Читать книгу Prevent, Survive, Thrive - John G. West - Страница 15

CHAPTER FIVE

For Men

YES, MEN CAN AND DO have breast problems. As with women, the vast majority are not related to cancer. It has been estimated that a young man has a better chance of winning the lottery than of being diagnosed with breast cancer . . . but surprisingly, it is possible.

The same can’t be said for testicular cancer, the most common malignancy in males between the ages of fourteen and forty. So why mention testicular cancer in a chapter on breast issues in men? The reason is simple: A breast lump can be the first sign of a hidden testicular cancer.

A great deal of progress has been made in treating testicular cancer, but to maximize the potential for cure, it is still important to detect the malignancy at its earliest stage. Also, delays in diagnosis often result in the need for more aggressive treatment, which may include both chemo and radiation therapy.

In addition to the possibility of testicular cancer in young men, there is a chance of breast cancer in older men. As with women, age is a significant predictor of the types of breast problems males are likely to experience. Therefore, in discussing issues on the masculine side, it is logical to divide them into three age categories, recognizing there is a fair amount of overlap between the age groups.

NEWBORNS TO PUBERTY

It is common for newborn babies of both sexes to have enlarged breasts, and some will have lumps below their nipples. This is a self-limiting condition, and no treatment is required. In most cases, the enlargement will go away in a matter of weeks.

In the years between birth and the onset of puberty, breast problems are rare for both sexes. Still, breast lumps and breast infections can occur, and any changes should be reported to a pediatrician.

Puberty is when breast problems become more common in boys. Enlargement on one or both sides is often associated with pain, tenderness, and a distinct mass. A breast lump in this age group is referred to as gynecomastia, which roughly translates as “breasts like those of a woman.”

The term gynecomastia is actually well chosen, because it implies a hormonal origin to the problem, which in fact is the case. The term is reassuring, since it avoids any reference to breast cancer, which is extraordinarily rare in this age group. A careful history and clinical exam of the breast is all it takes to make the diagnosis. In most cases, reassurance and observation are sufficient. Though the risk of missing a breast cancer in this age group is extraordinarily low, I still advise parents to have the child return if there is any progression of symptoms, such as an increase in size or onset of pain or tenderness. When gynecomastia lasts longer than two years, the chances of the breasts returning to normal are greatly reduced. We encourage boys with persistent small lumps to wait them out since, over the next few years, many of these lumps will slowly go away.

Larger lumps are more problematic. Often these protrusions are so obvious they are visible even when the boy is wearing a T-shirt. The embarrassment can be devastating to young boys, who are often already self-conscious about their body image.

With boys who have a large lump or whose entire breast is enlarged because of an excess of fatty tissue, it is more difficult to obtain a satisfactory cosmetic result. In these unusual cases, referral to a plastic surgeon may be indicated.

Although there are reports of gynecomastia cases responding to hormone-blocking medications, I have no personal experience with this approach. If the family has an interest in trying a medical approach, I would recommend consultation with an endocrinologist.

MEN FOURTEEN TO FORTY

When I see a young male with a breast lump in this age group, the first thing that comes to mind is the possibility of an associated testicular cancer. Missing such a cancer in a young man can be just as dangerous as missing the diagnosis of a breast cancer in a young woman.

Thus, every breast lump in this age group needs special attention, even though the chances of it being the first sign of hidden testicular cancer are small. The key to avoiding a delayed diagnosis is for the treating physician to consider testicular cancer as a possibility. Specific questions should be asked about any history of testicular symptoms, such as swelling, tenderness, pain, lumps, or any other oddity the patient can remember. An examination of the testicles should also be done. If there is even the slightest possibility of an abnormal finding on clinical exam, a testicular ultrasound should be ordered.

It is important to keep in mind that the testicular exam can be completely normal and still harbor a “hidden” cancer. These “occult” testicular malignancies are often first detected by blood-test screening in young men with breast enlargement.

I routinely order the following blood tests for young men with breast lumps:

• AFP (alpha-fetoprotein)

• Beta hCG (human chorionic gonadotropin)

• LDH (lactate dehydrogenase)

If any of the three tests are elevated, I refer the patient to a urologist. I will not schedule surgical removal of a breast lump in a young male until the blood tests come back as normal and the rest of the workup has been negative.

In my experience it is rare to find hidden testicular cancers in this group of patients. That being said, I have a vivid memory of one young man who died of metastatic testicular cancer. His prognosis would have been much more favorable if his condition had been diagnosed two years earlier when he presented with a breast lump.

From what I’ve seen, breast lumps in the fourteen-to-forty age group are frequently caused by medications, the most common being body-building steroids. Often these muscle-enhancing hormones are not clearly labeled on the products. As a result, many of the young men who come to me with a breast lump are not aware that the product they’ve been taking contains steroids or steroid-like compounds.

Stopping the use of steroids is helpful in some cases, but often the breast lump persists, even when all medications are eliminated.

Another common cause of male breast enlargement in this age group is marijuana. Most of my patients deny smoking it, and I don’t push the issue. But I suspect more are using cannabis than are willing to admit it.

In this age group, there is also a long list of medications, noted in the chart below, that are associated with male breast enlargement. In some cases, stopping or switching medication helps, but again the results are unpredictable.

DRUGS THAT CAUSE GYNECOMASTIA

Category	Drugs
Hormone	Anabolic steroids, estrogen, androgen, growth hormone
Recreational Drugs	Marijuana, amphetamines, heroin
Anti-Ulcer Drugs	Cimetidine, Omeprazole, Ranitidine
CNS-Acting Drugs	Tricyclic antidepressants
Heart Medications	Digoxin, calcium channel blockers

As with adolescent males with breast lumps, men in this age group who experience a persistent lump have the choice of living with it or having it surgically removed. From my experience, the young men who choose surgical removal almost always have a favorable cosmetic result.

MEN FORTY AND OLDER

When I see a man in his forties or older with a new lump, I know the odds are high that it will not be cancer. Again, most of these lumps are caused by medications. The most common prescriptions associated with breast enlargement are those used to treat heart disease, prostate cancer, indigestion, and depression. But the list doesn’t end there. It seems as though every commonly prescribed drug will list gynecomastia as a possible side effect. A predominance of men over forty are on at least one of these medications, and with age the list grows.

For the most part, my job is to make certain a breast cancer is not the cause of the lump. It is usually easy to determine. Benign breast enlargement in older men feels like a smooth, hard disc of tissue, whereas cancers are hard and irregular to the touch, and often associated with dimpling in the skin or nipple.

I recommend a mammogram for all men over forty who find lumps. I also include the same blood tests for testicular screening for men in their forties and fifties as I do for younger men.

The mammogram is highly accurate in making the diagnosis of gynecomastia. In the past, I typically did a core needle biopsy to confirm the diagnosis. I have become so confident about the accuracy of the imaging workup that I now do core biopsy only in select cases. All patients with this condition are encouraged to return as needed if they have questions, or if the lump continues to grow. I routinely suggest a six-month follow-up exam.

Imaging is also accurate in identifying changes in the breast that require some form of tissue sampling to rule out male breast cancer. With these men I do an immediate core needle biopsy. Surgical removal is seldom needed for an accurate diagnosis.

In rare cases, the findings on the core biopsy are at odds with the findings on imaging, which means surgical removal is indicated.

Once a diagnosis of breast cancer is made, we discuss treatment options. Most older males choose mastectomy, but in select cases lumpectomy plus radiation is a reasonable alternative.

All males with invasive breast cancer should see an oncologist. These men should also get risk assessment and, in most cases, gene testing to determine if they carry a gene mutation.

One of the great problems in caring for males with breast lumps is that guys often are oblivious to changes in that area of their bodies. As a result, it is common for them to appear with large lumps that are distorting the shape of the breast and should be obvious to even a casual observer.

When I ask these fellows how long they have been aware of changes, they typically say they just noticed them. Yet the reality is they’ve probably been going on for a year or longer. Men just don’t think about breast exams.

They seem blissfully unaware of the issue of male breast cancer. I am not recommending that men do routine monthly breast self-exams, but I believe men should at least make the effort to know what their normal breasts are like, and to become more proactive in reporting changes.

WHAT I’D TELL MY DAUGHTER

• Most lumps in teens and younger can be safely observed.

• Surgery is rarely indicated for gynecomastia.

• Tests for testicular cancer should be performed for new breast lumps in males ages fifteen to forty.

• New lumps in males forty and over should be evaluated for the possibility of breast cancer.