated that having a breast problem would affect their masculinity.

Adding in other common emotions such as loneliness, a perceived stigma, vulnerability, and a sense of unfairness, it's clear that men with breast cancer need just as much support as their female counterparts. In some ways, men who are facing breast cancer today are coping with the same issues of stigma that women did three or four decades ago.

Coping With the Emotions of Male Breast Cancer

How can you cope with all of this? Studies in women have found that there are several factors which can affect the emotional response, and hence the ability to cope, with breast cancer. These include:

  • The ability to recognize and express emotions
  • A strong support network
  • The development of positive coping methods (as opposed to maladaptive methods such as alcohol use)
  • A belief system that helps people find meaning in illness

Unfortunately, many of these coping mechanisms are seen less often in men than in women. Traits which men often consider important including physical and emotional strength, invulnerability, control, and self-reliance are in some ways the opposite of what's been shown to be helpful in coping. Let's look at how men can cope with the emotions of breast cancer:

  • Express your emotions: Expressing emotions has been shown repeatedly to make a difference when it comes to coping with cancer. Unfortunately, it's not just men who have "learned" to hold their emotions inside. Health care providers seem slow to appreciate the emotional needs of men with breast cancer, and popular (but misguided) public opinion that you need to "keep a positive attitude with cancer to survive cancer" discourages the expression of emotions as well. While being positive, in general, can make it easier to cope with breast cancer, expressing negative emotions when you have cancer is just as important.
  • Develop positive coping strategies: Working with a cancer psychologist can be very helpful for men coping with breast cancer, but there are several coping techniques any man can begin right away. The technique of cognitive reframing, in particular, can help in many ways. With reframe strategies, a person's situation does not change, but his way of looking at it does. For example, instead of mourning the loss of hair on your head from chemotherapy you may celebrate not having to shave for several months. We use this example to note that sometimes you need to "fake it 'till you make it" with this approach, but in time it can be very effective. Take some time to learn about other coping strategies for reducing stress.
  • Nurture your spirituality: We have been learning that increased spirituality may improve the quality of life for people with cancer and has even been linked with survival in a few studies. According to the National Cancer Institute, spirituality refers to a person's thoughts and feelings about their purpose, their connection to others, and beliefs about the meaning of life. Some people find this through organized religion, whereas others may prefer communing with nature. Whatever spirituality means to you, find ways to nurture this part of yourself.
  • Expand your support system: Below we talk about support groups and support communities, but the kind of support which improves quality of life includes family and friends. This may require men to be more vulnerable than they are accustomed to, and can be downright frightening. Men may wish to start by finding one friend who can be their confidant.

Support Services for Men With Breast Cancer

It's not just that men with breast cancer aren't expressing their thoughts and needs, but a large burden resides in health care providers. It's been found that physicians underestimate the needs of men with breast cancer as well.

An example can be seen in looking at the programs available for women with the disease. These include patient/couple/family education, support groups, exercise groups, nutrition lectures, information on psychological symptoms, information on coping with hair loss (including free wigs and scarves), and much more. It's not that these resources are unavailable for men, but it can take more work to find them and your physician may be less likely to direct you.

What this often means is that men—who are less likely than women to seek out help—may need to seek out help even more than women with the disease. While this isn't ideal, it is where we are at the current time.

Post-Traumatic Stress Symptoms in Men With Breast Cancer

You've likely heard that veterans and people who have experienced natural disasters are at risk for post-traumatic stress syndrome, but many people who have gone through cancer treatment experience similar feelings. In a study published in the Journal of Clinical Oncology, roughly a fourth of men with breast cancer experienced post-traumatic stress symptoms. The symptoms can not only reduce your quality of life but can limit your ability to step back into the world once treatment is done. Take a moment to learn about post-traumatic stress in people with cancer.

Finding Support For Men With Breast Cancer

We have repeatedly seen that psychosocial support is important for women with breast cancer, and that appears to be no less the case for men. Not only is better support associated with better coping and quality of life, but has even been linked with survival in some studies.

Men, however, are less likely to seek out support and are less likely to openly talk about their diagnosis among friends and family for many reasons.

Finding other men who are coping with breast cancer can be invaluable, both in providing this support, and in giving you the opportunity to talk with others who are facing similar challenges.

Since breast cancer in men is relatively uncommon, many people do not have a local support group designed specifically for men with breast cancer. Yet there are many options. There is a very active online male breast cancer community. In fact, on Twitter, there are several men with breast cancer who are working tirelessly to bring awareness and reach out to men who are newly diagnosed with breast cancer. If you go on twitter, it is easiest to find these people by using hashtags.

Online, The Male Breast Cancer Coalition is an amazing effort to support men with the disease by reminding the public that "men have breasts too." Their website includes a number of survivor stories that can bring hope as well. The Susan G Komen Male Breast Cancer Patient Support Group is another option.

Being Your Own Advocate in Your Cancer Care

The studies to date on the psychological impact of breast cancer in men seem to repeatedly point out that "active" coping can make a difference. Active coping can involve learning all you can about your cancer (learn research your cancer online), seeking out information and support through social media, and seeking out support in your community and with family and friends.

It's important to be an active part of your treatment team. Cancer treatment is changing so rapidly that it is hard for any physician to stay abreast of all of the new studies and research. Plus, nobody is as motivated as you are to address your cancer. Take a moment to learn about how to be your own advocate in your cancer care.

Finally, consider talking to a counselor who has experience in working with men and breast cancer with all of the unique challenges it presents. To do so is not a sign of being weak, but is actually a tremendous sign of courage and strength. As a perk, studies even suggest that it improves survival. Survival rates are better than ever before for men with breast cancer, but even when treatment is done, side effects and stress can linger. If you have reached this point in your journey take a moment to learn about "cancer survivorship" and all of the options that are now available to help cancer survivors have a better "new normal."

Sources:

American Cancer Society. Cancer Facts and Figures 2017. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2017/cancer-facts-and-figures-2017.pdf

Johansson, I., Nilsson, C., Berglund, P. et al. High-Resolution Genomic Profiling of Male Breast Cancer Reveals Differences Hidden Behind the Similarities With Female Breast Cancer. Breast Cancer Research and Treatment. 2011. 129(3):747-60.

Kipling, M., Ralph, J., and K. Callanan. Psychological Impact of Male Breast Disorders: Literature Review and Survey Results. Breast Care. 2014. 9(1):29-33.

National Cancer Institute. Male Breast Cancer Treatment (PDQ) – Health Professional Version. Updated 05/25/17. https://www.cancer.gov/types/breast/hp/male-breast-treatment-pdq

Silva, T. Male Breast Cancer: Medical and Psychological Management in Comparison to Female Breast Cancer. A Review. Cancer Treatment and Research Communications. 2016. 7:23-34.

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