Signs and symptoms

Men need to know that breast cancer is not limited to only women. Possible signs of breast cancer to watch for include:

• a lump or swelling, which is usually (but not always) painless
• skin dimpling or puckering
• nipple retraction (turning inward)
• redness or scaling of the nipple or breast skin
• discharge from the nipple

These changes aren't always caused by cancer. For example, most breast lumps in men are due to gynecomastia. Still, if you notice any breast changes, you should see your health care professional as soon as possible.

Medical history and physical exam

If there is a chance you may have breast cancer, your doctor will want to get a complete personal and family medical history. This may give some clues as to the cause of any symptoms you are having and whether or not you might be at increased risk for breast cancer.

A thorough clinical breast exam will be done to locate any lumps or suspicious areas and to feel their texture, size, and relationship to the skin and muscle tissue. The doctor may also examine the rest of your body to look for any evidence of possible spread, such as enlarged lymph nodes (especially under the arm) or an enlarged liver. Your general physical condition may also be evaluated.

Tests used to evaluate breast disease

If the history and physical exam suggest breast cancer may be possible, several types of tests may be done.

Diagnostic mammography

A diagnostic mammogram is an x-ray exam of the breast. In some cases, special images known as "cone views with magnification" are used to make a small area of abnormal breast tissue easier to evaluate. The results of this test may suggest that a biopsy is needed to tell whether the abnormal area is cancer. Mammography is often more accurate in men than women, since men do not have dense breasts or other common breast changes that might interfere with the test.

Breast ultrasound

Ultrasound, also known as sonography, uses high-frequency sound waves to outline a part of the body. For this test, a small, microphone-like instrument called a transducer is placed on the skin (which is often first lubricated with gel). It emits sound waves and picks up the echoes as they bounce off body tissues. The echoes are converted by a computer into a black and white image that is displayed on a computer screen. This test is painless and does not expose you to radiation.

Breast ultrasound is sometimes used to evaluate breast abnormalities that are found during mammography or a physical exam. Ultrasound is useful for some breast masses.

Nipple discharge exam

If you have nipple discharge, some of the fluid may be collected and looked at under a microscope to see if any cancer cells are present. Even when no cancer cells are found in a nipple discharge, it is not possible to say for certain that breast cancer is not present. If you have a suspicious mass, a biopsy will likely be needed even if the nipple discharge does not contain cancer cells.

Biopsy

A biopsy involves removing a body tissue sample to be looked at under a microscope. A biopsy is the only way to tell if a breast abnormality is cancerous. Unless the doctor is sure the lump is not cancer, this should always be done. There are several types of biopsies. Your doctor will choose the type of biopsy based on your individual situation.

Fine needle aspiration biopsy (FNAB)

FNAB is the easiest and quickest biopsy technique. The doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area. The doctor can guide the needle into the area of the breast abnormality while feeling the lump. A local anesthetic (numbing medicine) may or may not be used. Because such a thin needle is used for the biopsy, the process of getting the anesthetic may actually be more uncomfortable than the biopsy itself.

Looking at the samples under a microscope can reveal whether most breast abnormalities are benign or cancerous. In some cases, the results of the FNAB are not clear, and another type of biopsy is needed.

Core needle biopsy

For a core biopsy, the doctor removes a small cylinder of tissue from a breast abnormality to be looked at under a microscope. The needle used in this technique is larger than that used for FNAB. The biopsy is done with local anesthesia in the doctor's office.

A core biopsy uses a larger needle to sample breast changes felt by the doctor or pinpointed by ultrasound or a mammogram. (When mammograms taken from different angles are used to pinpoint the biopsy site, this is known as a stereotactic core needle biopsy.) In some centers, the biopsy can be guided by an MRI scan.

Because it removes larger pieces of tissue, a core needle biopsy is more likely than an FNAB to provide a clear diagnosis, although it may still miss some cancers.

Surgical (open) biopsy

Sometimes, surgery is needed to remove all or part of the lump for microscopic examination. Usually this is an excisional biopsy, where the surgeon removes the entire mass or abnormal area, as well as a surrounding margin of normal-appearing breast tissue (as opposed to an incisional biopsy, where only part of the mass is removed). In rare cases, this type of biopsy can be done in the doctor's office, but it is more commonly done in the hospital's outpatient department under a local anesthesia (where you are awake, but the area around the breast is numb). You may also be given medicine to make you drowsy.

This type of biopsy is more involved than an FNA biopsy or a core needle biopsy, but it is more likely to result in an accurate diagnosis and, in some cases, may be the only surgery that is needed. It typically requires several stitches and may leave a scar.

Lymph node dissection and sentinel lymph node biopsy

These procedures are done specifically to look for cancer in the lymph nodes. They are described in more detail in the section, "How is breast cancer treated?"

Lab tests of breast cancer biopsy samples

Once breast tissue samples have been obtained from a biopsy, they are looked at in the lab to determine whether breast cancer is present and if so, what type it is. Other lab tests can help determine how quickly a cancer is likely to grow and (to some extent) what treatments are likely to be effective.

If a benign condition is diagnosed, no further treatment is needed. If the diagnosis is cancer, there should be time for you to learn about the disease and to discuss treatment options with your cancer care team, friends, and family. It is usually not necessary to rush into treatment. You may want to get a second opinion before deciding on what treatment is best for you.

Type of breast cancer

The tissue removed during the biopsy (or during surgery) is first looked at under a microscope to see if cancer is present. The biopsy is also used to determine the cancer's type. In men, most breast cancers are invasive ductal carcinomas.

Breast cancer grades

A pathologist (a doctor who specializes in diagnosing disease in tissue samples) also assigns a histologic grade to the cancer, which is based on how closely the biopsy sample resembles normal breast tissue. The grade helps predict the patient's prognosis (outlook). In general, a lower grade number indicates a slower-growing cancer that is less likely to spread, while a higher number indicates a faster-growing cancer that is more likely to spread.

The grade is based on the arrangement of the cells in relation to each other, as well as features of individual cells.

• Grade 1 (well-differentiated) cancers have relatively normal-looking cells that do not appear to be growing rapidly and are arranged in small tubules.

• Grade 2 (moderately-differentiated) cancers have features between grades 1 and 3.

• Grade 3 (poorly-differentiated) cancers are formed by cells that appear very abnormal, grow rapidly, and rarely form tubules.

This system of grading is used for invasive cancers but not for in situ cancers.

Estrogen receptor (ER) and progesterone receptor (PR) status

Receptors are cell proteins that can attach to certain substances, such as hormones, that circulate in the blood. Normal breast cells and some breast cancer cells have receptors that attach to the hormones, estrogen and progesterone. These 2 hormones often fuel the growth of breast cancer cells.

An important step in evaluating a breast cancer is to test a portion of the cancer removed during the biopsy (or surgery) for the presence of estrogen and progesterone receptors. Cancer cells may contain neither, one, or both of these receptors. Breast cancers that contain estrogen receptors are often referred to as "ER-positive" cancers, while those containing progesterone receptors are called "PR-positive" cancers.

About 9 out of 10 male breast cancers have either estrogen or progesterone receptors (or both). These cancers tend to have a better prognosis than cancers without these receptors and are much more likely to respond to hormonal therapy (see the section, "How is breast cancer in men treated?").

HER2/neu status

In a small number of breast cancers in men, the cells have too much of a growth-promoting protein called HER2/neu (often just shortened to HER2). This protein is made by cells under the instruction of the HER2/neu gene. Tumors with increased levels of HER2/neu are referred to as "HER2-positive."

In men with HER2-positive breast cancers, there are too many copies of the HER2/neu gene (known as gene amplification), resulting in greater than normal amounts of the HER2/neu protein. These cancers tend to grow and spread more aggressively than other breast cancers.

HER2/neu testing should be performed on all newly diagnosed breast cancers, because HER2-positive cancers are much more likely to benefit from treatment with drugs that target the HER2/neu protein, such as trastuzumab (Herceptin) and lapatinib (Tykerb). See the section, "How is breast cancer in men treated?" for more information on these drugs.

Testing of the biopsy or surgery sample is usually done in 1 of 2 ways:

• immunohistochemistry (IHC): In this test, special antibodies that identify the HER2/neu protein are applied to the sample, which cause it to change color if abnormally high levels are present.

• fluorescent in situ hybridization (FISH): This test uses fluorescent pieces of DNA that specifically stick to copies of the HER2/neu gene in cells, which can then be counted under a special microscope.

Many breast cancer specialists feel the FISH test is more accurate than IHC, but it is more expensive and takes longer to get the results. Newer test methods are now becoming available as well (see the section, "What's new in breast cancer research and treatment?").

Tests of ploidy and cell proliferation rate

The ploidy of cancer cells refers to the amount of DNA they contain. If there's a normal amount of DNA in the cells, they are said to be diploid. If the amount is abnormal, then the cells are described as aneuploid. Although these tests may help determine prognosis, they rarely change the course of treatment and are considered optional. They are not usually recommended as part of a routine breast cancer work-up. Different methods can be used to measure ploidy:

• Flow cytometry uses lasers and computers to measure the amount of DNA in cancer cells suspended in liquid as they flow past the laser beam.

• Image cytometry uses computers to analyze digital images of the cells from a microscope slide.

Flow cytometry can also measure the S-phase fraction, which is the percentage of cells in a sample that are replicating (copying) their DNA. DNA replication means that the cell is getting ready to divide into 2 new cells. The rate of cancer cell division can also be estimated by a Ki-67 test, which identifies cells in the S-phase, as well as cells getting ready to replicate DNA, cells that have just completed DNA replication, and cells in the process of dividing. A high S-phase fraction or Ki-67 labeling index means that the cancer cells are dividing more rapidly, which indicates a more aggressive cancer.

Tests of gene patterns

Researchers have found that looking at the patterns of a number of specific genes at the same time (sometimes referred to as gene expression profiling) can help predict whether or not an early stage breast cancer is likely to come back after initial treatment. This can help when deciding whether additional (adjuvant) treatment such as chemotherapy might be helpful after initial treatment. Two such tests (Oncotype DX^® and MammaPrint^®), which look at different sets of genes, are now available.

While some doctors are using these tests (along with other information) to help make decisions as to whether or not to offer chemotherapy, others are waiting for more research to prove they are helpful. Large clinical trials of these tests are now under way. These tests have been studied mainly in breast cancers in women, and it's not yet clear if they would be as useful in breast cancers in men. Still, men may want to discuss whether or not these tests might be appropriate with their doctors.

Last Medical Review: 09/24/2008
Last Revised: 05/13/2009