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Health problems are intensely private affairs, but men like Senator John Kerry and General Colin Powell are increasingly forthright about prostate cancer. Still, most guys are reluctant to own up to "women's problems" like breast disease. But men have breasts, too. The male breast is much smaller than its female counterpart. It also has a simpler structure as it can't produce milk. This makes breast disease much less common in men than women. But men can develop benign and malignant breast problems. Early detection is the key to preventing more serious illness or death, so every man should understand the basic elements of male breast disease. Men and women make both male and female hormones. In men, the male hormone testosterone and other androgens are dominant; they keep the breast tissue small. In women, the hormone estradiol and other estrogens have the upper hand. Men also have small amounts of estradiol, which is a byproduct of testosterone metabolism. Enlargement of the male breast, called gynecomastia, is usually benign — harmless — and is often reversible. Some men have prominent breasts because they are overweight. But true gynecomastia is caused by an enlargement of the breast's glandular tissues, not by excess fat. The glandular tissue is concentrated under the nipple, but fat is spread around the whole breast. Gynecomastia is very common during adolescence. Up to 70% of boys experience it at puberty. It is usually mild and short-lived. It is much less common in adulthood, occurring in fewer than 1% of men. Two-thirds of the men who have gynecomastia have it in both breasts. The breast enlargement is usually mild and painless, but about a third of men complain of tenderness. The most common causes of gynecomastia are liver disease and certain medications. Each accounts for about 25% of cases.
Less common causes of gynecomastia include:
These diverse disorders have two things in common: low androgen levels and high estrogen levels. But competitive athletes and men who take "Andro" (androstenedione supplements) or abuse male steroid hormones can also develop gynecomastia. That's because part of everyone's androgens are converted to estrogens; men who boost their androgens to artificially high levels get abnormally high estrogen levels in the bargain. About 2,000 American men will develop breast cancer each year. This is quite a small number compared with the over 200,000 American women who will be diagnosed with the disease. Still, the incidence of male breast cancer has risen 25% in the past 25 years, and about 400 men will die from the disease this year. While it's a far cry from the 40,000 breast cancer deaths in women, it's a reminder that the early diagnosis and treatment of breast cancer can save men's lives, too. Most men with breast cancer notice the problem themselves. A firm, painless lump appears, usually under the nipple. The nipple itself is often ulcerated, but bleeding or discharge is rare.
The lump that signals breast cancer is much firmer than the tissue of benign breast enlargement. In fact, gynecomastia does not increase a man's risk of developing breast cancer. The average man with breast cancer is 60 - 70 years old. Although the causes of male breast cancer are not known, there are known risk factors:
Breast cancer is rare in men. Nevertheless, pay attention to changes. If you notice an abnormal thickening or lump near one of your nipples, ask your doctor to check it. He may order a mammogram or ultrasound. Based on the results, the next step may be a surgical biopsy or a fine needle aspiration. (The doctor sucks cells from the mass into a syringe, and then examines them in the laboratory.) Surgery (modified radical mastectomy) is the standard treatment for male breast cancer. Because most of these tumors have estrogen receptors, anti-estrogen therapy with the drug tamoxifen is often helpful. Radiation and chemotherapy also help, just as they do for female breast cancer. Male breast cancer responds quite well to treatment. The overall 5-year survival rate is about 60%. Early diagnosis can raise that to 90%. When men think about breasts, it's usually not their own that come to mind. Indeed, breast disease is not a "guy" thing. But men should listen to their bodies, which means noting any changes in their breasts. Bleeding, milky discharge from the nipple or uneven breast enlargement require immediate attention. Fortunately, when breast enlargement occurs, it is usually more worrisome than serious. Still, a medical examination can reassure many and provide lifesaving treatment to some. Harvey B. Simon, M.D. is an Associate Professor of Medicine at Harvard Medical School and a member of the Health Sciences Technology Faculty at Massachusetts Institute of Technology. He is the founding editor of the Harvard Men's Health Watch newsletter and author of six consumer health books, including The Harvard Medical School Guide to Men's Health (Simon and Schuster, 2002) and The No Sweat Exercise Plan, Lose Weight, Get Healthy and Live Longer (McGraw-Hill, 2006). Dr. Simon practices at the Massachusetts General Hospital; he received the London Prize for Excellence in Teaching from Harvard and MIT.
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