Richard Francis’s novel Taking Apart The Poco Poco begins inside the obsessive mind of a character called Raymond who sleeps in his kitchen, spends his first few moments of waking savouring the smells in his kitchen and howls when he finds a chicken on the washing-machine. It’s a page or three before the reader realises that Raymond is actually a dog. It’s neatly done.

However, the surprise of discovering that you’re seeing the world from the point of one of nature’s dumber mutts is nothing compared to the stunt the author pulls 150 pages later. Margaret, the novel’s central adult female character, is in hospital to have a lump in her breast examined. She strikes up a conversation with someone she takes to be a waiting husband and is amazed - as we are - to find she’s talking to a fellow patient.

A bloke with breast cancer? Most of us find it easier to get our heads around the idea of a talking dog. Male breast cancer is like open government, British manufacturing or the Tottenham Hotspur defence, a contradiction in terms, an oxymoron even. I mean, you can’t call those little things breasts, can you? You can and they do. Doctors diagnose over 200 men with breast cancer every year. (The figure is increasing slightly – there were 344 cases in the UK in 2013). That’s a tiny number compared to the thousands of women but for the blokes concerned the rarity of their condition comes as no consolation, quite the opposite. Each has to deal with a disease he thought he had no chance of ever getting.

One percent of cases

Stuart Gilder was one. And the former policeman’s honest enough to admit ‘I burst into tears the moment the door was closed. So did my wife. I had had a feeling that it was cancer but when they tell you it’s still a terrible shock. You wonder fleetingly “how long have I got?”. We hadn’t said much on the way home but we both thought a lot. I kept thinking how each journey begins with a single step and I had no intention of giving up. I decided cancer would be a word I’d speak not whisper.’ He was just 51. Two years later, after a mastectomy, chemotherapy and radiotherapy, he’s applying to become a Breast Cancer Care volunteer to help other men who find themselves in the same unexpected predicament.

Men make up less than one per cent of breast cancer cases. Dr Eadie Heyderman’s ‘Coping With Breast Cancer’ is one of the few books on the subject to discuss the condition in males. She says women and men have different, almost opposite, attitudes to their breasts. ‘Women think every breast lump must be cancer while men think a lump in the chest can’t be cancer and ignore it,’ she says. ‘The outcome for men and women is actually pretty similar for the same type and stage of the disease but men are more likely to wait before seeking treatment until the lump has broken through the skin to form an ulcer or become attached to the chest wall.’

The risk of breast cancer increases with age. Although it’s younger women who are most worried about the disease, it’s older women who get it. Eighty per cent of cases occur in women over 50. The highest risk group is women in their sixties. Men are more likely to get it in their seventies.

Cancer is caused by carcinogens in the environment but exactly why one person should succumb to them and another not depends on genetic and other individual factors. Professor Ian Fentiman, the professor of surgical oncology at London’s Guy’s Hospital who has treated several men with breast cancer says ‘cancer causing carcinogens enter the body from food, water or the air damaging the body’s DNA. Usually this is repaired but as the repair mechanism becomes less effective with age, the risk of cancer increases.’ 

Size matters

In female breast cancer, hormones, particularly oestrogen, play a major role. They don’t cause it but do appear to encourage its growth. The earlier her periods begin, the later her menopause, the fewer children she has, the later she starts having children - all these marginally increase a woman’s risk. Kate Law of the Cancer Research Campaign says: ‘Each time a woman ovulates she releases a surge of oestrogen; the more often this happens in a lifetime the greater the risk of breast cancer.’

Men have far, far lower levels of oestrogen which probably explains breast cancer’s later age of onset and far lower incidence among them but hormones are still involved. Hormone blocking drugs like tamoxifan, the best known anti oestrogen drug, are used in the treatment of both sexes while men who have the rare Klinefelter’s syndrome in which they are born with an extra female chromosome have a twenty times greater risk of breast cancer than the average male. But Fentiman, who also advises the Imperial Cancer Research Fund, stresses that ‘male breast cancer is not a sign that you’re less of a man. It’s just bad luck. In most cases of male breast cancer there is no hormonal abnormality.’

When it comes to breasts, size matters. Women have far more breast tissue for lumps to develop in whereas for most men, self-examination is as simple as putting a flat hand on the chest. However, men with larger breasts are also at marginally greater risk. Firstly, examination may be a little less easy and, secondly, fat, which, of course, is what tends to cause enlarged male breasts, produces oestrogen.

Indeed, the Imperial Cancer Research Fund believe men who are grossly overweight by the time they are thirty may double their risk of breast cancer. Interestingly this theoretical risk is not reflected - yet - in the figures: obesity is increasing, male cancer rates are not. They’ve stayed pretty static since 1971, in which time the number of female cases has increased by nearly a third.

Liver disease

Liver disease can also increase male oestrogen levels. Egypt has one of the highest rates of male breast cancer - five per cent of cases compared to one per cent in the UK - because of the prevalence of the infectious liver disease bilharzia. ‘In equatorial Africa, male breast cancer can rise to 20 per cent of cases,’ says Fentiman, ‘again an infection is probably the cause. But working in very high temperatures can be a factor too as it stops the testes working so well and upsets the testosterone-oestrogen balance. It used to affect steelworkers, for example.’

Diet is always the hot topic in breast cancer. Dairy products are currently in the dock but it’s unlikely to be as simple as that.  ‘Japanese women have a low incidence of breast cancer in Japan,’ says Kate Law, ‘but when they move to the west, their incidence goes up to western levels. It may be because they start eating fatty food which increases their oestrogen levels or it could be that something in the Japanese diet - soya, perhaps - protects against cancer.’ It could simply be that they start living a western lifestyle: not exercising, smoking, drinking and having smaller familes, later in life.

Genealogy is certainly involved, particularly for men. About 5-10 per cent of women who develop the disease come from families with a history of female breast cancer. Among men this proportion rises to one in five. Mutations in two genes - BRCA1 and BRCA2 - have been identified as the guilty parties and a test is now available for them.

Genetic testing

Stephen Wilshere was 69 when he was diagnosed with breast cancer, having already lost his mother and a daughter to the disease. He had the test and the varying reactions of his family are a case study in the issues surrounding genetic testing. ‘When I was told I had a breast cancer gene, my eldest daughter, who has her own children, decided to have the test too,’ he says. ‘She was told she hasn’t got it. But my son, who has no children, and my youngest daughter both decided not to be tested. Although my youngest is concerned about breast cancer and gets herself checked out regularly, she says she’s comfortable at present and doesn’t want to find out something she might not be able to handle.’

Because the numbers involved are so small even men in a high risk family are not themselves considered by the medical profession to be at high risk. Given the probablities this makes sense but problems arise when doctors fail even to acknowledge the possibility. In a survey of male patients at one New York cancer centre, three quarters had had to seek a second opinion before their breast cancer was recognised. The American Esquire magazine recently carried an article about an Oregon man whose diagnosis took over ten years despite repeated consultations with some half a dozen doctors. The reason? He was a young man - just 36 when his disease was finally identified. 

This may be an extreme case but the general delay in diagnosing men is real enough. In the US diagnosis takes eighteen months longer for a man than a women. Ian Fentiman says: ‘some men wait until they have had the lump for sixteen months before consulting a doctor. The average delay is eight months. In women it’s less than one. This means we often see men at a later stage when the possible outcome is less good.’ In the UK, 72 per cent of men are still alive five years after getting breast cancer. Early diagnosis considerably improves survival chances. Perhaps, it’s no coincidence that all the male breast cancer survivors quoted here went to see their GPs within a month of finding the lump.

Sure it can be embarrasing. The male breast cancer patient In Taking Apart The Poco Poco is desperately worried about being a bloke with a woman’s disease. ‘I keep imagining what it would look like if they put it in the local rag’ he says. ‘Stockport Man Dies Of Breast Cancer. What a way to go. Sometimes I think that’s the worst part.’

He should worry. Apparently until relatively recently, the treatment for advanced male breast cancer in the USA was an orchiectomy, popularly known as castration. Gulp. These days it’s a far less sensitive part of the anatomy that’s removed. ‘Losing a breast is a shock, of course,’ says Ron House, 74. ‘But it’s nowhere near as traumatic as for a woman for whom it’s the loss of a part of her personality as well as part of her body. Men just wind up with a scar instead of a nipple and you soon get used to that.’ After all, as every teenager wonders: why do men have nipples anyway?