Diagnosing male breast cancer – how can we do better?

Every October it seems as though the world turns pink for breast cancer awareness month. And rightly so – it’s the single most common cancer in the UK, with nearly 50,000 women diagnosed every year in the UK.

And although more than three quarters of women now survive breast cancer for at least 10 years, it still kills around 30 every single day.

Yet while breast cancer is seen very much as a women’s issue, around 350 men are diagnosed with breast cancer every year,  and they mustn’t be forgotten.

Many people don’t know that men can get breast cancer. But men do, in fact, have a small amount of breast tissue lurking behind their nipples. Both young boys and girls have this, but it only turns into more developed breasts in women during puberty, once their female hormones kick in.

And although it’s rarely talked about, up to six in 10 men suffer from breast swelling (called gynaecomastia) at some point during their lives , which is unrelated to cancer, as well as other non-cancerous problems. This makes it difficult for doctors to spot the very small number of men who have cancer among the much larger number who don’t.

Diagnosing men

Male and female breast cancers are actually very similar, so the choice of tests to help detect a possible breast cancer in men is the same as those used in women: physical examination of breast, and imaging in the form of mammograms (breast x-ray) and/or ultrasound. The next step is usually to take a sample of cells using a needle, known as a needle biopsy).

The challenge when examining men coming to a clinic with breast problems is to work out which tests will help most, and how to avoid unnecessary or uninformative investigations while not missing any actual cancers.

But there’s a problem. Most of the available evidence, from which national guidelines are made, focuses on women. So it’s not clear whether they also apply to men too.

Because of the lack of evidence, doctors investigating men with possible breast cancer have little in the way of national guidelines to help them. This leaves questions around exactly which tests to use under what circumstances.

Step forward consultant radiographer Kathryn Taylor and her colleagues at Addenbrooke’s Hospital in Cambridge. They’ve been exploring how best to investigate men with suspected breast cancer and recently published their findings in the journal Breast.

“We started this study because we were concerned that we were sending too many men for X-rays and even ultrasound examinations when they came to us with gynaecomastia,” Taylor told us. So to find some answers, she delved into the data.

Crunching the data for answers

Taylor and her colleagues looked back at the records of more than 1,100 men, aged 11 to 89, who had been referred to their Cambridge Breast Unit over a nine year period, usually with symptoms such as breast lumps, pain or swelling.

This was possible thanks to a database called JCIS – the Joint Clinical Information System – which was set up and funded by Cancer Research UK, the NHS, the National Institute for Health Research, and the Medical Research Council. The database records all kinds of information about the men, including their symptoms, the types of examinations they had, and the resulting diagnosis.

By looking carefully at all the data, Taylor was able to match up key symptoms with the types of investigations the men had, and whether they turned out to have cancer. Of the 1,140 men in the study, most came in with breast lumps and/or pain, nearly 700 of them had a mammogram, and around 350 had an ultrasound examination.

During this time, of the 25 men were found to have breast cancer – confirmed by a needle biopsy – all were over the age of 40 except one, who was just 29.

Because of the range of ages and symptoms, and the rareness of male breast cancer, the researchers concluded that a “one size fits all” approach isn’t appropriate.

Instead, their evidence suggests that men under the age of 40 with gynaecomastia don’t need a mammogram. But for men over 40, a mammogram would be a good idea, especially if there is a lump or nipple discharge, along with ultrasound if the X-ray and physical examination is inconclusive.

“Now,” says Taylor, “we can safely say that they don’t need that kind of investigation unless there are clinical signs of cancer, particularly lumps or nipple discharge.”

What next?

While male breast cancer is unlikely to get the same degree of media attention as female breast cancer, it’s important that it isn’t overlooked completely.

Taylor now hopes that her team’s findings will be taken on board by the wider medical community, so that men with breast cancer can be diagnosed and treated more quickly.

And, as well as making suggestions about how male breast cancer could be diagnosed more effectively, this work also highlights the importance of good quality data in cancer research.

As Taylor says: “Male breast cancer is much less common than female breast cancer, but the problem is there and it’s real – that’s why this paper is so important. Through their support of the JCIS database, Cancer Research UK helped to make this happen. It’s changed the way we investigate men here in our hospital, and I’d like to see it change everywhere.”

Kat

Reference:

Taylor K., Ames V. & Wallis M. (2013). The diagnostic value of clinical examination and imaging used as part of an age-related protocol when diagnosing male breast disease: an audit of 1141 cases from a single centre., Breast (Edinburgh, Scotland),    PMID: 23570843