by Ashling O’Connor
The guidelines for breast cancer screening in the cis-female population are well defined. These clear guidelines and widespread availability of screening have led to the reduction in breast cancer by as much as 40% over the last three decades. When it comes to the transgender population the guidelines are less clear. A transgender man is an individual with a male gender identity but a female sex assigned at birth (female-to-male). A transgender woman is an individual with a female gender identity but a male sex assigned at birth (male-to-female). Both transgender men and women can develop breast cancer so it is our responsibility as providers to ensure that they are recieving the appropriate care and screening tests.
Gender affirming hormones are often prescribed, typically anti androgens and estrogens in trans women and testosterone in trans men. Surgical intervention includes breast augmentation and orchiectomy in trans women and subcutaneous mastectomy in trans men. It is important to note that from a breast cancer risk perspective that unlike an oncological mastectomy a portion of breast tissue will remain to achieve a better aesthetic. The risk of developing breast cancer is thus higher than in cis women who have undergone prophylactic mastectomies. Those individuals who choose not to undergo mastectomy remain at their previous risk of breast cancer but also are less likely to seek screening or regular checkups so physician awareness and guidelines is extremely important.
It is estimated that approximately 1.6% of Americans identity as transgender or non binary
This number increases to approximately 5.0% when the population under the age of 30 is examined.1 Given these numbers it is extremely important that we provide access and equitable healthcare to this population.
It is widely known that hormone replacement therapy in post menopausal women increases the risk of breast cancer. The same consideration could be applied to the transgender population taking gender affirming hormones such as estrogens and progesterone.
The good news is that increased awareness and new mammography guidelines are in development. The American College of Radiologists and Society of breast Imaging guidelines may be broadly summarized into three categories:
1. Transgender females (male–female) individuals >40 years old with a history of past or current hormonal use >5 years with average risk should be screened with annual mammograms. Those aged 20-30 with a higher than average risk of breast cancer due to family history, personal history, genetic predisposition or history of chest wall radiation should also be screened with annual mammograms.
2. Transgender females with no history of hormonal therapy or increased risk due to family history personal history, genetic predisposition or history of chest wall radiation do not need to be screened.
3. Transgender male (female – male) If they have mastectomies then no need for further screening other than clinical examinations regularly. If no top surgery or if the surgery left residual breast tissue then these individuals require annual age appropriate screening.