Breast Cancer Awareness and Screenings
October is Breast Cancer Awareness Month and for people who are assigned female at birth
there is a 13% risk that they will develop breast cancer at some point in their life (American
Cancer Society, n.d.). White individuals who were assigned female at birth have a higher rate of
developing breast cancer. However, Black individuals who were assigned female at birth have a
higher rate of mortality if they develop breast cancer (American Cancer Society, n.d.). Breast
cancer risk depends on anatomy, hormone exposure, surgery history, family history, and
available screening guidance. For individuals who identify as transgender or gender diverse, the
prevalence is not so easily understood. Everyone's transitioning journey looks different, but
what is still important to understand is the risk as well as screening guidelines based on your
transitioning journey.
Hormone Therapy and How it Relates to Risk
Hormone therapy can be an important part of an individual’s transition journey. But does taking
HRT increase or decrease your risk of breast cancer? Current research suggests that breast cancer risk varies depending on factors such as the hormones a person uses, how long they have used them, their age, family history, genetics, and whether they have had chest or breast surgery.
In transgender men, the reduced exposure to estrogen and progesterone appears to lead to an
overall decrease in potential risk of breast cancer relative to cisgender women (de Blok et al., 2019). However, it should be noted that data is limited due to limited studies looking at these
factors within this population, and there is not enough evidence to conclude that testosterone
itself protects against breast cancer.
For transgender women taking estrogen and progesterone, available research suggests that
breast cancer risk is higher than among cisgender men but remains lower than among cisgender women (de Blok et al., 2019). Some breast cancers are estrogen- and progesterone-receptor positive; however, there is not enough evidence to conclude that testosterone or medications that reduce estrogen exposure protect transgender men from developing these cancers. Breast cancer risk should instead be considered in the context of an individual’s anatomy, hormone exposure, surgical history, age, genetics, family history, and other individual risk factors.
Gender Affirming Surgery Impacting Risk
With individuals who are transgender and who have had breast augmentation done, implants and denser breast tissues could lead to more false positive rates for breast cancer screenings. The modality of screening can also change if transgender women have had a breast augmentation done. Breast cancer screening is usually done with a mammogram, however this can be painful for transgender women. So, the other modality that could be done would be an ultrasound and if anything is found to be abnormal, then your provider could do a mammogram for a follow-up (Deutsch, 2016).
For transgender men who have had a bilateral mastectomy, removal of both breasts, mammography may not be technically feasible with limited to no breast tissue. It is recommended that you talk with your provider about mammography, ultrasound, MRI screening, and monthly self-breast examinations. If anything abnormal is felt or seen on the ultrasound, then a follow-up imaging study may need to be done.
Screening Guidelines
Screening Guidelines depend on an individual’s anatomy, hormone exposure, surgical history,
age, and individual risk factors. If transgender women have been receiving hormone therapy
for more than five years and have had breast augmentation or have breast tissue formation
then the guidelines recommend starting at age 50 (Deutsch, 2016). However, for women who
are assigned female at birth the screening process starts at age 40 and I typically follow that
start time frame as well for my transgender women patients. The guidelines also state to do the
screening modality, either the mammogram or ultrasound, every two years after the individual
starts their screening. Conversations with your providers about over-screening can also be
important (Deutsch, 2016; American College of Radiology, 2021). It is also recommended to
discuss self-breast examinations in both transgender women and men, and if any abnormal
lumps or bumps are felt, to encourage them to speak to their healthcare provider about this.
The guidelines for transgender men and individuals who were assigned female at birth who have not have chest surgery or who have had breast reduction rather than bilateral mastectomy, breast cancer screening should generally follow current screening recommendations for people with comparable breast tissue and risk factors (Deutsch, 2016; American College of Radiology, 2021).
For transgender men who have had a bilateral breast mastectomy or chest masculinization
surgery, it is still important to discuss breast cancer screenings and determine if these individuals would like to do the ultrasound annually starting at 40 or continue with monthly self-breast exams.
Of last note it is imperative that transgender individuals know their family history. If there is a strong family history of breast cancer in either transgender men or women, then it is good for
the patient and/or provider to discuss whether genetic risk assessment or referral for genetic counseling and possible BRCA testing may be appropriate. This is testing done to see if the
individuals have a genetic disposition for potentially developing breast cancer (Deutsch, 2016).
Conclusion
With the prevalence of breast cancer being not thoroughly studied within the transgender
population it is important for both patients and providers to have active conversations about
individual risk, screening, and modalities. There are different modalities in terms of screening for breast cancer ranging from monthly self-breast examinations to mammograms. Screening
recommendations may differ based on anatomy, age, hormone exposure, surgical history,
family history, genetics, and other individual risk factors.
It is important for both patients and providers to understand their risks of breast cancer in relation to family history and hormone therapy and how this could potentially impact their risk for breast cancer as well as understanding when to start screening or having that conversation. It is also important to be aware of changes in breast or chest tissue and to talk with a healthcare provider about any new lump, skin or nipple change, or other concerning symptom. With early detection and open and honest communication, breast cancer can often be detected at an earlier stage and treated with a high success rate.
Remember to be open and honest with your provider and patients and remember to stay happy and healthy!
References:
American Cancer Society. (n.d.). Key statistics for breast cancer.
https://www.cancer.org/cancer/types/breast-cancer/key-statistics.html
de Blok, C. J. M., Wiepjes, C. M., Nota, N. M., van Engelen, K., Adank, M. A., Dreijerink, K. M. A., Barbé, E., Konings, I. R. H. M., & den Heijer, M. (2019). Breast cancer risk in transgender people
receiving hormone treatment: Nationwide cohort study in the Netherlands. BMJ, 365,
l1652. https://doi.org/10.1136/bmj.l1652
Deutsch, M. B. (2016, June 17). Screening for breast cancer in transgender women. UCSF
Gender Affirming Health Program. https://transcare.ucsf.edu/guidelines/breast-cancer-women