Breast cancer in males

Following the breakthroughs and increasingly successful screening programmes in most recent years, breast cancer in women has become increasingly talked about. Throughout October, social media is filled with information on breast cancer in women, what to do if diagnosed, memorable fundraising events that will generate thousands of pounds, and the heartwarming stories of survivors and patients fighting against this horrible disease. In the UK, 1 in 7 females will be diagnosed with breast cancer at some point in their lifetime. If we look at other areas in the world, this statistic shifts significantly: in the USA 1 in 8 females will develop the condition, whilst in Japan, it is 1 in 38 females. Although the percentages of breast cancer incidence differ around the globe, they all underline one common characteristic: many women and their families throughout the globe will suffer because of breast cancer (Figure 1).

Interestingly, though, with how prevalent breast cancer is in women, breast cancer in men is hardly ever mentioned. Whilst breast cancer is much more common in women, with around 55 thousand diagnoses every year, only 400 males a are diagnosed annually, which is equivalent to 1% of breast cancer diagnoses in the UK. However, the unlikelihood of a disease does not mean that it is any less significant. Conditions like epilepsy, strangulated inguinal hernias, alpha-1 antitrypsin, and Paget’s disease are all conditions with an incidence of around 1% or less. Nevertheless, they all may severely change the lifestyle of patients and even cause death - the fact that they have a low presence makes them no less important. This makes one wonder, what causes breast cancer in men and women to differ so extensively in numbers, and why is breast cancer in men so undisclosed?

To answer this question, we must first understand what breast cancer is. Cancers are cells that grow uncontrollably, often forming tumours in the tissue or organs of the body and usually caused by a mutation or environmental factors, such as carcinogens. Cancers can be classified as benign and malignant, the difference being that benign cancers will stay in the original location, whilst malignant cancers are invasive. In other words, the tumour may spread to nearby tissues and lymph nodes or metastasise, spreading to other locations in the body. Breast cancer can be divided further into several types – this is one of the reasons finding a “cure” for breast cancer is so complicated. In men, the two most common types of breast cancer are invasive ductal carcinoma, which can spread through the ducts to the body, and ductal carcinoma in situ, which arises in the ductal lining of the breast tissue. But what causes these cancers to develop in men?

There are multiple risk factors to consider when it comes to breast cancer in men, one of the most common being genetic mutations. Genetic mutations are when a copy of the DNA sequence in a gene has a change, and it can cause a different function or phenotype of the gene. In breast cancer, two critical and potentially inheritable mutations are in the genes BRCA1 and BRCA2, which increase the risk of breast cancer in both men and women. Furthermore, this is why taking the family history of breast cancer is essential: an individual with a positive family history for breast cancer may wish to take a genetic test to confirm whether they have the mutated genes. After all, genes are inherited. Hence, if one parent has the mutated gene, they could pass it on to their children. In addition, it is important to understand how breast cancer can only occur in breast tissue. Therefore, even if a male has the mutated gene, they could only have said cancer if there is breast tissue where the hormones oestrogen and progesterone can bind to and lead to mutation, causing the cancer to further multiply and spread – this is not always the case. Another genetic risk for breast cancer is a diagnosis of Klinefelter syndrome. This syndrome, which affects less than 1% of newborn males, involves having an extra X chromosome, leading to the body producing higher levels of oestrogen and lower levels of androgen. Androgens are a group of sex hormones, usually found at higher levels in men, one example being testosterone.

Meanwhile, oestrogen appears to be another risk factor. This natural hormone has been shown to correlate with breast cancer. A study in the Nature Journal found that the inhibition of oestrogen has decreased the incidence of cancer in patients considered high-risk. But how are men exposed to the hormone? Aside from being diagnosed with Klinefelter syndrome, men can be exposed to hormone therapy treatments, which include drugs that could contain oestrogen. Likewise, another treatment that’s considered a risk factor is chest radiation therapy. Radiation is one of the known carcinogens of cancer, causing cells to mutate. Therefore, elevated levels of radiation could increase the risk for a patient. Other factors such as obesity, age and liver disease should also be carefully considered. As you can see, the list of risk factors for men is abundant, so why is it that breast cancer is still more present in women? And why is the general male public less aware of these risks, as they are for women?

The answer to the first question is easy enough. Although the list of risk factors for breast cancer in men seems extensive, it is even longer for women. Furthermore, women are considered at higher risk as certain risk factors that both men and women share are more prevalent in women. For instance, oestrogen is produced in larger quantities by women. Additionally, a higher proportion of women are taking hormone replacement therapy drugs. Hormone replacement therapy (HRT) drugs are usually given to post-menopausal women to supplement more hormones, such as oestrogen. In the 90s alone, one study found that 22% of post-menopausal women took HRT whilst another study found that 51% of women have discussed taking the drug with their doctors. Meanwhile, the number of men taking HRT is much smaller, and usually these have a lower quantity of oestrogen, focusing more on testosterone. Although it is important to consider that within this time, incidences of individuals taking the hormones could change as the culture, awareness and research into hormone therapy changes.

The second question, on the other hand, is slightly more complicated to answer. Of course, regardless of the rarity and prevalence of a condition in the population, the aim would be to treat and cure all. However, despite the significant impact and importance the NHS has on British healthcare, its limited resources meant that the most pressing and widespread issues were given priority. For instance, concentrating resources towards the C-19 virus during the last few years. Similarly, all healthcare systems globally are under constant pressure of this public health issue, managing its resources. Nevertheless, this does not mean that treating and raising awareness towards male breast cancer is less urgent and necessary. Another issue is the misinformation towards male breast cancer. In March 2023, a study in the American Journal of Men’s Health found that 61.1% of the participants (a total of 270 women and 141 men) were unaware that men could, in theory, have breast cancer. If we think about breast cancer, it is in many incorrect ways associated with femininity, perhaps from the organ it is found it arises on and to the colour (pink) used to represent breast cancer. Therefore, it all boils down to a convenient misconception, often following illogical stereotypes, that “large, strong, macho men” would never have this “women-only condition”.

But how do we diagnose men with a condition they may not even know they could have? Following the process for diagnoses, specialists may recommend men with a strong family history to do regular screenings from the age of 35. Whilst screening is found to be an effective method when diagnosing women, its success in men is limited. For a majority of men, their process for diagnosis will start by noticing symptoms. Symptoms can be as obscure as a “different feel” to the breast tissue, or something more visible like a lump or hard mass. In theory, this would encourage men to approach their GPs which can then lead to the next steps of screening. However, many go seek experts late, often when seriously ill. This can both be explained culturally (such as Hispanics) and generationally, where older generations avoid medical consultations. This is very dangerous, as men often only received an official diagnosis of breast cancer six months after noticing symptoms, allowing the cancer to significantly grow within this time. On the other hand, an early diagnosis can allow for a swifter start to treatment, greater possibilities in treatment options, and could be less brutal for the patient. Hence, a better chance of treatment success and recovery. In summary, the procedures for the treatment of breast cancer in men do exist. However, for this treatment to be effective, healthcare professionals could consider increasing the awareness of the importance of regular screenings and appointments for early treatment.

Overall, breast cancer in men is indeed rare. However, one must not overlook its consequences or its significance solely due to statistics. Breast cancer in men impacts many lives of both the patient and their families. Understanding the risks and the process for diagnosis could be essential in the early treatment of male patients. However, a further understanding of the astigmatisms and culture around breast cancer could be useful when educating the public on this condition.

This article used “men” and “women” when describing breast cancer in patients. However, note that many individuals may not identify within these categories but could still be diagnosed and affected by breast cancer.

Written by Inês Isabel Couto André

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