Breast cancer (male) - Treating breast cancer in men

Treatment for breast cancer in men largely depends on how far the cancer has spread.

Most hospitals use multidisciplinary teams (MDTs) to treat men with breast cancer. These are teams of specialists who work together to make decisions about the best way to proceed with your treatment.

Deciding which treatment is best for you can often be confusing. Your cancer team will recommend what they think is the ideal treatment option but the final decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions you would like to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.

Your treatment plan

Your recommended treatment plan will depend on how far the cancer has spread. If the cancer has not spread significantly beyond your breast, a complete cure may be possible.

In these cases, surgery to remove the affected breast is usually recommended. This is often followed by radiotherapy, hormone therapy and/or chemotherapy to help prevent the cancer returning.

If the cancer has spread beyond your breast into other parts of your body, such as your lungs, a complete cure will not be possible. However, hormone therapy and chemotherapy can be used to relieve symptoms and slow down the spread of the cancer.

More information about these treatments can be found below.

Surgery

Surgery is usually recommended as the first treatment for breast cancer. Specifically, this involves an operation called a mastectomy.

A mastectomy procedure involves the removal of the entire breast, often along with the nipple and lymph nodes (glands) in the armpit. In some cases, part of the muscle under the breast may also be removed if there is a risk the cancer has spread to this area.

Once surgery has been completed there will be a straight scar across your chest where your nipple used to be and possibly an indentation around that area where the breast tissue used to be.

After surgery

Most men are well enough to leave hospital one to three days after surgery. After the operation, it's likely you will feel very tired and it may take a few weeks before you are well enough to start carrying out relatively strenuous activities, such as lifting objects or driving. Your MDT specialist nurse will be able to offer more specific advice about this.

The wound will take about two to three weeks to heal. It is important to keep the wound clean during this time. You should look for any signs that the wound may have become infected, such as redness and swelling around the wound or a discharge of pus. Inform your MDT as soon as possible if you suspect an infection.

It's difficult to predict when you will feel able to return to work. Some people choose to remain off work until other treatments, such as radiotherapy, have been completed. Others prefer to return to work in between treatments. Your MDT will be able to advise you, but the final decision will be yours.

It can take several weeks to fully recover from the effects of a mastectomy. A structured exercise programme, where the intensity and amount of time spent exercising is gradually increased, will probably be recommended.

Your MDT will be able to provide you with more advice or refer you to a physiotherapist (a specialist with training in rehabilitation using exercise).

The Royal College of Surgeons have produced a useful leaflet for people who are recovering after having a mastectomy (PDF, 363kb).

Complications of surgery

Following surgery, you may experience numbness or tingling at the site of the scar and in your upper arm. This is common and caused by nerve damage during surgery. The numbness and tingling should pass within a few weeks or months, although it can occasionally be permanent.

Another common complication is painful swelling in the arms and legs and, sometimes in other parts of the body, such as the head and chest. This is called lymphoedema and it is caused by the disruption of the lymphatic system (a series of channels and lymph nodes which is normally responsible for removing excess fluid from tissue).

If multiple lymph nodes (glands) are surgically removed it can disrupt the lymphatic system’s ability to drain fluid which can lead to swelling.

There is no cure for lymphoedema, but it is possible to control the symptoms using a combination of different techniques, such as massage and compression garments. See treating lymphoedema for more information.

Radiotherapy

Radiotherapy is a type of treatment involving a machine that releases high energy waves to destroy cancerous cells. It can be given a few weeks after surgery to prevent the cancerous cells returning.

A typical course of radiotherapy involves two to five sessions a week over the course of three to six weeks. The sessions are short and usually only last for 10 to 15 minutes.

Radiotherapy is not usually painful although you will probably experience some side effects. This is because the energy released during radiotherapy can also damage healthy cells.

Common side effects of radiotherapy can include:

• extreme tiredness (fatigue)
• feeling sick (nausea)
• sore, red, and irritated skin on the breast (similar in appearance to sunburn)

The side effects of radiotherapy should pass after your course of treatment has finished, although some men experience prolonged fatigue for several months.

Radiotherapy can also be used in cases of advanced breast cancer to slow down the spread of the cancer and relieve the symptoms of pain. This is known as palliative radiotherapy. Palliative radiotherapy is usually given in just one or two doses and does not usually cause any side effects.

Hormone therapy

About 90% of cases of breast cancers in men are oestrogen receptor positive or ER+ (E is used because the American spelling of oestrogen is ‘estrogen’). This means the cancerous cells require oestrogen to grow. Oestrogen is a type of hormone found in low levels in men and in much higher levels in women.

The aim of hormone therapy is to block the effects of oestrogen on the breast tissue to prevent the cancer reoccurring after surgery. It can also be used in cases of advanced breast cancer to slow down the spread of the cancer.

Tamoxifen

Tamoxifen is a hormone medication widely used for breast cancer. It is available in tablet or liquid form and prevents oestrogen from entering the breast tissue cells.

However, the ideal length of treatment with tamoxifen is unclear. Studies in women with breast cancer suggest a five year course of treatment is the most effective in preventing the return of cancer and extending survival rates. However, it is unclear if this also applies to men.

Tamoxifen can also cause unpleasant side effects, which will be taken into consideration when your MDT is deciding which treatments to recommend. You can discuss the pros and cons of long-term treatment with tamoxifen with your MDT.

Side effects of tamoxifen can include:

• reduced interest in sex (loss of libido)
• inability to obtain or maintain an erection (erectile dysfunction)
• headache
• feeling sick, although taking your medication with food may help to reduce this side effect
• changes in mood, such as feeling irritable or depressed

You should inform your MDT if you experience side effects that become particularly troublesome, as alternative medications are available.

Aromatase inhibitors

Aromatase inhibitors are an alternative type of hormone medication. They may be used if tamoxifen proves unsuccessful or if the side effects of tamoxifen are particularly troublesome. Aromatase inhibitors can also be used to slow the spread of advanced breast cancer.

In men, oestrogen is created when a protein called aromatase converts another hormone called androgens. Aromatase inhibitors block the effects of aromatase which, in turn, lowers the amount of oestrogen in the body.

Aromatase inhibitors are usually given in tablet form and taken daily for two to five years. As with tamoxifen, there is little available evidence (compared with female breast cancer) regarding the most effective length of dosage.

Side effects of aromatase inhibitors can include:

• joint pain
• lack of energy
• hot flushes
• skin rashes
• feeling sick
• being sick
• thinning of the hair

However, it's unlikely you will experience all of these.

Chemotherapy

Chemotherapy is used to treat cases of breast cancer where hormone therapy would be largely ineffective because the cancerous cells are not oestrogen receptor positive (ER+). It's usually given after surgery to help prevent the cancer returning or it's used to treat the symptoms of incurable cancer.

Chemotherapy for breast cancer involves taking a combination of cancer-killing medications. Treatment is usually given every two to three weeks, over the course of six months.

You may be given chemotherapy tablets (oral chemotherapy), chemotherapy injections (intravenous chemotherapy) or a combination of both.

The side effects of chemotherapy can include:

• feeling sick
• being sick
• diarrhoea
• loss of appetite
• mouth ulcers
• tiredness
• skin rashes
• infertility
• hair loss

However, the side effects should resolve once your treatment has finished. Following treatment, your hair should grow back after about three to six months.

Chemotherapy can also weaken your immune system, making you more vulnerable to infection. It is therefore important to report any symptoms of a potential infection to your MDT such as:

• a high temperature of 38^oC (100.4^oF) or above
• flu-like symptoms, such chills or joint pain
• a general sense of feeling unwell

You should also avoid close contact with people known to have an infection.

If you are sexually active, you should use a condom for 48 hours after receiving a dose of chemotherapy medication. This is because the medication used in chemotherapy could pass into your semen and cause irritation in the tissue of your partner’s genitals.

You should avoid having children while receiving chemotherapy because many of the medications can damage your sperm and increase your chances of having a baby with a birth defect. Again, using a reliable method of contraception, such as a condom, is recommended

Depending on the medications used, it may be several months after your course of chemotherapy has ended before you can safely have children. Your MDT will be able to give you a more detailed recommendation.

Biological therapy

Biological therapy uses medication to block the effects of a protein called human epidermal growth factor receptor 2 (HER2) in cases where HER2 is contributing to breast cancer.

Biological therapies are sometimes referred to as targeted therapies because they are designed to target biological processes that cancers rely on to grow and reproduce.

If you have high levels of the HER2 protein and are able to have biological therapy, you will probably be prescribed a medicine called trastuzumab. Trastuzumab, also known by the brand name Herceptin, is usually used after radiotherapy or chemotherapy to prevent cancerous cells returning.

Trastuzumab

Trastuzumab is a type of biological therapy known as a monoclonal antibody. Antibodies occur naturally in the body and are created by the immune system to destroy harmful cells, such as viruses and bacteria. The trastuzumab antibody targets and destroys cancer cells designed to respond to the HER2 protein.

Trastuzumab is given intravenously (through a drip, directly into a vein). You will receive the treatment in hospital. Each treatment session takes up to one hour and the number of sessions you need will depend on whether your breast cancer is in its early or more advanced stages. On average, for early breast cancer you will need to have a session once every three weeks, and for more advanced cancer you will need to have weekly sessions.

Trastuzumab can cause side effects, including heart problems. This means that it is not suitable if you have a heart problem, such as angina, uncontrolled high blood pressure (hypertension), or heart valve disease. If you need to take trastuzumab, you will need to have regular tests on your heart to ensure it is not causing any problems.

Other side effects of trastuzumab can include:

• an initial allergic reaction to the medication, which can cause nausea, wheezing, chills and fever
• diarrhoea
• tiredness
• aches and pains