Male Breast Cancer: Raising Awareness and Understanding

Breast cancer in males is a rare cut clinically significant disease. Males have many of the same risk factors as females, but delay in seeking health care puts them at greater risk. Richard Pullen, Ed.D., MSN, director of the R.N. to BSN program in the School of Nursing, explains why males might put off reporting a lump in their breast or even checking for lumps. Dr. Pullen tells us what to look for, how we can help reduce the social stigma and instead support those who are at risk for developing breast cancer.  One of the ways to start is by having conversations about awareness, so share this episode with your friends and family.

Transcript

Melissa Whitfield  0:10 
Hello and welcome back to Texas Tech Health Check from Texas Tech University Health Sciences Center. I'm your host, Melissa Whitfield. We want you to get healthy and stay healthy with help from evidence based advice from our physicians, health care providers and researchers. Male breast cancer is a rare but significant disease accounting for approximately 1% or 2800 males in the US of all breast cancer diagnosis. Dr Richard Pullen, registered nurse, Professor and Director of the RN to BSN program in the School of Nursing, is our guest for this episode. Dr Pullen talks to us about breast cancer in males, the risk factors, symptoms, self checks, diagnosis, treatment, recovery, and what we can do to bring awareness and support to those males who have been diagnosed with breast cancer.

Melissa Whitfield  1:09 
Dr Pullen, welcome to our podcast.

Dr. Richard Pullen  1:12 
Well, thank you, Melissa, for the invitation.

Melissa Whitfield  1:15 
Well, how are you doing?

Dr. Richard Pullen  1:16 
I'm doing well, you know, it's springtime, and we have some thunderstorms out there, and the rains nice and kind of renewal. So I'm doing good.

Melissa Whitfield  1:24 
Absolutely. Well. Again, welcome to our podcast, and if you could tell our listeners a little bit about yourself, your expertise and what you do here at the Health Sciences Center.

Dr. Richard Pullen  1:33 
Absolutely. And again, thank you, Melissa, for the invitation to be here to talk about a very important topic. I'm Dr Richard Pullen, and I am a registered nurse, and my expertise medical, surgical nursing, oncology, lupus, autoimmune hepatitis, Munir disease, teaching and also leadership, and I've been in academia full time for 32 years. I'm professor and RN to BSN program director in the School of Nursing. And my education, I have earned a Doctor of Education degree in higher education leadership. I have a master's degree in nursing education. I'm a certified nurse educator. I'm a fellow in the Academy of Nursing Education, a fellow in the American Academy of Nursing. And Piper Professor of Nursing and Melissa, one thing that I like to do is I enjoy writing in peer review clinical nursing journals. I analyze the published science and translate the evidence into nursing care using what nurses call the nursing process. And I've always thought that writing for publication is a great way to teach a global community of nurses about various topics, and just a good way to teach beyond the walls of a college.

Melissa Whitfield  3:10 
Well, today you're here to teach not just us, TR and me, about this topic, but also our listeners, bigger audience, about breast cancer in males.

Dr. Richard Pullen  3:20 
Absolutely. And as we talk about this most important topic, you'll see that a major framework is education from an inter professional perspective. So it's about nursing, but it's also about all our other wonderful health profession colleagues that help people to stay well and also to treat manage their illnesses along the way.

Melissa Whitfield  3:48 
Well, let's get to it.

Dr. Richard Pullen  3:50 
Sure.

Melissa Whitfield  3:50 
Can males get breast cancer? And how common is it?

Dr. Richard Pullen  3:55 
Breast cancer is the most common cancer in females. We'll start there, worldwide and also in the United States. It's interesting, Melissa in 2024 an estimated 2.3 million females were diagnosed with breast cancer worldwide, and 670,000 died. 1% of all breast cancer diagnoses are in males and in 2024 about 42,250 females and 530 males died from breast cancer in the United States. And when we look at some demographic variables, non white males have the highest incidence of breast cancer, which may be due to genetic factors. We'll talk about that in a minute, health status, socio economic factors and access to care. That's that's a big issue worldwide. Chronic health conditions such as COPD, cardiovascular disease, arthritis, obesity and a lack of health insurance predispose a person to cancer and other health conditions. And the five year survival rate of males and females with breast cancer is similar. But interestingly, breast cancer in males is frequently diagnosed at a later disease stage, and it makes it a little more challenging to manage in the five year survival rate according to the surveillance epidemiological end result. So that's called SEARS, is based on the extent of the disease. When the disease is localized, confined to a localized area, the prognosis is about 95% survival at five years, that's that's very high, but when it goes into the lymph nodes, it's about 84% but the bad news is, if we don't catch it early enough, and it metastasizes, in other words, spreads to other body organs, the five year survival rate is about 20% so it's quite low. So and I think, I think those stats tell us that there's an extreme need to educate and teach about those signs and symptoms and get on it very early. But when we take all the stages together, the relative five year rate of survival is about 80% so again, early diagnosing.

Melissa Whitfield  6:44 
Well, then I know you talked about some of the risk factors about cancer, but some, what are some of the risk factors for breast cancer? And is it mostly hereditary?

Dr. Richard Pullen  6:54 
Well, it's a combination of many factors, but let's you mentioned something about hereditary so let's talk about genetics. Okay, and there's a lot of research on genetics in breast cancer, in males and females. And the first thing I want to say is that there's a doubling of risk in males with the first degree relative with breast cancer. So if you have a family history, whether that's your male father or your mother, then you have a greater risk of developing breast cancer and the mutations. And there's two genes that I'm going to talk about here, initially. It's breast cancer one and two. Breast cancer one and breast cancer two. Sometimes they're called BRCA one and BRCA two, okay, and when there's mutations or changes in those genes, then that can set up for malignancy, and about 20% of males and females with breast cancer will have genetic mutations predisposing them to their breast cancer, and that's very interesting about BRCA one and two. The first time they were identified, it was in a female with breast cancer, so that's why it's called breast cancer one and breast cancer two, okay, BRCA one and BRCA two. But interestingly, those mutations, those genetic mutations, can also be found in ovarian cancer. That's quite interesting, prostate cancer, pancreatic cancer and colon cancer. So for instance, as a man, if I had mother or father that had the BRCA one or two, then I am more prone to not only breast cancer, but also the other forms of cancer I just told you, including prostate cancer. So quite, quite interesting. And there are other genes, lots of genes. So I said, BRCA one, BRCA two. And there's also the phosphatase tension homolog gene in checkpoint kinase two. But genes, so there's a lot of genes that are Interplay here, and there's a lot of research going on right now on, really, these are the things we know about genes, genes, but probably more genes that we still need to find out about. Then I also want to say that most breast cancers in males are estrogen receptor positive and estrogen promotes breast tissue development and causes mutations or changes in DNA that cause cell proliferation out of controlled cells, which leads to carcinogenesis. Another risk factor is males with a higher estrogen level. And there's a syndrome called Klinefelter Syndrome, where a male has an extra X chromosome. That's quite interesting, and that increases the risk for breast cancer. This syndrome causes reduced testosterone, smaller than average size testicles, reduced sperm production, infertility, decreased body hair, gynecomastia or excess suppressed tissue in men and increased estrogen and also males receiving estrogen therapy have a similar effect. Now another major risk factor is aging, especially as we get past the age of 60, and aging really is a primary risk factor for breast cancer, particularly between ages 60 and 70 for males, and that's about five years later than for females. So we tend as males to develop breast cancer a little bit later than females. And also another risk factor is males with a previous diagnosis, if they've had breast cancer on one of their breasts, the contralateral breast can also be affected. Also if there's a history of testicular injury, let's say, as a as a child or or maybe there was an infection involving the testicles, like Orchitis or some or Epididymitis. So a previous disease or infection or trauma to the testicles is another risk factor for developing breast cancer later in life. Now I want to make a point here. Another risk factor is a high body mass index with overweight to obese the fat cells are called adipocytes, and adipocytes are inflammatory mediators. They cause inflammation, okay? And so if we have chronic inflammation in our body that tends to over time, can cause distortions or mutations in the DNA, causing not only breast cancer, but many forms of cancer, and I think you'll see that that's emerged as a major risk factor in many forms of cancer these days. Okay, we're almost finished with the risk factors. Alcohol consumption is another risk factor, and that may be as a result of, let's say, excessive use of alcohol, and that can cause some problems with the liver, and that can cause problems with the liver function, and also set up for breast cancer, and also if there's a previous history of radiation to the chest. So those I know that's a lot of information, but there's a lot of risk factors involved there, and I certainly hope I've answered your question.

Melissa Whitfield  13:02 
Yes, absolutely. So Are there guidelines for a certain age where males should be checking for breast cancer and what should they be checking for?

Dr. Richard Pullen  13:10 
Yeah, it's interesting. No, right now, at the moment, there's not a standard criteria for when males should start checking. Now with females, obviously there are standards with mammograms, routine mammograms, and there is also some discussion out there about the use of breast self exams as a standard too. But we don't want to get too, too comfortable in just saying, well, you need to do your examine your breast, because, particularly with females, we want her to get those mammograms too so, but with males, no, not yet. There's not a standard. But I think any time past puberty, and certainly at the age in 20s, that I find that it's critical that we educate males about checking for abnormalities in his breast.

Melissa Whitfield  14:12 
Are breast exams the same as they are for female.

Dr. Richard Pullen  14:16 
I think they're pretty, pretty similar. Obviously males, for the most part, don't have as much tissue, but I think one thing that we can do is check the breast out routinely in one or more breast lumps, a painless lump in the breast or arm pit may develop. I'm going to talk a little bit about the symptoms first, okay, and then we'll talk about how we can how we can do the exam. Changes in the skin, a dimpled, puckered, red or scaly skin may appear on the breast, anything that's abnormal. My philosophy on the skin, anything that stays on the skin for a while. So it needs to be looked at. It can do nothing but harm anywhere in the body. Sometimes patients, Melissa, see several dimples or divots that look like the skin of an orange around the breast too, okay, and a patient may experience unusual pain or sensitivity in the breast area, the tissue and also the nipple too. Okay needs to be checked. There may be nipple changes or discharge. And when a patient has breast cancer, their nipple may turn inward. It's kind of a puckering inward, and it's puckering inward because the malignancy is pulling it that way. It's pretty, pretty interesting. That's in females, too, and again, if there's any discharge. So the big thing is looking anything that's unusual that should not be there, needs to be brought to the attention of a physician pretty promptly, because something that is an early stage can be fixed pretty early, but can turn into something that would have a horror prognosis.

Melissa Whitfield  16:13 
Recently, I received an email to remind me of my own mammogram, and the email was dipped in pink, and if you go get a breast exam, everything is pink. How can we encourage males to seek care when everything is for women?

Dr. Richard Pullen  16:27 
I know, I know, first of all what we're doing here and again, thank you for this opportunity. It's educating not only the public, but also our health care professionals, nurses, physicians, everyone in the health care community, because we just don't deal with it very often, and when we do, then it tends to be more of an issue. But I think through education, and I think that nurses, nurses and also our physician colleagues, all the health professions we need to teach males to perform their breast exams. Check them out. You know, I've listed just a few few steps. Stand in front of the mirror and look for breast symmetry. Just look at check yourself out. You know, nipple puckering or indention, okay, and any lumps. Just look. And females can do this too. Just check yourself out. And if you have a spouse, have them check these areas out too. And that can be a part of how you relate to each other, too. So it may not be that the male finds the the issue. It might be his spouse that finds it. So that can be something that you can do together. Raise the arms above the head. Continue inspecting the breast, including the axilla underneath the arm. Use the pads of the fingertips to firmly feel or palpate the breast, the areola, okay, the nipples and axilla for lumps or tenderness using a circular motion. And when you're under the arm, you're going to have to, I call it getting really deep, not just something superficial, get in there and use the pads of those fingers, fingers to feel lumps that might be something deep, okay, which may be an enlarged lymph node. Gently squeeze the nipples for any discharge. Males may also assess their breasts in axilla while in the shower, and females can do the same thing feeling a little deeper and firmer than they would normally by soaping their bodies. So this is something that actually can be done just about every day.

Melissa Whitfield  18:59 
What is treatment like breast cancer in males?

Dr. Richard Pullen  19:04 
Well, I think before I answer that, I want to back up just a little bit. I think it's important that, as far as encouraging males is we need to raise public awareness. And of course, as I mentioned, we're doing this podcast. Encourage open conversations about breast cancer in males, use gender inclusive language about breast cancer. It's a male and female problem. Okay? Educate males about signs and symptoms. Educate males about the importance of early detection, and these are the same things that I would say to females also. The treatment, of course, we we diagnose it by the patients or the physician and the healthcare team diagnose this through the patient signs and symptoms, and of course, a comprehensive health history, any genetics, any other issues, mammograms, we diagnose through mammograms, perhaps ultrasound also and also MRI, maybe a PET scan and a PET scan is useful, not only to identify the primary side of malignancy, but also if there's any metastasis, obviously throughout the body. Treatment, the treatment is oftentimes hormone therapy, like with Tamoxifen and also aromatase inhibitors. Those are drug classifications, also targeted therapy. Targeted therapies are great medications these days that can help in many forms of cancer, to add quality of life to the patient, but targeted therapies are very simply stimulate the immune system to kill malignant cells. And these targeted therapies are great too, because it reduces the need to some degree or the amount of chemotherapy and all the bad side effects that chemotherapy can bring. But these immunotherapies, such as Trastuzumab, which is a monoclonal antibody, is very effective in breast cancer, chemotherapy with the Paclitaxel and sometimes these medications, some hormone therapy, immunotherapy and chemotherapy are given kind of in a as a composite treatment plan. But again, it depends on the stage of the disease. Also radiation therapy may be a part of the treatment plan. And also surgery, too, we might do a lumpectomy remove the mass, or a mastectomy, which is the surgical removal of one or both breast, and there can be reconstruction of the breast even in males. I was talking to a friend the other day about that, and she says, are you kidding me? Well, of course, because I I'm at the gym all the time, and have been forever and ever. And I know, I know that men are proud of their their breasts or their pecs, absolutely and so anyway, can't you, I always say, can't you, just imagine me going into the gym and say, how many of you guys out there check your breast? You know, they probably just would have, you know, have a seizure or something. But anyway, that's what we need to do is get down to into those public areas to bring awareness to breast cancer in males.

Melissa Whitfield  22:48 
What is recovery like for males, physically and mentally?

Dr. Richard Pullen  22:51 
Yeah, a diagnosis of cancer is always devastating, because we're faced with our mortality and of course, it depends on the stage of breast cancer, and there are various stages, right? So there's a lot of uncertainty and fear. So I think it's important that we have breast cancer survivors. So if I'm a male with breast cancer, then a female who survived, a male who has survived, would be a great source of comfort with me, for me and also going to support groups too. But care for patients, males with breast cancer, is administered or is framed again, as I said earlier, through an inter professional perspective, there's nurses, of course I'm a nurse. There's also physicians, highly educated in oncology. There may be surgical oncologist, maybe social worker, also maybe counselors and psychologists and pharmacists, a lot of different people to help people to cope with this devastating diagnosis. And of course, if there's advanced metastatic disease, when mortality or the prognosis does not look favorable, then we have to bring in our wonderful end of life care professionals and hospice. So, but, but again, I think that going back to the the earlier we can identify it and address it, then the better prognosis. So early recognition is important. Also nurses in the healthcare team physicians and surgeons assess, of course, we need to assess what breast cancer means to the to the male. What does it mean to him, allow him or encourage him to talk about his fears. That's so very important, which is important in all that we do. We need to teach patients and their partners and spouses, bring them in. And the differences between a lumpectomy, maybe a modified mastectomy, a radical mastectomy and lymph node dissection, teaching the patient about post operative wounds, dressings and drainage collection systems is critical, so a lot of teaching before any surgery. Now, remember that, you know, early on, it may be maybe a lumpectomy and that's it, and the patient may be a day surgery, or maybe in the hospital, maybe no more than a couple of days, and then go home. But if there's major surgery, removal of the breast, then the patient will be in the hospital for a while with drainage tubes. Teaching about the effects and side effects of radiation therapy is important. We need our wonderful nurses and oncologists out there to talk about the side effects of radiation therapy, and also the side effects of immunotherapy. There's a lot of skin side effects and some other side effects too. And then also, chemotherapy does some wonderful things, but it also can make you very, very sick. So all of these things need to be taught up front, as indicated based upon the degree of disease the patient has. Just a lot of teaching. Some other things post operatively, if they're having surgery, is monitor and trend evaluate, evaluate those vital signs, the oxygen saturation, and review the labs, complete blood count and comprehensive metabolic panel, and we want to make sure that the patient is hemodynamically stable. But again, my big thing here, that I want to focus on, is early recognition and treatment and public awareness.

Melissa Whitfield  27:02 
What can happen if it's left untreated?

Dr. Richard Pullen  27:04 
Well, we've talked about that a little bit here is that, first of all, if something is abnormal on the breast, just by looking at it in the mirror or feeling the breast, the nipple, underneath the arm, it's not going to go away. If it's cancer, it's not going to go away. It's going to get worse. And something elation, a malignancy, that is in situ, which means just there, just in sight, you know, that's kind of a good term in situ, it's just there. It's confined to a small area. Then that's the time to take care of it. If it just sits there, then it's not going to do any good over time. And I don't know what time means, will mean different things to different people. Is that the limb tissue will pick up malignant cells and transfer them to different areas of the body, so the cancer can spread very easily by the lymph tissue and maybe to the bones, the liver, anywhere else throughout the body. And of course, at that point we're talking about metastatic disease. So that's what can happen. And remember, advanced disease or metastatic disease, the five year survival rate by SEAR is only 20% that's not high, okay, so the outcome is poor if it's not managed early.

Melissa Whitfield  28:34 
You talked about having these conversations, but what more can we do to encourage breast cancer exams, and how can we support those who have been diagnosed with breast cancer?

Dr. Richard Pullen  28:43 
Well, I think that again, public awareness, we need to talk about it. These things happen, and support groups, advocacy groups, education in the home as a male grows up, I think it's important that parents, early on and as the male and female, as they grow into puberty, start talking about these important things with different exams and teaching them so that when they mature into adulthood in relationships, that that that will be a pattern of just checking to make sure that they're not having any problems with breast cancer. I think in the school system, it needs to be brought out. I think we need to move away from the fact that it's a stigma. If you talk about males with breast cancer, it happens, and it can be very mild, minor, or it can be life threatening. We need to understand that when we talk about the breast, obviously, the breast and females, they're there for lactation. They also are an identity, a female identity. Right? And also they're an organ that are as responsive to sexual stimulation. And so males, the breast, the nipples, are there for a reason, and they're not just there by accident, and most men also have breast sensitivity during during sexual stimulation. So they're there for a reason, and we need to be doing a lot of teaching and talking about these issues, even if we're uncomfortable with them. But you know, we really need to educate the public, educate each other, to help save lives, and that's what's most important.

Melissa Whitfield  30:34 
Is there anything else that you would like to add?

Dr. Richard Pullen  30:37 
Again, I am very appreciative of your time, Melissa on this most important topic. And of course, my article is published on breast cancer in males through a peer reviewed publication that came out just last month. It's called Nursing the Peer Reviewed Journal of Clinical Excellence. And I think that there is something in there, obviously for nurses, but I also think our physician colleagues, the public, I think there's some terminology in there, they'll understand, but all of our wonderful inter professional colleagues, I think can glean something. And we need to get moving on educating, and not only educating, but we need to bring awareness that, yes, this does happen. I was talking to a colleague the other day, and I said something about 500 or 600 males have died last year. And my colleague said, well, that's not very many. And I said, well, it is to them. And so when something doesn't occur very often, it makes it more imperative, more critical, for us to be on the stick, to be aware and be proactive in preventing it.

Melissa Whitfield  31:48 
Well, thank you so much for coming on our podcast and talking to us about male breast cancer, definitely something that we need to talk about more. Thank you.

Dr. Richard Pullen  31:56 
Well, Melissa, thank you so much.

Melissa Whitfield  31:59 
And we can't wait to have you back on.

Dr. Richard Pullen  32:01 
Would love to come talk. I could always do that. Thank you.

Melissa Whitfield  32:06 
Thank you for listening to Texas Tech Health Check. Make sure to subscribe or follow wherever you listen to podcasts. This information is not intended to be a substitute for professional medical advice. Always seek immediate medical advice from your physician or your health care provider for questions regarding your health or medical condition. Texas Tech Health Check is brought to you by Texas Tech University Health Sciences Center and produced by TR Castillo, Suzanna Cisneros, Mark Hendricks, Kay Williams and me, Melissa Whitfield.