Case Report

Breast Cancer Risk Assessment and Screening in Transgender Patients

Transgender, non-binary, and intersex (TNBI) older adults experience significant disparities in sexual and reproductive healthcare. Utilizing data from 50 semi-structured individual interviews with TNBI older Americans, we examine how TNBI older adults experience and mitigate inequity in sexual and reproductive healthcare. We explore elders' negotiation of inequity through what we term resourcefulness strategies – tactical processes involving marginalized communities obtaining and utilizing resources to minimize inequalities within and beyond healthcare settings. Resourcefulness strategies differ from resiliency insofar as they directly acknowledge the need for social privilege, capital, and resources – on a community level – to overcome difficult situations (e.g., inequalities in healthcare), rather than drawing upon individual coping strategies alone. Our analysis reveals medical providers' lack of cultural competency with TNBI communities and older adults as primary drivers of TNBI older adults' experiences of inequity within sexual/reproductive healthcare settings. Consequently, TNBI older adults aimed to minimize inequity in sexual/reproductive healthcare through particular resourcefulness strategies. Specifically, we found a bifurcation in respondents’ strategies, wherein trans men engaged in health service avoidance while trans women and non-binary respondents engaged in health service self-advocacy. These strategies required respondents to assume primary responsibility for transforming (or avoiding) sexual/reproductive health services that were perceived as lacking or actively harmful. We argue that such approaches are neither effective nor structurally-sustainable for attaining older-age and TNBI-affirming, inclusive, and culturally-competent healthcare for TNBI older patients.

We report a case of breast cancer in a transgender woman (assigned male sex at birth, gender identity female) of Ashkenazi Jewish descent with BRCA2 mutation who had been taking cross-sex hormone therapy for 2 years. In addition to demonstrating breast cancer imaging findings and risk factors, this case draws attention to the paucity of research and data regarding breast cancer in transgender women and exemplifies the need for evidence-based consensus breast cancer screening recommendations for transgender women.

Les patients transgenres ont un risque sénologique mal connu malgré leur nombre et leur acceptation sociale croissante. Les données épidémiologiques sont généralement extrapolées par rapport à celles des femmes cisgenres et ménopausées. Les hommes effectuant une transition vers le genre féminin deviendront des femmes transgenres. Ces patients bénéficieront d’une hormonothérapie à base d’œstradiol afin d’acquérir des caractères sexuels secondaires féminins. L’incidence des néoplasies mammaires est similaire à celles des hommes cisgenres. L’âge de découverte de ces néoplasies est plus tardif et les cancers sont décelés à un stade plus évolué que chez les femmes cisgenres. Après 5 ans d’hormonothérapie et à partir de 50 ans, il est consensuel de leur faire bénéficier d’une mammographie de dépistage sans que le rythme soit clairement défini. Les femmes effectuant une transition vers le genre masculin deviendront des hommes transgenres. Ces patientes bénéficieront d’une hormonothérapie à base de testostérone afin d’acquérir des caractères sexuels secondaires masculins. Ces patientes peuvent bénéficier d’une mastectomie totale bilatérale avec greffe du mamelon appelée « top surgery ». En fonction des facteurs de risque familiaux, le chirurgien pourra demander un bilan préopératoire, restant à sa discrétion. Seul le dépistage biennal classique en l’absence de chirurgie mammaire est consensuel. Certaines sociétés savantes recommandent de réaliser un examen clinique annuel de la paroi thoracique si la « top surgery » a été réalisée. Les radiologues doivent connaître les spécificités liées à la prise en charge des patients transgenres pour permettre une prise en charge optimale.

Transgender patients have a poorly understood breast cancer risk despite their growing number and social acceptance. Epidemiological data are generally extrapolated from cisgender and postmenopausal women. A transgender woman is the result of the transition from male to female. These patients will benefit from hormone therapy based on estradiol in order to acquire female secondary sex characteristics. The incidence of breast neoplasia is similar to that of cisgender men. Nevertheless, it has later onset than for cisgender women and is often discovered at a more advanced stage. After the age of 50 years-old and after 5 years of hormone therapy, transgender women can benefit from a screening mammogram without a clearly defined rhythm. A transgender man is the result of the transition from female to male. These patients will benefit from hormone therapy based on testosterone in order to acquire male secondary sex characteristics. These patients can benefit from a total and bilateral mastectomy with nipple transplant called “top surgery”. Depending on family risk factors, the surgeon can prescribe a preoperative assessment, remaining at his discretion. Without breast surgery, only conventional biennial screening is admitted. Some guidelines recommend an annual clinical examination of the chest wall if “top surgery” has been done. Radiologists must know the specifics related to management of transgender patients for better care.

As the transgender community gains visibility and recognition, healthcare disparities have become more apparent. Reports estimate that 1–1.5 million people belong to this community in the United States. Despite efforts to become more inclusive, access to healthcare is challenging in a system built on a binary model that exacerbates gender dysphoria and on healthcare insurance schemes that do not cover gender affirmation therapy. Another large challenge is the paucity of scientific and medical knowledge when it comes to caring for the transgender community. More research to build knowledge is necessary to provide evidence-based quality care. In an attempt to bring guidance for gynecologic and breast cancer screening for the transgender male population, we conducted a review of the literature published in PubMed. Here, we present a review of the challenges, as well as guidelines for breast, uterus, and cervix screening for the transgender male population.