Health: You don't have to be female to get breast cancer

No breasts? You can still get breast cancer. And men who put off seeing a doctor about a lump are at high risk. By Roger Dobson

STEPHEN WILSHERE was returning home from a summer holiday when he felt a lump on his right breast. He was certain it had not been there before, and prodded again to make sure it was real. "It was a very hot Sunday, and I had put my hand under my shirt to scratch my shoulder when I felt this hard lump. I didn't say anything at the time... but the next day I showed my wife and she said I ought to see the doctor."

A few days later, after a biopsy, he was diagnosed with breast cancer and within a fortnight the ex-pilot and retired computer specialist had a mastectomy, followed by radiotherapy and treatment with tamoxifen.

Breast cancer affects one in 1,000 men, compared to one in 11 women. But a new study suggests that men who are high achievers may carry a much greater than average risk of the disease. Researchers found that rates were highest among graduates, men on high incomes, and those with assets of pounds 35,000-plus.

Breast cancer in men and women is essentially the same disease, so researchers believe that studying it in men may be an effective way of investigating environmental causes.

Dr Ann Hsing and her team believe that the investigation of male breast cancer may provide unique clues about environmental and occupational risks that are difficult to detect in women. This is because they can be masked by confounding factors such as pregnancy, breast-feeding and age at menstruation.

Male breast cancer is much rarer, but one of the problems is men's reluctance to see a doctor. While messages aimed at women have been highly successful in raising awareness of the disease and promoting self-examination, men are still in the dark ages of health education.

"The worst aspect of male breast cancer is that men are dying of ignorance,'' says Professor Ian Fentiman, professor of surgical oncology at Guy's Hospital. "We are still finding that the average duration of symptoms is six to nine months.

"That's a long delay, and the reason is that men don't even think about it as a possibility. The real message is that if a man finds a lump on one side it needs to be looked at, particularly if it is not painful."

Treatment for male breast cancer is similar to that for women, but usually involves a mastectomy because there is too little tissue for more conservative surgery to be effective. That is usually backed up by removal of the lymph glands, radiotherapy for the chest wall and treatment with tamoxifen, which appears to have good results with hormone-sensitive male breast cancers.

Men get breast cancer seven years later than women, on average, but survival rates are almost exactly the same for both sexes if they report their symptoms at the same stage. However, the overall outcome is worse for men because they tend to get diagnosed much later.

One of the mysteries surrounding male breast cancer is the cause, especially in men who do not carry a gene that predisposes for the disease. Over the years a range of culprits have been looked at, including high-temperature jobs that may affect the testes, and overhead power cables which have been thought to affect the release of the hormone melatonin from the pineal gland.

The environmental effects of exposure to hormones from the female contraceptive pill have been investigated; so, too, have various occupational carcinogens, cosmetics and perfumes.

"A whole range of things have been looked at. We are not sure, for example, whether electromagnetic fields are a risk factor. There was a study which suggested that people who worked with generators and transformers might have a slight increase in risk. The perfume industry has been looked at, and at one time the wearing of braces was considered, but that has been discredited," says Prof Fentiman.

"I don't think there is any occupation where you can turn around and say, `this job is a serious risk factor for male breast cancer'. The trouble is that you are dealing with small numbers, so there will always be the risk of chance associations."

Research carried out by Dr Anne Hsing of the US National Cancer Institute and colleagues in Italy shows that although risk factors cannot be pinned down with any certainty to specific jobs, they can be linked to social class and wealth.

The research, reported in the Journal of Occupational and Environmental Health, examines the cases of 201 men who died from breast cancer and finds clear differences in socioeconomic circumstances. Those with family incomes above pounds 35,000 had a 50 per cent greater risk than those on lower incomes. Men with assets greater than pounds 35,000 were twice as likely to get the disease as those with few or no assets; those who went to college were also as twice as much risk as men who left school early.

Similar observations have been made by Professor Fentiman in his own practice in London: "I have quite a lot of patients with male breast cancer who are high-flying executives." he says.

Just what that means is not clear, but one lifestyle variable between socioeconomic groups is diet.

"As well as reproductive factors, other factors that are related to high socioeconomic status, such as diet and other lifestyle habits, may be important, and deserve further investigation," says Dr Hsing.

For some men, like Stephen Wilshere, the matter is more clear-cut. He carries the gene for breast cancer that caused the death of his mother and one of his daughters. "I have been tested to see whether I am carrying the gene for breast cancer, and I am. It means a one in two chance that any of my children will also carry the gene. If they are male and they are carrying it, there is a 10 per cent chance of their developing cancer, but for females it is between 80 and 85 per cent."

Since his mastectomy, he has worked as a volunteer for Breast Cancer Care, helping other men to come to terms with their diagnosis. "When they get the results, it affects different people in different ways. Some doctors are wonderful at breaking the news, and others are terrible; they back into the furthest corner of the room and say something like, `I don't think I've very good news for you'," he says.

The message for men, he concludes, is to get symptoms checked early and to remember that taking out the tumour is not the end of the story: "Anyone can remove the lump; the clever thing is to stop the little bugger coming back again."

Breast Cancer Care's free help line deals with concern about male breast cancer: 0500 245345

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