Confronted with a diagnosis of breast cancer a man may experience a miscellany of emotions: fear, anger, depression and guilt. Transfixing these problems is the question “Why me?” To deal effectively, sympathetically and knowledgably requires medical and nursing personnel who have experience with this rare disease. This is difficult to achieve in local hospitals so the best approach will be to set up national networks based around hubs of expertise. In the UK, with 350 new cases of MBC every year, 3 hubs would each oversee >100 cases annually.

It would not be necessary for patients to travel to the hub. Their cases would be discussed by the central multidisciplinary meeting together with a senior clinician from the referring hospital. The information needs of newly diagnosed cases could be met by an outreach services provided by appropriately trained Breast Care Nurses with support from selected MBC patients, either at home or in the local hospital. A major step towards reassuring worried patients would be the knowledge that they were being cared for by experienced professionals. Modern technology facilitates this without the need to travel.

The hub team would ensure central registration of all MBC together with a minimum data set so that epidemiological studies could be rendered more effective. As an example, there is evidence that statins may reduce the risk of recurrence in women with breast cancer [1, 2] and reduce mortality [3]. This needs examination in patients with MBC since there is an increasing drive to prescribe statins almost ubiquitously.

Once a treatment plan had been formulated and agreed both centrally and locally, the patient’s suitability for participation in randomised controlled trials should be considered. Additionally a central library of tissue and blood specimens would enable many pressing questions to be answered. This should be the first step in a serious approach to improving our understanding of MBC. To paraphrase a once popular British Prime Minister the answer is “Collaboration, collaboration, collaboration”. We have a potentially valuable resource of MBC which is at present underexploited. As an example of what can be achieved, geneticists have been at the forefront of collaboration in the investigation of MBC, yielding important data which indicate some of the differences between the disease in males and females. Another instance of very successful clinical research collaboration is the Danish Breast Cancer Cooperative Group (DBCG) which has carried out landmark randomised trials in a country with only 5½ million inhabitants [4]. In England and Wales, a large national case–control study is underway to investigate potential risk factors and genetics for breast cancer in men compared with their non-blood relatives as controls. Participants were accrued between 2007 and 2016 (REC reference 07/MRE01/1).

At the forefront of the problem is the stereotypical male psyche which seeks out and enjoys high-risk activities. This is not just a problem of downhill off piste skiing or sky-diving but there has been a hard-core of macho magnetism that draws men to smoke legally and illegally, overdrink and under-exercise. This is associated with a general feeling of invulnerability leading to avoidance of simple health precautions including contact with doctors [5]. In the Western world we are in the midst of an epidemic of obesity which on a systemic basis will increase the risk of malignancy including MBC. At a local anatomical level the incidence of gynaecomastia is increasing and this will delay diagnosis because the patient will not be aware of the cancer until it has emerged from the subcutaneous adipose blanket.

Health awareness cannot be forced upon men but the peer-group attitudes may be modified by sensitive health education in secondary schools. This may be of particular importance in sub-Saharan Africa where MBC represents ≥10% of all cases [6] . The possible explanation is immune deficiency from endemic hepatitis B which affects one in eight of the inhabitants [7].

Educational drives are likely to focus on reducing the population risks of obesity including maturity onset diabetes and cardiovascular disease together with encouragement not to start smoking. As a result education about rare diseases such as MBC is likely to be engulfed by the tsunami of information concerning more pressing and common problems. In any discussion of breast cancer it should be pointed out that males can be affected and the commonest symptom is a lump. Although approximately 80% of MBC patients present with a lump nevertheless as with FBC pain may be present in 10% of cases. As part of the counselling of BRCA mutation carriers the potential risk for male siblings should be discussed to target this high risk group [8].

Triple assessment should be standard in a man with a suspicious breast mass but can be omitted in asymptomatic individuals with gynaecomastia. In terms of resource allocation this will become a larger problem as more men develop pseudo-gynaecomastia as a result of the obesity epidemic. All MBC cases should have bilateral mammography with breast and axillary ultrasound to determine the extent of the malignancy. Core biopsy represents the standard of care for work-up of MBC since knowledge of receptor status and tumour grade are essential for optimal management [9]. This will enable the collection of a minimum dataset for all cases of MBC. Such an approach is essential for the planning and analysis of the large multicentre trials which it is hoped will affect a sea change in our understanding of MBC.

Studies from the US have clearly shown that socio-demographic differences are central to the worse outcome of poorer people so that to a major extent the solution may be political [10]. In the sum of human problems, MBC does not feature as an important concern but educational and economic improvements will lead to a greater likelihood of general health awareness. Seeking medical help with early symptoms that could herald malignant disease, including MBC, will enable earlier diagnosis with need for less extensive local and systemic therapy with a greater chance of long-term cure.

There is an inherent paradox which needs investigation. Genotypic males who take estrogens, often a part of management of their transsexuality, are at increased risk of breast cancer but approximately half of the tumours that develop are estrogen receptor negative [11, 12] . This suggests that there is an alternative pathway to the usual model of estrogen stimulation of estrogen sensitive tissue. Studies of hormone replacement therapy in females have demonstrated that the combination of estrogen and progestin increases FBC risk compared with estrogen alone [13]. Endocrine interventions require structured investigation in those centres specialising in gender realignment for transsexual individuals.

Another paradox concerns the lack of association between alcohol intake and incidence of MBC [14] whereas there is a clear relationship between daily intake and risk of FBC [15]. This is all the more surprising in that obesity is a significant side effect of increased alcohol intake and is also a major risk factor for MBC. Government interventions to reduce obesity have not so far met with great success. It is to be hoped that the impact of obesity on cancer risk will be understood eventually by the general public. If this happens they may then respond by behavioural change in a similar manner to the tobacco/lung cancer studies by giving up smoking. Self-interest is likely to be the major driver towards a more healthy lifestyle.

Very considerable effort has been expended to show that after matching for stage there is little difference in the outcome for women and men with breast cancer. Worthy though this toil may have been, it misses the more important point of the emerging differences between MBC and FBC. These are not congruent diseases and some of the asymmetric features are outlined in Table 12.1. Although mutations of BRCA1 are responsible for approximately 7% of FBC they are associated with only 1% of MBC. Conversely BRCA2 mutations are associated with 1 in 10 of MBC cases versus only 1 in 50 of FBC.