• 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.
IT’S BREAST PAIN that most often brings patients to our clinic. Although the majority of such women will not have cancer, it is still essential for the physician to keep in mind that pain can be an early cancer symptom—and it’s his or her responsibility to identify the rare patient whose pain is triggered by a hidden malignancy.
Breast soreness is most common in young women. It typically starts several days before the onset of menstruation and gets worse until the beginning of the period. That discomfort is generally associated with rising hormone levels, whereas the onset of the period is followed by a reduction in the intensity of the pain.
We refer to this pattern of pain as cyclic breast pain and it is considered normal. However, pain that occurs independent of the menstrual cycle is referred to as noncyclic breast pain and often requires medical attention.
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