A pink ribbon for men: Why there's a dire need for male breast cancer awareness

Pune resident Hari Narayan, 45, hits the pool daily after work, his navy blue swim shirt making him stand out among the bare male torsos on display at the pool in the centre of 24 posh towers that make up his housing complex in Aundh. "I'm not craving attention," smiles the finance manager as he rubs his hair dry after a post-swim shower. "My surgical scar from when part of my left breast was removed after I was detected with cancer attracts far too much attention. I'm tired of recounting the same story and facing the same incredulous reaction of disbelief. I remember a regular at the pool who once saw the scar in the locker room and asked me about it.

When I said male breast cancer (MBC), the guy actually cracked up."

While epidemiology suggests an incidence of one case for 100,000 men, MBC is often misdiagnosed as endocrinal disorder or simply diagnosed too late. The stigma attached to male breasts also prevents some from seeking medical attention until it is sometimes too late.

Unlike many others, Narayan doesn't betray signs of bitterness about being one of the rare few – even among the 1 per cent – to have contracted MBC, that too so early, when most known cases occur in the 68-72 age group.

"It came to me from god. Anything that has touched his hand and come down can't be all bad. Yes, the discovery left me shaken and the surgery and chemotherapy that followed was hard on my family and me, but it's also part of his master plan that I've survived and gone back to my previous life as a better person. Battling cancer taught me to cherish life and people around me. I've become more empathetic and want to increasingly look at things from the person's point of view too." He adds, "I eat healthy, have stopped drinking and smoking and become regular with my fitness routine of running in the morning and swimming in the evening. Overall, I'm happy to meet this new me in the mirror."

It seems hard to believe that he was contemplating suicide barely two years ago, when he was diagnosed with the disease. "It was Diwali. It'd been over eight months since I detected a lumpy growth while soaping myself in the bath. I dismissed it as harmless and ignored it for several months." He only panicked when there was a retraction of the nipple and the lump which had grown and could now be moved felt hard. That's when he told his wife, who consulted a family doctor in Coimbatore. "My mom had breast cancer. Both her breasts were removed. My grandmom also died of breast cancer. So that's how we went for tests."

Detailed investigations confirmed MBC. He had a 'retroareolar nodule' in the right breast, which was growing. There were also "beginnings of infiltration of the pectoral muscle". For the latter, he still blames his own stupidity and ignorance. Yet he was lucky that this was only Stage II of the disease. "I remember the crackers and celebrations all around while my school-going daughter and wife kept crying. I thought this was the big full stop in my life," his voice giving away how close he is to tears at the memory.

About 150km away, retired mechanic Ronald Carmichael too had MBC barely a year ago. "In a way it's better this happened now. I don't feel any shame or difficulty about what happened. Not that I mind, but people who hear about it go easy with questions at my age," says the septuagenarian, whose mother and sister also battled breast cancer.

Unlike Narayan though, who struggled to explain to his bosses at work to seek leave, Carmichael had no such problems. Early detection and proactive visits to the doctor helped. "The moment I felt a small growth near my nipple, I promptly went to our family doctor, who referred me to the oncologist. The cancer had barely begun, so my treatment too was easier." He also brushes off the surgical scar. "I'm not Salman Khan to go without a shirt," laughs this grandfather. "At this age, my wife and I need each other for companionship and support. Its not about how hot we look without clothes."

Narayan admits that he went through hell when it came to physical intimacy. "I still don't know whether it was the chemo, medication or just the discomfort of how I looked, but I would simply not feel like having sex. It didn't help that I've always found my nipple area to be my erogenous zone. It was hard on me and my wife. It took us a long while and several visits to a sexologist to find our rhythm as a couple again."

Well-known oncosurgeon Dr. Vinay Deshmane says both Narayan and Carmichael are lucky. "Breast cancer in males is often diagnosed late as men may not seek medical attention as quickly as women do. In addition, since men have smaller breasts than women, the tumour is often closer to the skin or underlying chest wall, which increases the likelihood of the cancer spreading to the chest wall and lymph nodes."

He admits that the medical fraternity still doesn't fully understand and know enough about the disease. "Since incidence is rare, treatment strategies for MBC aren't based on data on enough randomised clinical studies in men. Most treatment recommendations are extrapolated from data for women."

Agreeing with Deshmane, Kochi-based medical social worker-counsellor Tresa Mathew adds that young MBC patients have it tough because there is so much stigma attached with anything to do with male breasts. "From early on, socialisation reinforces the notion that this is a female domain. I've met young men whose problems got compounded because of misdiagnosis. Breast enlargement in young men (gynaecomastia) is dismissed as an endocrinal disorder. This can cause potential misdiagnosis and delay treatment in the early, critical stage."

At the home of Mathew's late patient Rahul Thomas, who succumbed to MBC in 2011, his family and friends are yet to come to terms with his death. His friend Shaju Mathew recounts remorsefully, "I was too young and foolish to know better. I'd often join other classmates in teasing him for his 'moobs' (man-boobs). I remember him tearing up once when a school bully actually squeezed his breasts on the ground. Yet, he was so full of life despite the constant bullying and teasing through school and college."

Thomas' 76-year-old mother Achamma breaks down while talking about him. "He was the youngest and inherited the curly ringlet hair from my side of the family. I'd not allowed his hair to be cut till he was four," she remembers. "How could someone I was so attached to go away, leaving me to grieve him?"

Both friends and family agree that excessive teasing over his enlarged breasts led him to clam up about the progressive growth in his right breast.

By the time Thomas approached doctors, the well-hardened tumour was nearly 3.5 cm. He underwent radiation therapy in November 2009 and seemed to be doing well. But within a year, he got jaundice and lost nearly 20kg in three weeks. He was diagnosed with cervical and dorsal nodules. "He'd simply keep passing out as he went through another round of investigations for platelet count, liver function tests, chest imaging, bone scan and an abdomen ultrasound," elder sister Kunju remembers."When abdominal ultrasonography showed the presence of several hepatic nodules, we began losing hope. He had no appetite. His fever kept shooting up and his skin turned bluish. He kept pleading to be saved till he died of multiple organ failure in February 2011. All that the doctors could give him then was morphine."

There's a lesson in Rahul Thomas' tragic death.

As Dr. Deshmane says, "While awareness about self examination routines for male-specific cancers like testicular cancer is greater, we need to increase awareness and education on MBC among men too so that timely intervention can save lives."

Who is at risk?
Though there is a need for more empirical data to establish the exact conditions that place some men at higher risk of breast cancer, there is broad consensus in the medical fraternity on the following factors:

Testicular abnormalities like undescended testes, congenital inguinal hernia (when an intra-abdominal structure, such as the bowel or omentum, protrudes through a defect in the abdominal wall), inflammation or removal of one/both testicles, and mumps that affect the testes

Klinefelter's syndrome (a condition affecting males where cells have an extra X chromosome in addition to the normal XY), characterised by a tall, thin physique, small, infertile testes and enlarged breasts puts men at a 50-fold greater risk of MBC over the general male population. Klinefelter's syndrome is present in three to seven per cent of men with breast cancer

Family history of breast cancer increases MBC risk by 2.5 times. 15-20 per cent MBC cases have a family history of the disease

Those suffering from gynaecomastia or liver disease

Alcoholics

Those exposed to regular and high electromagnetic fields

Those exposed to heat volatile organic compounds (eg: tetrachloroethylene, perchloroethylene, trichloroethylene, dichloroethylene and benzene)