When America’s first lady disclosed that she had breast cancer, the story made headlines. That was back in 1974, and until Betty Ford made her courageous announcement, public discussion of the disease was taboo. Mrs. Ford was cured, and the publicity she generated promoted crucial cancer research and helped motivate millions of women to get life-saving tests and treatment.

Because of the frank discussions Mrs. Ford initiated, a celebrity’s breast cancer has moved off the front page. But in 2003, when a former U.S. senator made a similar announcement, it was again headline news, this time because the patient was a man, Edward W. Brooke of Massachusetts.

Men like Senator John Kerry and General Colin Powell are increasingly forthright about prostate cancer, but 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, and it cannot produce milk. Because of this smaller size and simpler structure, breast disease is much less common in men than women. Still, men can develop important breast problems, both benign and malignant. Early detection is the key to a successful outcome, so every man should understand the basic elements of male breast disease.

Jogger’s nipple Irritation of the nipple is more common than enlargement of the breast itself. Pain, redness, and even bleeding of the male nipple are fairly common complications of intense, prolonged exercise — hence the common names “jogger’s” and “marathoner’s” nipple. The cause is not running itself but the mechanical irritation of the runner’s shirt rubbing up and down against his chest, especially in hot, humid weather. You don’t have to give up running to cure jogger’s nipple. Instead, apply some petroleum jelly to your nipples before you run. Plastic Band-Aids are even better; round “spots” are particularly handy. Or simply run without a shirt when it’s hot or humid.

Hormones and the male breast

Breast enlargement is never welcome in men. Fortunately, though, gynecomastia, enlargement of the male breast, is usually benign and is often reversible.

Some men have prominent breasts simply because they are overweight. But true gynecomastia is caused by an enlargement of the breast’s glandular tissues, not by an excess of fat. The glandular tissue is concentrated under the nipple, but fat is spread around the whole breast area.

Male glandular tissue is under the influence of two groups of hormones. Testosterone and other androgens (male hormones) keep the breast tissue small; estradiol and other estrogens (female hormones) stimulate the growth of breast tissue. Every normal person produces both hormones. In men, the androgens are dominant, while estrogens have the upper hand in women. But even a slight shift in the balance between testosterone and estradiol — a by-product of testosterone metabolism — can lead to gynecomastia.

Benign breast enlargement

Gynecomastia is quite common during adolescence; up to 70% of boys experience it at the time of puberty, but it is usually mild and short-lived. It is much less common in adulthood, occurring in less than 1% of men. Two-thirds of the cases involve both breasts. The breast enlargement is usually mild and painless, but about a third of men complain of tenderness.

Gynecomastia has many causes; the two most common are liver disease and medication, each of which accounts for about 25% of cases.

Liver disease. One of the liver’s many functions is to break down estrogens. Liver disease, especially alcoholic cirrhosis, impairs that function, so high estrogen levels and enlarged breasts may result. By impairing liver function, congestive heart failure can sometimes produce gynecomastia. This gynecomastia will resolve only if liver function improves (which rarely happens in cirrhosis).

Medication. Many drugs have been implicated as occasional causes of gynecomastia. High on the list are digoxin (Lanoxin), used for heart disease; spironolactone (Aldactone), a diuretic; cimetidine (Tagamet), used for gastritis, ulcers, and heartburn; ketoconazole (Nizoral), used for fungal infections; and finasteride (Proscar) and dutasteride (Avodart), used for benign prostatic hyperplasia (BPH). Other drugs that may be implicated include phenothiazines, methyldopa, isoniazid, phenytoin, and imipramine. Herbal remedies that contain phytoestrogens are also responsible for breast enlargement. Since the body converts some testosterone to estrogen, high doses of the male hormone can lead to breast enlargement.

Street drugs hardly belong on the same page as prescription medications. Still, marijuana, amphetamines, and heroin can all cause gynecomastia — along with much more serious problems. Breast enlargement due to medications or drugs will resolve once the offending drug is discontinued.

Treatment of prostate cancer. Because prostate cells are stimulated by androgens, a prime goal in the treatment of advanced prostate cancer is to reduce androgen levels. This can be accomplished by surgically removing the testicles, by administering anti-androgen drugs such as bicalutamide (Casodex) or flutamide (Eulexin), by giving injections of goserelin (Zoladex), leuprolide (Lupron, Eligard, Viadur), triptorelin (Trelstar), or histrelin (Vantas) to reduce testosterone production, or by administering estrogen. All these treatments can be helpful for prostate cancer, but all can produce gynecomastia. Anti-androgens and estrogens pose the highest risk. All in all, many men who receive androgen deprivation therapy develop gynecomastia. Fortunately, it is usually mild and acceptable, and it can be controlled by radiation or surgery if it’s troublesome. And new research shows that tamoxifen, an anti-estrogen medication used for breast cancer in men and women, is very effective for benign breast enlargement triggered by prostate cancer treatment and other causes.

Less common causes

Some men with testicular cancer (particularly choriocarcinomas) develop gynecomastia. Although it’s not common, every man with gynecomastia should have his testicles checked. Recovery from malnutrition or from a serious chronic illness may be associated with breast enlargement. An overactive thyroid gland can also produce it. Old age is another occasional cause, probably because testosterone levels tend to decline over the years. About one in 500 to 1,000 boys are born with Klinefelter’s syndrome (the presence of an extra X chromosome, the female sex chromosome), which can cause gynecomastia. Much less common causes include testicular failure and, rarest of all, various estrogen-producing tumors.

These diverse disorders have two things in common: low androgen levels and high estrogen levels. But competitive athletes and other men who take Andro or abuse male steroid hormones can also develop gynecomastia. That’s because a portion of everyone’s androgens are converted to estrogens, and men who boost their androgens to artificially high levels get abnormally high estrogen levels in the bargain.

Male breast cancer

About 2,030 American men will develop breast cancer this year — actually quite a small number next to the 178,480 cases that will be diagnosed in American women. Still, the incidence of male breast cancer has risen 25% since the early 1980s, and about 450 men will die from the disease this year. While it’s a far cry from the 40,460 breast cancer deaths in women, it’s a reminder that the early diagnosis and treatment of breast cancer can save male lives, too.

Most men with breast cancer notice the problem themselves, but most don’t get help as quickly as Senator Brooke did: He was encouraged to seek treatment by his wife, herself a breast cancer survivor. Breast cancer in men produces a firm, painless lump, 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.

Although the causes of male breast cancer are not known, risk factors have been identified (see “Risk factors for male breast cancer”). Heredity and age play important roles. Men with a strong family history of female breast cancer are at higher than average risk. In particular, more than 6% of men who inherit the BRCA2 breast cancer gene will be diagnosed with breast cancer. Men who have been treated for prostate cancer have twice the risk of breast cancer, but that risk is still very small. Many of the other risk factors involve abnormally low testosterone levels.

Risk factors for male breast cancer Advancing age A family history of breast cancer, particularly involving the BRCA2 gene Obesity Jewish ancestry Treatment for prostate cancer Klinefelter’s syndrome Infertility Testicular abnormalities Radiation exposure Alcohol abuse

Diagnosis and treatment

Except in men with the BRCA2 gene, breast cancer is rare in men. Formal breast self-examination is not necessary, but breast awareness certainly is. If you notice an abnormal thickening or lump in the vicinity of one of your nipples, ask your doctor to check it. He may order a mammogram or ultrasound. If the results are worrisome, the next step will be a surgical biopsy or a fine needle aspiration, in which cells from the mass are sucked into a syringe, then examined 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 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%, but early diagnosis can improve that substantially.

PSA in females Breast cancer may not be a guy thing, but prostate specific antigen (PSA) sure is. The protein is produced by prostate cells — but is it truly specific to the prostate? Interestingly, it is not. A 2002 report notes that sensitive tests can detect very low levels of PSA in the blood and breast tissue of healthy women. Women with breast cancer tend to have even lower levels, but women with overactive adrenal glands tend to have higher levels.

Men, too

When men think about breasts, they are not likely to focus on themselves. Indeed, breast disease is not a “guy” thing. But men should listen to their bodies, and that includes noting any changes in their breasts. Asymmetrical enlargement, bleeding, or milky discharges from the nipple require immediate attention. Fortunately, when breast enlargement occurs, it is usually more worrisome than serious. Still, a medical examination can reassure many and provide life-saving treatment to some.

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