Men and breast cancer: breaking the silence

Bavina Sookdeo

When most people hear the words “breast cancer,” they think of women.

But clinical oncologist Dr Nazreen Bhim issues a reminder: “Breast cancer can affect anyone with breast tissue.”

And that includes men.

Globally, male breast cancer accounts for less than one per cent of all breast cancer cases. In TT, the numbers are similarly small – but the impact is no less profound.

“Our national cancer registry shows breast cancer is the leading cancer overall in recent years,” said Bhim. “Male cases form a very small fraction of that total. Between 2015 and 2020, the national breast cancer incidence was around 75 per 100,000 (population-wide), with male cases making up less than one per cent by international benchmarks.”

Still, those few cases carry unique challenges – from delayed diagnoses to stigma – that make awareness critical.

Bhim, who works out of Medical Associates Hospital, trained at the University of Cape Town, South Africa, in the treatment of adult cancers with chemotherapy, radiation therapy and brachytherapy, as well as paediatric radiation therapy. She did an advanced radiation therapy fellowship at the renowned MD Anderson Cancer Center, Houston, Texas, where her special interests were stereotactic radiation therapy and prostate and gynaecological brachytherapy.

This is a form of internal radiation therapy in which high-dose radiation is applied directly to a tumour by putting tiny amounts of radioactive material in or next to the cancerous area. This method minimises the amount of radiation to which healthy tissue is exposed.

She is also certified in palliative care, which aims to provide relief from pain and other symptoms of serious illness and to help patients cope with the side effects of treatment.

Men and risk

Which men are at risk of breast cancer? It typically affects older men, she explained: the median age at diagnosis is around 69.

“Locally, our experience mirrors this: most men present in their late 60s to early 70s.”

Unlike women, men are less likely to suspect cancer if they have symptoms such as a lump or nipple changes.

“Most men notice a painless, firm lump behind or near the nipple-areola complex,” said Bhim. Other red flags she mentioned include nipple retraction or inversion, discharge (especially if it’s bloody), skin dimpling, ulceration, or a new lump in the armpit.

“Because men have little breast tissue, even small tumours can affect the nipple early,” she noted.

One of the most significant risk factors for male breast cancer lies in genetics, which can also increase their chance of developing other cancers.

“BRCA2 (and to a lesser extent BRCA1) mutations significantly increase a man’s lifetime risk of breast cancer and also raise prostate and pancreatic cancer risks.”

BRCA1 and BRCA2 are tumour-suppressor genes that help repair damaged DNA and prevent cancer development.

For most men, the lifetime risk is about one in 726, but that rises dramatically for BRCA2 carriers – up to ten per cent.

Differences from women

While male and female breast cancers share many features, there are key biological differences. “Male breast cancers are more often hormone-receptor positive and less often triple-negative,” Bhim said.

“Triple-negative” breast cancer means the cancer cells lack three key receptors – oestrogen, progesterone and human epidermal growth factor 2 (HER2) – that doctors usually target with treatment.

But because these receptors are absent, triple-negative cancers don’t respond to hormone or HER2-targeted therapies, making them more aggressive and harder to treat.

Also, she added, “They’re usually diagnosed at an older age and historically at a slightly larger size or more advanced stage – partly due to delayed presentation.”

That delay is partly cultural. Many men don’t realise they’re at risk, and even fewer feel comfortable seeking help.

Bhim warned of several factors that lead to male breast cancer being diagnosed at a later stage in many cases: stigma or embarrassment; misattribution to gynecomastia (breast growth so that they look like female breasts) or infection; and limited rapid-access treatment pathways for male breast symptoms.

Diagnosis

Diagnosis in men follows clear, evidence-based guidelines.

“For any man over 25 with a palpable lump, we start with diagnostic mammography and add ultrasound as needed. For those under 25, we start with ultrasound and proceed to (a) mammogram if suspicious features appear.

“The final confirmation comes from a core-needle biopsy. MRI is rarely indicated for initial work-up in men.”

These procedures, she emphasised, are safe, accessible and accurate – and the earlier they’re done, the better the outcome.

Treatments

Once diagnosed, men have access to the same range of treatments as women.

“Treatment is tailored to the stage and biology of the tumour.”

Bhim listed:

Surgery: usually simple or modified radical mastectomy; sentinel lymph node biopsy when appropriate.

Systemic therapy: endocrine therapy (typically tamoxifen for ER+ disease), chemotherapy when indicated, and HER2-targeted therapy (such as trastuzumab) for HER2+ tumours.

Radiation therapy: post-operative radiotherapy when the relevant criteria are met.

These are available locally “across public and private sectors, with multidisciplinary decision-making” she pointed out.

Most men undergo flat closure after surgery, which is generally well accepted cosmetically.

“Where desired, nipple–areola reconstruction or scar revision can be offered by plastic-surgery teams,” Bhim added. “Complex reconstructions are uncommon in males, but select cases are feasible locally. The choice depends on stage, comorbidities and patient preference.”

How to lessen your risk

“Men with a personal or family history of breast, ovarian, pancreatic or prostate cancers, especially at young ages, should seek genetic counselling and testing,” advised Bhim. “For high-risk men, we recommend annual mammography from around 50 years old, or ten years earlier than the youngest male case in the family.”

When it comes to improving awareness, Bhim recommended several key steps, including screening and early detection of breast cancer in men at a national level. She emphasised the need for nationwide messaging that clearly communicates the risk – that “men get breast cancer too,” particularly those 60 and older.

She also highlighted the importance of primary-care prompts, such as quick-referral systems for any man who goes to a doctor with a breast lump or nipple change.

In addition, she advised the establishment of a high-risk pathway, including funding for genetic counselling and testing for families who meet clinical criteria, and offering annual mammography for male BRCA carriers.

To further reduce diagnostic delays, Bhim suggested the creation of rapid-access breast-symptom clinics that include men.

She underscored the importance of strengthening data collection and registry systems to capture male-specific cancer statistics and outcomes.

She also urged men “If you feel a lump, see a doctor – don’t wait.”

A painless lump, nipple changes or discharge warrants assessment, she said.

Can TT handle male breast cancer?

Asked how well-equipped TT’s healthcare system is to manage breast cancer in men, from diagnosis to treatment, she said the country has core capabilities – diagnostic imaging (mammography, ultrasound), tissue diagnosis and immunohistochemistry, standard surgeries, systemic therapies (including endocrine and HER2-targeted agents) and radiotherapy.

She noted that there can be bottlenecks due to wait times, drug access and genetic services. However, she emphasised that “the essential pathway exists and is functional, with room to strengthen timeliness and supportive care.”

Encouragingly, Bhim added, “Most male breast cancers are hormone-sensitive and treatable, especially when caught early.

“Tell your doctor about any family history; if there’s a pattern, ask about genetic counselling.”