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Clinical: Male breast cancer

Key learning points

 - The specific challenges associated with identifying breast cancer risk in men

 - Detecting and referring men with breast masses before the condition spreads

- Longer-term treatment and outlook

Aman's lifetime risk of developing cancer is set to reach one in two by 2027 according to Cancer Research UK.1 The risk is also increasing for women, however this is not as fast as it is for men. The lifetime risk of cancer is an approximation of the risk that a newborn child has of being diagnosed with cancer at some stage during its life. 
Cancer survival has doubled over the last 40 years. The reasons for this are varied and include the fact that there are more sophisticated techniques being developed in order to detect the disease and improvements in treatments increasing survival. The biggest risk factor for cancer and the increase in risk is mainly due to age, as more people are now living longer. 
Men and cancer
White et al.2 note that men have an increased risk of developing and dying more prematurely from cancers that affect men and women equally. A significant determinant of health status is gender, and practice nurses must take this into account when devising, developing strategy and policy associated with healthcare provision for men. The ways in which men face challenges that are associated with their health and wellbeing and how they access services differ to their female counterparts and being aware of this can help the nurse work with men, responding to their individual needs and beginning to address the gender inequalities that men face. Men are disproportionally affected by cancer and despite this there is no gender-specific discussion in attempts to eradicate inequalities.
Breast cancer epidemiology
Breast cancer in men is rare, but nonetheless less brings with it the same fears, anxieties and uncertainties that the condition can evoke in women. There is lack of awareness among the public as well as healthcare professionals that breast cancer can also affect men.3 Breast cancer in men remains an under-researched area.
In 2010, 49,564 women and 397 men were diagnosed with invasive breast cancer in the UK, with 11,684 female and 78 male deaths resulting from invasive breast cancer in 2011. There were 5,765 women and 26 men in the UK in 2010 diagnosed with in situ breast carcinoma.4 Table 1 provides an overview of male and female breast cancer statistics.
Risk factors
Male breast cancer often occurs where there is an imbalance between androgens and oestrogens. The risk factors associated with breast cancer for men are similar to those for women however there are some differences. As with women the single biggest risk factor is age. The majority of cases are diagnosed between 60 and 70 years.
High oestrogen levels have been linked to male breast cancer and can occur in men who are overweight or obese, those with chronic liver disease and in men with some specific genetic conditions. The rare genetic condition Klinefelter's syndrome 
results in low testosterone and increased gonadotrophins. In these men breast cancer is up to 50 times more frequent.5 Men who have been over-exposed to radiation are more likely to develop breast cancer.
Genetics play an important role in this condition, and the BRAC2 gene is more common than BRAC1. A recognised breast cancer gene in the family increases the risk of breast cancer, for example, the man's mother or sisters. Niewoehner and Schorer6 note that other high-risk groups include those from sub-Saharan Africa and Ashkenazi Jews.
Clinical features
Male breast cancer occurs at an older age than it does in women and often diagnosed at a later stage. The symptoms, diagnosis and the treatment for men with breast cancer are all similar to those for women with breast cancer.7
The most common symptom for men with breast cancer is a lump in the breast area; rarely there is pain. There may be nipple inversion and this can be accompanied by discharge. Changes to the skin may be apparent, for example, oedema or ulceration. Gynaecomastia is very rare. There may be a palpable mass present as well as axillary lymph nodes. Table 2 outlines the signs and symptoms that may alert the nurse to the possibility of breast cancer in men with gynaecomastia.
Investigations and diagnosis
A detailed holistic health history should be undertaken and a physical examination. The man should be given time to express his concerns and appropriate responses made. 
Imaging will include mammography and ultrasonography. Fine needle aspiration cytology (FNAC) or either core or open biopsy will be required if imaging dictates. It is preferable to biopsy as malignant cells on FNAC may be a ductal carcinoma in situ as opposed more invasive disease.9 If there is evidence of metatastic spread then further investigations may be required, for example a bone scan.
Tumour staging
The staging system (tumour, nodes, metastases [TNM]) is used 
for male breast cancer. This is the same used for female breast cancer. 
Men should be provided with the opportunity to make informed decisions about care and treatment, in partnership with healthcare professionals. Care provision should be supported by evidence-based written information tailored to individual needs.
If the man agrees then carers and relatives should have the opportunity to be involved in decisions about treatment and care and should also be offered information and support that they need.
The treatment for male breast cancer in men is the same as it is for women and depends on the staging of his cancer. Treatment options can include surgery, chemotherapy, radiotherapy, hormone therapy.
Mastectomy is the most common form of surgical treatment. A wide total excision will be required as male breast tissue is not as dense as it is in a woman.
A skin graft provides a muscle flap. Sentinel lymph node biopsy may be performed assisting with further screening and lymph clearance might be needed.8 
Breast reconstruction is not usually undertaken, however there are methods the surgeon can use to enhance the appearance of the operative site post-operatively. Nipple recreation can be considered but while the shape can be recreated, the new nipple will not respond to temperature or touch.9 Tattooing a new nipple and areola can also be considered; referral to a breast care nurse specialist should be made.
Adjuvant local radiotherapy or post-mastectomy is recommended, as there is a paucity of breast muscle in the male, the cancer is always close to the breast wall. Regional lymph node involvement can also be treated with radiotherapy.
Chemotherapy is usually given post surgery and a variety of regimens can be used. The decision to use chemotherapy depends on a number of factors such as:10
 - Size of tumour (larger than 2 cm).
- Presence of lymph node involvement.
 - High grade cancer.
Adjuvant hormone therapy
Most male breast cancers are hormone receptor positive. Tamoxifen as adjuvant hormone therapy is used and improves survival.6,9 Men can experience the same side effects as women including nausea and hot flushes. Tamoxifen can also result in weight gain, insomnia and changes in mental health such as depression. Tamoxifen may also cause erectile dysfunction and a loss of libido.
Advanced disease
Where there may be metastatic spread or more advanced disease, hormonal therapies are the key treatments. Chemotherapy has been used as a second line of treatment and may also be appropriate for palliative care.(11) Fentiman (8) and  Gordino (9) suggest other approaches to treatment, including:
 - Gonadal ablation.
 - Orchidectomy.
 - Adrenalectomy.
 - Hypophysectomy.
Adjuvant aromatase inhibitors, such as anastrozole. 
There is often a delay in a diagnosis of male breast cancer, and prognosis at presentation is worse when compared to women.12 Five-year survival will depend on the stage of the disease (75-100% for stage I disease and 30-60% for stage III disease).9 The risk of carcinoma occurring in the other breast is also increased.
Early detection
Early detection improves the outcomes of treatment. There are many similarities between breast cancer in men and women, but there are some important differences that can impact on detecting it early.
The most apparent difference between the male and female breast is size. As men have very little breast tissue, it can be easier for men (and health care professionals) to palpate small masses. However, as men have so little breast tissue, cancers do not need to progress far to reach the nipple, skin covering the breast, or the muscles below the breast. Male breast cancers are often slightly smaller than women's when first found; yet they have often spread to nearby tissues or lymph nodes with an impact on prognosis. 
Screening may be advocated, particularly in those with a strong family history of breast cancer and/or with BRCA mutations detected by genetic testing.
The role of the nurse
A diagnosis of cancer for any person can have a shattering impact on their health and wellbeing. Men being diagnosed with breast cancer may feel confused and isolated as this is a rare and usually female cancer. This has the potential to impact on a man's sense of identity and masculinity.
There is a need for an increased awareness of breast cancer in men (and also amongst health care providers) as well as the provision of gender sensitive information. Failure to provide information in this way can lead to an increase in fear, anxiety and distress for men.3
The nurse has an important role to play in offering men information and providing support. The nurse can offer men details about formal support networks. Brain et al3 have noted that a third of men would be interested in attending patient support groups. Men may be less likely to disclose their feeling of distress and their need for help. 
Breast cancer in males, along with other cancers, is increasing. Male breast cancer has been under-investigated; this is in contrast to much research concerning other types of male-specific cancer, for example, testicular and prostate cancer.
A diagnosis of breast cancer can be particularly difficult for men. Practice nurses have an important role to play in understanding the condition and offering information and support as well as providing details concerning the availability of formal support groups. 
3. Brain K, Williams B, Iredale R, France L, Gray J. Psychological Distress in Men With Breast Cancer. Journal of Clinical Oncology 2006;24(1):95-101.
4. Cancer Research UK. 2014. Breast Cancer Statistics.
5. Wiess JR, Moysich KB, Swede H. Epidemiology of Male Breast Cancer”. Cancer Epidemiology Biomarkers and Prevention 2005;14(1):20-6.
6. Niewoehner CB, Schorer AE. Gynaecomastia and Breast Cancer in Men. British Medical Journal 2008;336(7646):709-13.
8. Fentiman IS, Fourquet A, Hortobagyo GN. Male Breast Cancer. Lancet 2006;367(9510):595-604.
9. Giordano SH. A Review of the Diagnosis and Management of Male Breast Cancer. Oncologist 2005;10(7):471-9.
11. Breast Cancer Care. Improving the Care of People with Metatastic Breast Cancer: Final Report. London: Breast Cancer Care; 2008.
12. Hayes TG. Pharmacologic Treatment of Male Breast Cancer” Expert Opinion on Pharmacotherapy. 2009;10(15):2499-2510.