Table 2 Themes, sub-themes and codes

Navigating through a threat to masculinity and one’s existence

1. Emergence and awareness of a ‘foreign’ illness and threat to one’s existence

2. Coming to terms with a gendered disease

3. Opening up/ coming out of the illness closet

● Living with an exotic or women’s disease

● Threat to oneself and coming face to face with one’s mortality/ death

● Shock and needing emotional support at the cancer diagnosis

● Feeling like an outsider/ stigmatised as being the only male patient with breast cancer at the hospital/ gynaecological units

● Until diagnosis, most men did not know about MBC (which delayed the timing of seeking healthcare/ diagnosis)

● Left in the cold after receiving diagnosis of cancer

Navigating through treatment

1. Therapeutic interventions

2. Navigating through feminised treatment pathways

3. Living with the effects of care/ ongoing treatment

● Hair loss from chemotherapy

● Mastectomy scars

● Breast cancer treatment (and some procedures) was developed with women in mind. So, taking the same hormonal therapy medications such as Tamoxifen as females and its subsequent side effects such as hot flushes, sweating and decreased libido/ lowered sexual potency were considered frustrated

● Being treated as a woman going through treatment pathways designed for women

● Men with breast cancer felt health care practitioners did not know much about their disease and treatment regimen; some practitioners lacked sensitivity and did not take the patients seriously

● Difficulties with finding a doctor to treat them due to reimbursement issues (the GPs felt their specialty was women’s practice and did want to attend to the men with breast cancer)

● Generally, they were satisfied with the medical care; some felt the services and procedures at the hospital failed to consider their needs)

● Some men were unconsciously addressed as ‘Mrs’ in waiting rooms or in their letters

● General lack of male-specific psychosocial support and information tailored to their needs

● Some men or their wives had to persist before being referred to the consultant surgeon

● Living with mastectomy scars/ body image changes

● Feeling that exposure to environmental toxins had caused the cancer

● Questioning about the cause of the cancer

● Lack of information specifically about breast cancer

● Being put on medication originally prescribed for females with breast cancer (Tamoxifen)

● Postoperative support and advice were lacking

● Not surprised to be diagnosed with breast cancer, but the men were shocked at receiving a diagnosis of breast cancer as it is considered a gendered disease

● Some men disclosed to close family and friends and others did not disclose to anyone

● Not wanting sympathy or to be stigmatised

● Lack of awareness as perceived about breast cancer among men

● Feeling awkward while discussing sensitive issues

● Wishing their condition were called something else, rather than breast cancer

● Younger men affected by altered body image than older men

● General lack of information about breast cancer and the treatment process in males

● Most were generally not interested in talking to other men with other forms of cancers

● Participants did not describe delay in seeking healthcare

● Wives/ partners played a key role in pushing for early health seeking

● Men reacted stoically following breast cancer diagnosis

● Healthcare professionals were less sensitive and “matter of fact” attitude

● Not fully open about their diagnosis

● Some men were concerned about their appearance (some would stare at their scars; unable to remove their shirts during outdoor events)

● Disappointed at the lack of information on breast cancer specific to men

● Men showed pictures of females who had undergone mastectomy and not male mastectomy

● Majority of men would appreciate a chance to discuss with another man with breast cancer on basis

● Receiving the cancer diagnosis as a lightning strike

● Being scheduled for mammography or being told of having a lump led to feelings of being men with breasts

● Feeling dumbfounded with a cancer diagnosis and its location

● Feeling of having breasts, not only a chest

● Feeling like a freak because of the gendered status of the disease

● Living with visually disturbing mastectomy scars

● Concerns about the wound, but not the so significant gendered part

● Men concerned about their body image and upper-body mobility following affecting mastectomy

● Mastectomy re-sculptured their muscles necessitating a need to amend their masculinity

● Living with a disfigured chest from the scars

● Living with the side effects of the adjunct hormone therapy (sudden mood alterations, hot flushes, emotional explosions, PMS, altered sexual lives, loss of erections etc.)

● Younger men more concerned about their physical bodies than older men

● Managing breasts and masculinities

● Having troubles with scheduling mammography (feeling like the only male in the sorority)

● Embarrassing to interact with healthcare staff about MBC

● Feeling out of place/ alone at clinics

● Lonely process in coming to terms with the reality of the diagnosis/ having breasts

● Being the only man among women during rehabilitative care (some experienced positive experiences as they got the chance to share with the women)

● Feeling exotic and excluded from the group during the rehabilitative/ aftercare phase

● Not seen as gendered malignancies like testicular cancer which participants could lay a legitimate claim of ownership

● Giving the illness a gendered status

● Associating the illness more closely with femininity than masculinity

● Body image changes/ sexuality concerns

● Some surgical procedures following MBC impacted on their masculinity, and in some instances, their sexual orientation

● Public information regarding male breast cancer is scarce

● Distress because of living with inaccurate information on the disease and misunderstandings

● The experience of loss of libido and erectile dysfunction following tamoxifen therapy. This impacted on their masculinity

● Healthcare staff were excellent but were often unaware of the specific information and psychological needs of men

● Feelings of being marginalised in the clinics (as HCPs attempted to conceal them from the female clients by asking them to wait in other parts of the clinic or use alternate entry/ exit routes)

Coping and support systems

1. Active coping strategies

2. Family support

3. Support from healthcare providers and other support groups

● Healthcare staff were excellent but were often unaware of the specific information and psychological needs of men

● Some men experienced reluctance in sharing their unusual problem or disclosing their problem

● Trying to find the right name for the disease (chest cancer, cancer on the chest etc.)

● Support from wives, and family

● Receiving emotional support from wives, partners, and other female friends

● Attending support groups (although others were sceptical about joining)

● Other coping strategies included physical activity, acupuncture, psychosocial services at the hospital

● Unwilling to discuss MBC diagnosis with other family members/ close friends; but they did not feel embarrassed

● Need to speak to men with similar experience of MBC

● Although dealing with the disease had been difficult, younger men reported gaining new insights in life and changing their views and life priorities

● Amending or reformulating their masculinities (men with breasts and cancer, seeking emotional support from close friends and partners, opening up to others about their cancer experiences)

● Concealment a life-threatening cancer and its location to manage their sense of oddity

● Feeling lucky of having the cancer at a part not considered “vital”

● Mixed reactions of the physicians (some referred immediately, and others did not express suspicion about a cancer diagnosis/ wait and see attitude which led to late delays with diagnosis)

● Difficulties in accessing gynaecological care (rejection by some healthcare centres due to billing issues)

● Some men were satisfied with in patient care and did not differ from routine care; some men felt being in a special position such as receiving more attention from healthcare professionals whilst others did not feel comfortable with it as being the only male in a room for a procedure whereas the women were divided into the rooms