ArticleLiterature Review

Breast Cancer Screening, Management, and a Review of Case Study Literature in Transgender Populations

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Abstract

Because of a lack of uniform collection of gender identity data, population-level breast cancer statistics in the transgender community are unknown. With recent estimates that at least 0.6% (1 in every 167 people) of the U.S. population is transgender, guidance on breast cancer risk, screening, and management in this population is needed. Such guidance should examine modifications, if any, to recommendations in cisgender populations, taking into consideration any history of hormone therapy exposure or breast surgery. This article describes existing evidence on breast cancer incidence in transgender women and men, and attempts to make rational recommendations regarding the screening for and approach to managing breast cancer in transgender populations. Current data are mostly limited to case reports which are reviewed here. More prospective, population-level research is needed to better understand the risks and predictors of breast cancer in this population, as well as to better inform the most appropriate screening modality, age of starting screening, and interval. Ultimately, a risk score calculator similar to existing risk models such as the Gail score, as well as an approach to shared decision making that involves patient-centered perspectives, is needed to best guide practices in this area.

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... It is important to note that in transgender women, a comparatively lower cumulative lifetime estrogen exposure and lack of progesterone exposure may contribute to a lower breast cancer risk than seen in cisgender women. 26 However, transgender women have a higher prevalence (60%) of dense breast tissue, an independent risk for breast cancer, and increased rates of false-negative mammograms. 27,28 Routine screening mammography before the age of 50 has been shown not to decrease breast cancer mortality in cisgender women. ...
... For transgender women not beginning estrogen therapy until after age 50, it is not recommended to begin breast cancer screening until a minimum of 5 years of feminizing hormone use. 26 Because of the likely lower incidence of breast cancer in transgender women, screening mammography is recommended every 2 years. Clinical breast exams are controversial with some sources recommending them annually. ...
... 2 However, other sources recommend against routine clinical breast exams due to the common, but not concerning, symptoms of breast pain, tenderness, and nodularity associated with breast development in transgender women. 26 Breast implants may be associated with a delayed diagnosis. 30 In transgender women with breast implants, screening and diagnostic mammography, breast ultrasound, and magnetic resonance imaging (MRI) are all possible. ...
Article
As sex and gender are assigned at birth before gender identity development, many individuals experience feelings of discordance between their gender identity and their sex and gender assigned at birth. The transgender community has not been well understood by medical and mental health fields. As such, this marginalized and vulnerable community faces multiple barriers to receiving health maintenance and specialized care, both at the community and patient-specific level. Many transgender individuals undergo some form of transition to the gender that matches their gender identity. Transition efforts look different for each patient because gender and gender identity occur along a continuum. Transition may include social, hormonal, and/or surgical components. As providers are caring for transgender patients, it is imperative to understand where a patient is in their gender transition and how hormonal and/or surgical therapies affect their cancer risk and screening. The aim of this article is to describe appropriate cancer screening practices and important care considerations for the primary care physician and generalist gynecologist taking care of transgender individuals.
... Estrogen starts to encourage breast growth and body fat redistribution within 3-6 months, with full effects in 2-3 years and 2-5 years, respectively. 12 It is, therefore, warranted to at least wait a year after beginning estrogen before performing augmentation. Further increase in volume may occur after augmentation. ...
... Although there are no commonly agreed on breast cancer screening guidelines for trans females, University of Califor- nia, San Francisco has recommended that screening should not start before the age of 50 years and after the patient at least have been on exogenous hormones for 5-10 years. 12 Limitations of this study include that the measurements in the cis-female population were performed by different surgeons, and there may be variability in the measurement method. There was also significant variation in which preoperative measurements were taken for cis-patients, preventing the full cohort to be compared with the trans cohort for each preoperative measurement. ...
... As noted previously, estrogen begins to promote breast growth and body fat redistribution within 3-6 months, but its full effects are not seen for several years. 12 These circumstances produce a complexity in the patient population that is unparalleled by the cisgender group. ...
Article
Full-text available
Background: Gender confirming primary breast augmentation is becoming more common. The purpose of this study was to compare the demographic and anatomical differences in cis-female and trans-female populations. Methods: This was a retrospective analysis of trans-female patients and cis-female patients undergoing primary breast augmentation at a single institution. Analysis included patient demographics and preoperative chest measurements including sternal notch to nipple distance (SSN), breast width (BW), nipple to inframammary fold distance (N-IMF), and nipple to midline distance (N-M). Continuous variables were compared using independent t tests, and discrete variables were compared using Pearson’s χ2 tests. Results: Eighty-two trans-female and 188 cis-female patients undergoing primary breast augmentation were included. Trans-female patients were older (40.37 versus 34.07), more likely to have psychological comorbidities (50% versus 12.23%), and had a higher body mass index, 27.46 kg/m2 versus 22.88 kg/m2 (P = 1.91E-07), than cis-female patients. Cis-female patients most commonly had an ectomorph body habitus (52% versus 26%), whereas trans-female patients most commonly had an endomorph body habitus (40% versus 7%). Pseudoptosis or ptosis was more commonly seen in cis-female patients (P = 0.0056). There were significant differences in preoperative breast measurements including sternal notch to nipple distance, BW, and N-M between groups, but not in N-IMF. The ratio of BW/N-IMF was statistically significant (P = 2.65E-07 on right), indicating that the similarity in N-IMF distance did not adjust for the difference in BW. Conclusions: The trans-female and cis-female populations seeking primary breast augmentation have significant demographic and anatomical differences. This has implications for surgical decision-making and planning to optimize outcomes for trans-female patients.
... Numerous studies provide recommendations for which patients should undergo screening and when, as well as the ideal screening modality. 4,5,34 However, to our knowledge, no previous studies that compiled current breast cancer screening recommendations for all relevant patient populations in a single decision-making model. Furthermore, as Maglione et al 34 described, there is a lack of definitive data generated by randomized clinical trials to identify the best screening practices for this patient population. ...
... This recommendation furthers patient education and provides an additional element of sensitivity after what can often be an unexpected test result. 5 Additional recommendations are provided for patients with Klinefelter syndrome. 38 The recommendations summarized in Figure 1 are not evidence based; for this reason, if evaluated and assigned a rating by the US Preventive Services Task Force, these screening recommendations would most likely receive an "I" rating at this time, indicating insufficient evidence. ...
... However, these recommendations are based on currently accepted best practices by the professional physician societies that treat these patient populations. 5 These recommendations would provide a strong foundation for future randomized clinical trials to provide evidencebased screening guidelines in these patient populations. transgender patients. ...
... There is currently no reliable evidence to guide the screening of transmasculine patients after mastectomy. Annual chest wall exams, ultrasound and MRI have all been suggested but further research is needed before any recommendations for screening in this patient population can be considered evidence based (41)(42)(43)(44). The best recommendation for transmasculine patients at any point in their transition is, "Screen often and screen what you have" (43). ...
... There is no current data or recommendations on how (41). There has been one case report of a transgender female with a BRCA-1 mutation. ...
... Breast cancer screening guidelines are an evolving area of medicine, with respect to what age to begin screening and frequency, which is made more complicated in transgender women by a poor understanding of the effect of GAHT and the lack of reliable epidemiologic data. However, for transfeminine patients' mammograms are recommended every two years in patients over 50 and who have 5-10 years of GAHT treatments (41). All screening should be based on shared decision making, and patients and providers may want to start screening at an earlier age or shorter number of years of hormone exposure in patients with a significant family history. ...
Article
Over the last 50 years cancer mortality has decreased, the biggest contributor to this decrease has been the widespread adoption of cancer screening protocols. These guidelines are based on large population studies, which often do not capture the non-gender conforming portion of the population. The aim of this review is to cover current guidelines and practice patterns of cancer screening in transgender patients, and, where evidence-based data is lacking, to draw from cis-gender screening guidelines to suggest best-practice screening approaches for transgender patients. We performed a systematic search of PubMed, Google Scholar and Medline, using all iterations of the follow search terms: transgender, gender non-conforming, gender non-binary, cancer screening, breast cancer, ovarian cancer, uterine cancer, cervical cancer, prostate cancer, colorectal cancer, anal cancer, and all acceptable abbreviations. Given the limited amount of existing literature inclusion was broad. After eliminating duplicates and abstract, all queries yielded 85 unique publications. There are currently very few transgender specific cancer screening recommendations. All the guidelines discussed in this manuscript were designed for cis-gender patients and applied to the transgender community based on small case series. Currently, there is not sufficient to evidence to determine the long-term effects of gender-affirming hormone therapy on an individual's cancer risk. Established guidelines for cisgender individuals and can reasonably followed for transgender patients based on what organs remain in situ. In the future comprehensive cancer screening and prevention initiatives centered on relevant anatomy and high-risk behaviors specific for transgender men and women are needed.
... In particular, there is a need for larger observational studies, longer-term prospective studies, and clinical trials. Deutsch et al (34) recommend the development of a risk score calculator similar to the Gail score to best guide practices. ...
... Many of these guidelines also highlight the importance of considering other risk factors when tailoring an individualized screening program for a patient, such as deleterious genetic mutations such as that of the breast cancer gene (BRCA), genetic conditions such as Klinefelter syndrome, moderate obesity (body mass index >35), and a personal history of breast cancer. For example, the UCSF Center of Excellence for Transgender Health recommends that clinicians choose to reduce the age of onset of screening or increase the frequency of screening in patients with substantial family risk factors (34,36). ...
... A large subset of transgender men (men who were assigned to the female sex at birth) undergo hormone therapy while undergoing the genderaffirming process. The goals of hormone therapy are to induce masculinizing changes while minimizing feminine secondary sex characteristics (34). Testosterone is the mainstay of therapy, with common formulations including testosterone enanthate and cypionate delivered intramuscularly or subcutaneously (16). ...
Article
Transgender is the umbrella term for individuals whose gender identity and/or gender expression differs from their assigned sex at birth. With the rise in patients undergoing gender-affirming hormone therapy and gender-affirming surgery, it is increasingly important for radiologists to be aware of breast imaging considerations for this population. While diagnostic imaging protocols for transgender individuals are generally similar to those for cisgender women, screening guidelines are more variable. Currently, several professional and institutional guidelines have been created to address breast cancer screening in the transgender population, specifically screening mammography in transfeminine individuals who undergo hormone therapy. This article defines appropriate terminology with respect to the transgender population, reviews evidence for breast cancer risk and screening in transgender individuals, considers diagnostic breast imaging approaches, and discusses special considerations and challenges with regard to health care access and public education for these individuals. ©RSNA, 2019.
... After exclusions, 2260 trans women and 1229 trans men were included in this study (fig 1). The median age at start of hormone treatment in trans women was 31 years (interquartile range 23-41 years) and in trans men was 23 (interquartile range [19][20][21][22][23][24][25][26][27][28][29][30][31] years. The median person time in trans women was 13 (interquartile range 5-23, range 0-63) years and in trans men was 8 years (interquartile range 3-20, range 0-47) years. ...
... 26 breast cancer screening advise Current recommendations suggest that trans women and trans men who have not undergone mastectomy should be biennially screened with mammography from the age of 50 years and if they are using hormone treatment for more than five years. [27][28][29] After subcutaneous mastectomy, monitoring of trans men with mammography is not considered feasible owing to the minimal residual breast tissue, and therefore self examination is advised, although there is no evidence for effectiveness. 2 27 29 The absolute risk of breast cancer in transgender people is still low in this study, and, more importantly, is not increased compared with cisgender women. We believe therefore that awareness in both doctors and transgender people 30 is of more importance than the start of screening at a younger age or intensifying available screening, even though the median age at diagnosis in the current study was lower than in cisgender women. ...
... Rates of breast cancer are well described in cisgender women, with one in eight women experiencing a lifetime diagnosis of breast cancer. 1 However, the risk of developing breast cancer is not well established in individuals who identify as transgender men, two-spirit, nonbinary, or other gender expansive identities and were assigned female at birth (henceforth referred to with the umbrella term "transmasculine"). Several large cohort studies have demonstrated that transmasculine individuals may have a lower overall incidence of breast cancers than cisgender women. ...
... This is of particular importance, as transmasculine individuals, regardless of testosterone utilization or desire for mastectomy, face barriers to accessing comprehensive breast cancer screening, surveillance, and treatment, services that are often offered within gendered structures. 1 Given the relatively recent increase in cultural acceptance and financial accessibility through health insurance coverage, many transmasculine individuals may not have undergone gender-affirming mastectomy and retain natal breast tissue. 5 In those who develop breast cancer, these patients may desire gender-affirming top surgery in addition to oncologic treatment. ...
Article
Full-text available
Background: Transmasculine individuals may not have undergone gender-affirming mastectomy and retain natal breast tissue. Our center offers simultaneous oncologic mastectomy with gender-affirming reconstruction to patients who are diagnosed with breast cancer. This study is the first reported series of concurrent gender-affirming and oncologic mastectomies. Methods: A retrospective chart review of all patients undergoing gender-affirming mastectomy at a single institution from February 2017 to October 2021 was performed. Patients were included who had breast cancer diagnoses or pathologic lesions preoperatively. Demographic factors, comorbidities, surgical details, and oncologic history were collected. Both plastic surgery and breast surgery were present for the gender-affirming oncologic mastectomies. Results: Five patients were identified who presented for gender-affirming mastectomy in the context of breast pathologies. Average patient age was 50.2 ± 14.8 years, and no patients used testosterone at any time. Two (40%) patients had a prior breast surgery that included a breast reduction in one patient and breast conserving lumpectomies in another. Sentinel lymph node biopsies were performed in all patients. Only one patient had a positive sentinel lymph node and was subsequently referred for postoperative radiation and chemotherapy. No oncologic recurrence has been detected with 20.6 and 10.0 months of mean and median follow-up. Conclusions: When performed in a multidisciplinary and collaborative setting with breast surgeons and plastic surgeons, oncologic mastectomy can be performed safely while concurrently offering patients an aesthetic gender-affirming reconstructive outcome.
... Less than 1% of the population of the United States identifies themselves as transgender. This is likely under-reported to avoid social stigma and exclusion [2]. A member of the transgender community says, "There isn't a trans moment… It's just a presence where there was an absence. ...
... Click here to view linked References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 [2]. Based on information collected from the administration of major hospitals in Pakistan, a mammogram was never done on any transgender. ...
... Current guidelines recommend following breast cancer screening guidelines for transgender women on hormones. 19,44 Medical providers should seek to optimize cardiovascular and bone health for transgender patients by encouraging healthy eating and exercise and adequate vitamin D intake and treating hypertension, diabetes, dyslipidemias, and tobacco use. ...
... If they have had chest masculinization surgery (mastectomy), chest wall examinations as well as breast cancer screening should be discussed, as complete removal of breast tissue during surgery does not usually occur. 19,44 Screening for osteoporosis follows the same guidelines as for cisgender women. 42 ...
Article
Transgender people have a gender identity that differs from their sex assigned at birth. For many transgender individuals accessing gender affirming hormone therapy (GAHT) is an important and medically necessary step in their gender transition. Both feminizing and masculinizing regimens are safe when used within established hormone protocols and are associated with significant improvements in mental health outcomes, including reduction in depression, anxiety and gender dysphoria. Clinicians should be aware of the current best practice guidelines for initiating and maintaining patients on GAHT.
... After exclusions, 2260 trans women and 1229 trans men were included in this study (fig 1). The median age at start of hormone treatment in trans women was 31 years (interquartile range 23-41 years) and in trans men was 23 (interquartile range [19][20][21][22][23][24][25][26][27][28][29][30][31] years. The median person time in trans women was 13 (interquartile range 5-23, range 0-63) years and in trans men was 8 years (interquartile range 3-20, range 0-47) years. ...
... 26 breast cancer screening advise Current recommendations suggest that trans women and trans men who have not undergone mastectomy should be biennially screened with mammography from the age of 50 years and if they are using hormone treatment for more than five years. [27][28][29] After subcutaneous mastectomy, monitoring of trans men with mammography is not considered feasible owing to the minimal residual breast tissue, and therefore self examination is advised, although there is no evidence for effectiveness. 2 27 29 The absolute risk of breast cancer in transgender people is still low in this study, and, more importantly, is not increased compared with cisgender women. We believe therefore that awareness in both doctors and transgender people 30 is of more importance than the start of screening at a younger age or intensifying available screening, even though the median age at diagnosis in the current study was lower than in cisgender women. ...
Article
Full-text available
Objective To investigate the incidence and characteristics of breast cancer in transgender people in the Netherlands compared with the general Dutch population. Design Retrospective, nationwide cohort study. Setting Specialised tertiary gender clinic in Amsterdam, the Netherlands. Participants 2260 adult trans women (male sex assigned at birth, female gender identity) and 1229 adult trans men (female sex assigned at birth, male gender identity) who received gender affirming hormone treatment. Main outcome measures Incidence and characteristics (eg, histology, hormone receptor status) of breast cancer in transgender people. Results The total person time in this cohort was 33 991 years for trans women and 14 883 years for trans men. In the 2260 trans women in the cohort, 15 cases of invasive breast cancer were identified (median duration of hormone treatment 18 years, range 7-37 years). This was 46-fold higher than in cisgender men (standardised incidence ratio 46.7, 95% confidence interval 27.2 to 75.4) but lower than in cisgender women (0.3, 0.2 to 0.4). Most tumours were of ductal origin and oestrogen and progesterone receptor positive, and 8.3% were human epidermal growth factor 2 (HER2) positive. In 1229 trans men, four cases of invasive breast cancer were identified (median duration of hormone treatment 15 years, range 2-17 years). This was lower than expected compared with cisgender women (standardised incidence ratio 0.2, 95% confidence interval 0.1 to 0.5). Conclusions This study showed an increased risk of breast cancer in trans women compared with cisgender men, and a lower risk in trans men compared with cisgender women. In trans women, the risk of breast cancer increased during a relatively short duration of hormone treatment and the characteristics of the breast cancer resembled a more female pattern. These results suggest that breast cancer screening guidelines for cisgender people are sufficient for transgender people using hormone treatment.
... Variability in the anatomy of TGD bodies, use of gender-affirming hormones, and surgical interventions make determination of appropriate cancer screening programs a challenge for health care providers [10][11][12]. For example, a potential risk factor for cancer in the TGD population is gender-affirming hormonal treatment (HT), but the long-term impact of HT on health outcomes for TGD people is not clear, and not all TGD people elect to have HT. ...
... The prevalence of mammography among transgender women is low, with only 55% of transgender women up to date with screening recommendations compared to 70% of cisgender women [10]. Transgender men may continue to be at risk from breast cancer, even after having top surgery, or removal of the breasts [12]. Colorectal cancer (CRC) screening, which is a non-sex-based screening and not affected by gender-affirming interventions, provides a suitable screening comparison of screening behaviors between cisgender and TGD individuals. ...
Article
Full-text available
Introduction Approximately 1.4 million transgender and gender diverse (TGD) adults in the United States have unique health and health care needs, including anatomy-driven cancer screening. This study explored the general healthcare experiences of TGD people in the Washington, DC area, and cancer screening experiences in particular. Methods Twenty-one TGD people were recruited through word of mouth and Lesbian Gay Bisexual Transgender Queer (LGBTQ)-specific community events. Participant interviews were conducted and recorded via WebEx (n = 20; one interview failed to record). Interviews were transcribed using Rev.com . Two coders conducted line-by-line coding for emergent themes in NVivo 12, developed a codebook by consensus, and refined the codebook throughout the coding process. Member checking was conducted to ensure credibility of findings. Results Three major themes served as parent nodes: health-care seeking behaviors, quality care, and TGD-specific health care experiences. Within these parent nodes there were 14 child nodes and 4 grand-child nodes. Subthemes for health care seeking behaviors included coverage and costs of care, convenience, trust/mistrust of provider, and provider recommendations for screening. Subthemes for quality of care included professionalism, clinical competence in transgender care, care coordination, provider communication, and patient self-advocacy. Overall, transgender men were less satisfied with care than transgender women. Conclusions Results suggest a need for improved provider communication skills, including clear explanations of procedures and recommendations for appropriate screenings to TGD patients. Results also suggest a need for improved clinical knowledge and cultural competency. Respondents also wanted better care coordination and insurance navigation. Overall, these findings can inform health care improvements for TGD people.
... [38][39][40] Current guidelines for transgender men recommend chest-wall exams after mastectomy as well as a discussion of the risks and benefits of mammography. 15,41 Transgender men who have the capacity for pregnancy, that is, have a uterus and ovaries, can get pregnant while on testosterone 42 and may therefore need counseling about fertility and contraceptive options. 43 There are no standard guidelines addressing when to start screening for osteoporosis in transgender women; however, 1 author suggests starting after age 40 years if risk factors are present. ...
Article
There are approximately 1 million transgender and gender-diverse adults in the United States. Despite increased awareness and acceptance, they frequently encounter medical settings that are not welcoming and/or health care providers who are not knowledgeable about their health needs. Use of correct terminology, following best practices for name and pronoun use, and knowledge of gender-affirming interventions can create office environments that are welcoming to transgender clients. Health disparities faced by transgender patients that impact access to care include higher rates of mental health issues, substance use disorders, violence, and poverty. Transgender women are at greater risk for HIV acquisition and are less likely to achieve viral suppression compared with cisgender (nontransgender) individuals. Medical providers can facilitate HIV prevention efforts by offering pre- and postexposure prophylaxis to transgender patients at risk for HIV infection. Improving health outcomes requires attention to cultural competency and an understanding of lived experiences and priorities of transgender people.
... There is well-established evidence that estrogen hormone-replacement therapy (HRT) in postmenopausal women increases the risk of breast cancer [20]. Transgender women usually will have less lifetime exposure to estrogen and progesterone [21]. Therefore, evidence regarding breast cancer risk in transgender women is conflicting [22]. ...
Article
Gender-affirming surgery is becoming more accessible, and radiologists must be familiar with both terminology and anatomy following gender-affirming surgical procedures. This essay will review the most common gender-affirming genital surgeries, their post-operative anatomy, and common complications by providing intraoperative photographs, illustrations, and cross-sectional images. Routine radiologic imaging recommendations for transgender patients will also be reviewed.
... Two studies recommend population screening of FtM transsexuals according to current guidelines of natal women [55e58]. One study additionally recommends shared decisionmaking in order that FtM transsexuals can decide together with their physicians if they need screening, after having received information about the harms and benefits of screening [59]. Another study additionally recommends screening transsexuals with a history of five years of hormone therapy [60]. ...
Article
Full-text available
BACKGROUND: Female-to-male (FtM) transsexuals may use testosterone therapy for masculinization, which potentially influences the risk of breast cancer development. Guided by our case report, we aimed to investigate the evidence regarding the risk of testosterone therapy on breast malignancy in female-to-male transsexuals and evaluate breast cancer screening in this subgroup. METHODS: We conducted a systematic literature search according to the PRISMA checklist in June 2020 in PubMed/MEDLINE and Ovid/EMBASE. Reference lists of included articles were screened to find additional articles that met the inclusion criteria. All cohort studies and case reports evaluating breast cancer in FtM transsexuals after testosterone therapy were included. RESULTS: We found 23 cases of FtM transsexuals who developed breast cancer after testosterone therapy, including our own case. Moreover, we evaluated ten retrospective cohort studies investigating breast malignancy in the transsexual population. The cohort studies showed no elevated risk in FtM transsexuals compared to natal women. Including our own case, nine cases were described in which breast malignancy was incidentally found during routine histological examination after mastectomy. High-level evidence for a correlation between testosterone therapy and breast malignancy is missing. CONCLUSION: Few cases are described of FtM transsexuals with breast malignancy. However, cases such as these make physicians aware of the possibility of breast cancer in FtM transsexuals. Radiological screening of FtM transsexuals for breast cancer prior to mastectomy and histological screening of the mammalian tissue after mastectomy should be considered; physicians should decide together with every individual FtM transsexual if screening is necessary.
... Although there is a paucity of data regarding breast cancer incidence in transgender women, a recent update of The Netherlands cohort reported an elevated breast cancer risk in transgender women, compared to reference cisgender males, but below that of cisgender women (24). Malignancies detected by screening mammography in transgender women are rare (25); one cancer in a transgender woman was detected by screening mammography (16). A palpable carcinoma arising in a silicone granuloma in a cisgender woman with free silicone injection has also been reported (26). ...
Article
Full-text available
Objective To define MRI features of free liquid silicone injection (FLSI) of the breast in transgender women considering surgical management. Methods This study was IRB–approved. MRI images from transgender women with FLSI imaged between 2009 and 2019 were reviewed. Presence and location of fibrotic masses (FMs) in the breast(s) and pectoralis muscle and patterns of granulomas were correlated with clinicopathologic findings. Background enhancement was quantified. Comparisons were performed using two-tailed Fisher exact and Student’s t test. Results Of 21 transgender women with FLSI (mean age 46.8 years), 13/21 (61.9%) had a dominant FM measuring over 4 cm; these were limited to breast and pectoralis in 6/21 (28.6%), breast in 9/21 (42.9%), and pectoralis only in 2/21 (9.5%). Four of 21 patients (19.0%) had no FMs, and 4/21 (19.0%) had masses under 4 cm. Mean size of the dominant FM was 7.4 cm (range 4–12 cm). FMs were enhancing in 5/13 (38.5%) and contained T2 high signal granulomas in 8/13 (61.5%). While 18/21 (85.8%) of cases showed mild to moderate overall background enhancement, the majority 7/13 (61.5%) of dominant FM were non-enhancing. About half of cases (11/21, 52.4%) had diffuse foci, and half (10/21, 47.6%) had diffuse foci and masses throughout the breast and pectoralis muscle. These foci and masses displayed T2 high signal in 13/21 (61.9%). There were no occult carcinomas observed. Conclusion MRI performed on symptomatic FLSI patients considering surgical treatment is helpful in assessing the extent of silicone infiltration and fibrotic reaction of the breast and pectoralis muscle.
... However, it is important to expand knowledge about the risks involved in these treatments, because, although the literature is limited, there are case reports of 'BREAST-CANCER' in transgender population [69]. It is necessary to explore the hormonal implications of the treatments carried out by trans people, in order to understand the interaction between hormone therapy and breast cancer in this population, as there is evidence that, in cisgender women, estrogen is related to the development of the disease [70]. ...
Preprint
Gender and identity issues permeate society as a whole. Therefore, the matters involving transgender individuals should be analised in order to understand the difficulties experienced by this population and the social practices implemented. In this sense, the objective of this study was to investigate the strategic themes and their evolution in relation to the theme. For this, a bibliometric performance and network analysis (BPNA) was carried out with the existing data in the Web of Science database between 1954 and march 2021. Twenty-three thousand and four hundred and seventy-one (23,471) articles were identified, which were included in the SciMAT software to perform a bibliometric analysis, resulting in the graph of the thematic evolution structure and the strategic diagram, in which 8 motor themes and a cross-cutting theme of great magnitude are highlighted, which are discussed in depth. The results show the relation between the transgender theme and gender, identity, sexual orientation, hormone therapy and gender-affirming surgery. It is concluded that, despite the large number of associated researches, some areas of study are still incipient, such as the inclusion of transgender people in the formal labor market and in the prison context, thus opening field for further studies.
... As a result, most trans women will undergo demasculinization and feminization through hormonal and surgical treatments [6]. Hormone therapy is known to increase fat deposition at the waist, and to a lesser extent, promote breast development for up to 5 years after therapy initiation [10,12]. Unfortunately, breast growth can remain limited to the effect of estrogen therapy alone and a majority of trans women will seek to undergo breast augmentation to achieve a gender-congruent chest [11,18,19]. ...
Article
Full-text available
Background The morphometric results after breast augmentations are generally understood to be clinically different between trans(gender) and cis(gender) women. The objective of this study was to establish these morphometric differences between the augmented breasts of trans and cis women and their implications for preoperative planning and expectation management of trans women. Methods A single-center, observational cross-sectional study was conducted. Three-dimensional images (VECTRA) of the chest were taken and used to measure preset morphometric parameters. Subsequently, several proportional morphometric outcome variables were calculated. We compared body, breast, and nipple dimensions and their interdependence between trans and cis women. The main outcome sets were (1) the relative dimensions of the chest, (2) the position of the breasts relative to the chest, (3) and the position of the nipple relative to the breast and nipple size. Results A total of 22 transgender and 22 cisgender women were included. The results showed that the breasts of the trans women were positioned more cranial. Furthermore, the nipple-areola complexes (NAC) were significantly smaller and positioned relatively more latero-cranial on the breasts. Conclusions Morphological characteristics of augmented breasts differ significantly between trans and cis women. The results of this study identified distinct differences between the augmented breasts of trans and cis women. Because of the apparent differences in results, surgical considerations, expectation management, and shared decision-making should play an even more pronounced role in breast augmentations in trans women. Level of evidence: Level III, risk/prognostic study.
... Breast cancer is the most common cancer compromising the quality of life and psychological health of women [1]. Its treatment efficiency presents obvious enrichments as the medical techniques advance with years [2]. ...
Article
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Objective: To explore the application of professional whole-process case management during nursing in patients with triple-negative breast cancer. Methods: This study recruited 60 patients with triple-negative breast cancer who were diagnosed and treated at Department of Breast Surgery in our hospital assessed for eligibility between June 2018 and June 2020, and we assigned them at a ratio of 1 : 1 via the random number table method to receive either general nursing (control group) or professional whole-process case management plus general nursing (observation group). We analyzed and evaluated the hospitalization, the indwelling time of drainage tube, complications, recovery, quality of life, posttraumatic growth, and nursing satisfaction between these two groups at registration, discharge, and the sixth month after surgery, respectively. Results: Professional whole-process case management achieved a shorter duration of drainage tube placement and hospitalization and a lower incidence of postoperative complications versus general nursing (P < 0.05). Moreover, the observation group had got better recovery (P < 0.05) and a better quality of life at discharge and 6 months after surgery (P < 0.05). Professional whole-process case management obtained higher scores of posttraumatic growth and higher nursing satisfaction versus general nursing (P < 0.05). Conclusion: Whole-process case management promotes the postoperative recovery of patients with triple-negative breast cancer and shortens the duration of drainage tube indwelling and hospitalization, which lowers the incidence of postoperative complications, improves their quality of life, and enhances nursing satisfaction.
... In transwomen, based on the current knowledge and the incidences described above, it seems reasonable to refer transwomen to participate in the population screening for breast cancer in the same schedule as cisgender women. 61,62 The need for screening for prostate cancer has been extensively studied in cisgender men. Although screening induces a slight reduction in prostate cancer-related mortality, it has also many disadvantages because of the relatively high false-positive rate. ...
Article
Gender-affirming hormonal treatment (HT) in transgender people is considered safe in general, but the question regarding (long-term) risk on sex hormone-related cancer remains. Because the risk on certain types of cancer differs between men and women, and some of these differences are attributed to exposure to sex hormones, the cancer risk may be altered in transgender people receiving HT. Although reliable epidemiologic data are sparse, the available data will be discussed in this article. Furthermore, recommendations for cancer screening and prevention will be discussed as well as whether to withdraw HT at time of a cancer diagnosis.
Chapter
Transgender and gender non-binary people have become more visible and accepted in society, however, their medical needs are frequently unmet. Primary care medical providers often lack knowledge about how to provide appropriate and culturally competent health care, both transition-related care as well as preventive care services. This chapter provides guidance to the medical provider on how to apply gender- and anatomy-based primary care recommendations to patients of transgender experience.
Article
Transgender men or Female-to-Male (FtM) patients' risk of breast cancer and screening recommendations remain unclear. The objective of this study is to perform a systematic review of the literature and document all reported cases of FtM breast cancer as well as provide research recommendations. Following PRISMA guidelines, MEDLINE, ProQuest, PubMed, and Cochrane Database of Systematic Reviews were searched from inception until September 15, 2016. Screening and data extraction were performed in duplicate by two independent reviewers (RH and JS). Study quality was assessed using a component-based system. Study characteristics, patient demographics, breast cancer characteristics, presentation and management are reported. Eight articles met inclusion criteria representing 17 transgender men with breast cancer. Median age at diagnosis was 44.5 years. Breast cancer types included: 8 invasive ductal carcinomas, two tubular carcinomas and seven unrecorded. Twelve of the 14 known hormone status tumours were estrogen receptor positive (85.7%), of which nine were also progesterone positive. The most common was breast lump (n = 6) and four patients had local regional or distant disease at presentation. Management was reported for ten patients: six patients underwent mastectomy (60.0%), three radiation (30.0%), and five chemotherapy (50.0%). Breast cancer is present in transgender men and the risk is dependent on top surgery; those with top surgery appear to be lower risk than natal females. More longitudinal studies and better population data are required to contribute to evidence-based screening recommendations.
Article
Purpose: To evaluate transgender patient care, gender inclusivity, and transgender health-related policies at breast imaging facilities across the United States. Methods: A survey on breast imaging facilities' policies and practices regarding transgender care was distributed to the membership of the Society of Breast Imaging, consisting of approximately 2,500 breast radiologists across the United States. The survey was conducted by e-mail in January 2018. Results: There were 144 survey respondents. Responses showed that 78.5% of facilities have gender-neutral patient bathrooms, 9.0% have a separate waiting area for transgender patients, and 76.4% do not have dominant pink hues in their facilities, although 54.2% have displays with female gender content. Also, 58.0% of intake forms do not ask patients to provide their gender identity, although 25.9% automatically populate with female phrases. Within the electronic health record, 32.9% lack a distinct place to record patients' preferred names and 54.9% lack a distinct place to record patients' gender pronouns. The majority (73.4%) do not have explicit policies related to the care of transgender patients. Only 14.7% of facilities offer lesbian, gay, bisexual, and transgender training. Conclusion: Our national survey demonstrates that many breast imaging facilities do not have structures in place to consistently use patients' preferred names and pronouns, nor provide inclusive environments for transgender patients. All breast imaging facilities should recognize the ways in which their practices may intensify discrimination, exclusivity, and stigma for transgender patients and should seek to improve their transgender health competencies and foster more inclusive environments.
Article
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.
Article
Resumen El término «transgénero» hace referencia a las personas que experimentan su identidad de género de manera diferente del género asignado en el nacimiento. La glándula mamaria representa un claro signo de feminidad e identidad corporal, por lo que su tratamiento adquiere especial relevancia tanto en varones como en mujeres transgénero. Los tratamientos de reasignación de género (hormonales o quirúrgicos) afectarán directamente al tejido glandular mamario, lo que puede afectar al riesgo de presentar un cáncer de mama y modificar así los procesos diagnósticos y terapéuticos. Se realiza en este estudio una revisión y resumen de la literatura científica más relevante sobre este campo, abordando los aspectos clínicos referentes al diagnóstico y el tratamiento de la enfermedad mamaria en pacientes transgénero.
Chapter
Gender-affirming surgeries are increasingly common in the United States. For many transgender and gender nonbinary (TGNB) patients, gender-affirming surgery is a critical aspect of their overall health and wellness, with a significant impact on mental health and social functioning. Primary care clinicians are in a unique position to guide TGNB patients seeking gender-affirming surgery. This chapter provides an overview of the preoperative assessment and perioperative management for the most common gender-affirming surgeries, from the perspective of a primary care clinician.
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In the United States, there are approximately one million transgender adults. Although not all transgender people opt to undergo gender-affirming medical or surgical interventions, a large national survey (The US Trans Survey) that included approximately 28,000 transgender and gender nonbinary participants indicated that 42% of transgender men, 28% of transgender women, and 9% of gender non-binary individuals had undergone at least one transition-related surgery. Over half of the individuals surveyed wanted to have a transition-related surgery in the future. Due to increased insurance coverage and better access to qualified surgeons, primary care providers are more likely to encounter patients seeking these procedures. The goal of this chapter is to provide direction to primary care providers who may be caring for transgender people who have undergone gender affirming surgeries, including an understanding of common postoperative concerns, serious complications and future preventive care needs.
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In the United States, at least 1.4 million adults identify as transgender. Despite growing national awareness, the transgender population experiences disparities in breast care access and breast health outcomes. One of the challenges of breast care delivery to transgender patients is the lack of evidence-based screening guidelines, which is likely partly due to the infrequency of transgender breast cancer cases. Several gender-affirming hormonal and surgical interventions are available that impact the imaging appearance of the breasts and the risk of breast cancer. Breast imaging radiologists should be familiar with the imaging appearance of expected findings and potential complications following gender-affirming interventions. It has been shown that the incidence of breast cancer in transgender women is higher than in natal males but still lower than in natal females, implying that estrogen supplementation confers an increased breast cancer risk. It is proposed that transgender women follow the screening guidelines for natal females if they have risk factors for breast cancer and received hormone therapy for > 5 years. However, further research is necessary, especially in transgender women who have no risk factors or received hormone therapy for ≤ 5 years. The breast cancer risk of presurgical transgender men is considered equivalent to that of natal females, but the risk markedly decreases following bilateral mastectomy. It is proposed that transgender men follow the screening guidelines for natal females if they have any preserved breast tissue, or that they undergo annual chest wall and axillary physical exam if they are status post bilateral mastectomy.
Article
Female transgender (male to female) is an individual assigned male sex at birth born but who identifies itself and desires to live as female. To achieve and maintain these characteristics, sometimes, it is necessary to undergo hormone therapy and/or surgical treatment. Benign lesions have been described including: fibroadenoma, lobular hyperplasia, pseudoangiomatous stromal hyperplasia, myofibroblastoma, angiolipoma and benign prosthesic reactions. And malignant pathology such as: ductal carcinoma in situ, Paget's disease, infiltrating carcinoma of non-special type (ductal, NOS), secretory adenocarcinoma, malignant phyllodes tumor and breast implant associated anaplastic large cell lymphoma. The described cases of each of these entities are reviewed. In conclusion, hormonal action or prosthesis implantation in female transgender can lead to associated pathologies in the mammary gland that follow a similar pattern to that found in the male breast. Although breast cancer is less frequent than in cisgender women, gynecological control or screening is recommended by some associations.
Article
Résumé 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.
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Vaginoplasty is the most common genital surgery performed for gender affirmation. Annually, there are more than 3000 performed each year. Vaginoplasty is a safe, reliable technique for performing genital transition in transgender female patients. Penile inversion vaginoplasty is the most common technique used today, although there are several other methods of vaginoplasty: penile inversion, visceral interposition, and pelvic peritoneal vaginoplasty. Overall, outcomes are excellent. It is recommended surgeons follow the World Professional Association for Transgender Health (WPATH) guidelines for determining who is a candidate for surgery. There are no absolute contraindications to vaginoplasty, only relative contraindications that include active smoking and morbid obesity. Important but rare complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula. When performed correctly in appropriately selected patients by expert surgeons, this is a rewarding operation for both patient and surgeon.
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The oncologic care of the transgender patient is an area of increasing interest as this patient cohort continues to grow. Caring for these patients may be challenging due to limited literature on this topic and a lack of standard screening recommendations. It is critical that providers have a thorough knowledge of the transgender patients’ surgical and medical history related to the affirmation process to guide their care. The following chapter describes the known oncologic concerns in these patients based on the limited available literature.
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There remain significant gaps in the evidence-based care of patients undergoing gender-affirming mastectomy with regard to implications for breast cancer development and screening. The current clinical evidence does not demonstrate an increased risk of breast cancer secondary to testosterone therapy in transgender patients. Gender-affirmation mastectomy techniques vary significantly with regard to the amount of residual breast tissue left behind, which has unknown implications for the incidence of postoperative breast cancer and need for screening. Subcutaneous mastectomy should aim to remove all gross breast parenchyma, although this is limited in certain techniques. Tissue specimens should also be routinely sent for pathologic analysis. Several cases of incidental breast cancer after subcutaneous mastectomy have been described. There is little evidence on the need for or types of postoperative cancer screening. Chest awareness is an important concept for patients that have undergone subcutaneous mastectomies, as clinical examination remains the most common reported method of postmastectomy malignancy detection. In patients with greater known retained breast tissue, such as those with circumareolar or pedicled techniques, consideration may be given to alternative imaging modalities, although the efficacy and cost-utility of these techniques must still be proven. Preoperative patient counseling on the risk of breast cancer after gender-affirming mastectomy in addition to the unknown implications of residual breast tissue and long-term androgen exposure is critical. Patient awareness and education play an important role in shared decision-making, as further research is needed to define standards of medical and oncologic care in this population.
Article
Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.
Article
Background Adherence to screening guidelines among transgender and non-binary (TGNB) populations is not well studied. This study examines breast cancer screening patterns among TGNB patients at an urban academic medical center.Methods Demographic information, risk factors, and screening mammography were collected. Mammography rates were calculated in populations of interest according to national guidelines, and mammogram person-years were also calculated. Univariate and multivariate logistic regression was performed.ResultsOverall, 253 patients were analyzed: 193 transgender women and non-binary people designated male at birth (TGNB DMAB) and 60 transgender men and non-binary people designated female at birth (TGNB DFAB). The median (interquartile range) age was 53.2 years (42.3–62.6). Most patients had no family history of breast cancer (n = 163, 64.4%) and were on hormone therapy (n = 191, 75.5%). Most patients where White (n = 164, 64.8%), employed (n = 113, 44.7%), and had public insurance (n = 128, 50.6%). TGNB DFAB breast screening rates were low, ranging from 2.0 to 50.0%, as were TGNB DMAB screening rates, ranging from 7.1 to 47.6%. The screening rates among the TGNB DFAB and TGNB DMAB groups did not significantly differ from one another. Among TGNB DFAB patients, univariate analyses showed no significant predictors for mammography. Among TGNB DMAB patients, not being on hormone therapy resulted in fewer odds of undergoing mammography. There were no significant findings on multivariate analyses.Conclusion Mammography rates in the TGNB population are lower than institutional and national rates for cisgender patients, which are 77.3% and 66.7–78.4%, respectively. Stage of transition, organs present, hormone therapy, and risk factors should be considered to guide screening.
Article
Sexual and gender minorities (SGM) include persons identifying as lesbian, gay, bisexual, transgender/non-binary, and queer experience a greater cancer burden than their heterosexual or cisgender counterparts. Access to cancer care includes prevention and early detection, however despite known increased risk for various malignancies among SGM individuals, cancer screening rates remain low. This commentary outlines disparities in cancer screening for SGM individuals and provides the current evidence-based screening guidelines for these patients.
Article
Transgender men and women experience an incongruity between their assigned sex at birth and their identified gender. Gender dysphoria is defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) as clinically significant distress or impairment resulting from misalignment in assigned and experienced gender. Transgender people have a history of negative experiences in health care and efforts should be made to create a welcoming environment through staff training, gender neutral restrooms, and gender inclusive electronic medical record systems. Transgender men and women face unique preventive health concerns in areas of metabolic screening, cancer screening, immunizations, and anticipatory guidance secondary to cross-sex hormone therapy, gender confirming surgical procedures, and certain high-risk behaviors. Here, the available data are reviewed and suggested best practices are outlined to optimize the preventive health for this patient population.
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While rare compared to female breast cancer the incidence of male breast cancer (MBC) has increased in the last few decades. Without comprehensive epidemiological studies, the explanation for the increased incidence of MBC can only be speculated. Nevertheless, one of the most worrying global public health issues is the exponential rise in the number of overweight and obese people, especially in the developed world. Although obesity is not considered an established risk factor for MBC, studies have shown increased incidence among obese individuals. With this observation in mind, this article highlights the correlation between the increased incidence of MBC and the current trends in obesity as a growing problem in the 21st century, including how this may impact treatment. With MBC becoming more prominent we put forward the notion that, not only is obesity a risk factor for MBC, but that increasing obesity trends are a contributing factor to its increased incidence.
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Breast carcinoma rarely occurs in cases of foreign body granulomas following liquid silicone injection. Although the Food and Drug Administration (FDA) banned the use of all silicone injection products in 1992, liquid silicone injection for breast augmentation continues to be performed illegally. We herein report a case of breast carcinoma following liquid silicone injection in a 67-year-old female. A total of 45 years after liquid silicone injection, the patient had felt a breast mass in the right breast. Mammography showed a smooth mass that retracted the right nipple. Due to the presence of a marked acoustic shadow caused by the granulomas, evaluating the mass on ultrasonography was difficult. However, magnetic resonance imaging (MRI) showed a lobulated mass under the right nipple. The mass exhibited low signal intensity (SI) on T1-weighted images and intermingled high and low SI on T2-weighted images. Heterogeneous early enhancement with central low intensity was noted on dynamic contrast-enhanced MRI. Several oval-shaped low SI structures in the adipose tissue and disruption of the pectoralis major muscle were also observed. We diagnosed the patient with invasive ductal carcinoma based on a stereotactic-guided Mammotome® (a vacuum-assisted biopsy system manufactured by DEVICOR MEDICAL JAPAN, Tokyo, Japan) biopsy and subsequently performed mastectomy and axillary lymph node dissection (with a positive result for the sentinel node biopsy). Histologically, invasive ductal carcinoma was observed in the silicone granuloma. The development of foreign body granulomas following breast augmentation usually makes it difficult to detect breast cancer; thus, various devices are required to confirm the histological diagnosis of breast lesions. The stereotactic-guided Mammotome® biopsy system may be an effective device for diagnosing breast cancer developing in the augmented breast.
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Transgender (TG) persons often receive, or self-treat, with cross-sex hormone (CSH) treatments as part of their treatment plans, with little known about their incidence of breast cancer. This information gap can lead to disparities in the provision of transgender health care. The purpose of the study was to examine the incidence of breast cancer in the largest North American sample of TG patients studied to date to determine their exposure to CSH, incidence of breast cancer, and to compare results with European studies in transsexual populations. We used Veterans Health Administration (VHA) data from 5,135 TG veterans in the United States from 1996 to 2013 to determine the incidence of breast cancer in this population. Chart reviews were completed on all patients who developed breast cancer. Age-standardized incidences of breast cancer from the general population were used for comparison. Person-years of exposure to known CSH treatment were calculated. Ten breast cancer cases were confirmed. Seven were in female-to-male patients, two in male-to-female patients, and one in a natal male with transvestic fetishism. Average age at diagnosis was 63.8 (SD = 8.2). 52 % received >1 dose of CSH treatment from VHA clinicians. All three males presented with late-stage disease were proved fatal. The overall incidence rate was 20.0/100,000 patient-years of VHA treatment (95 % CI 9.6-36.8), irrespective of VA CSH treatment. This rate did not differ from the expected rate in an age-standardized national sample, but exceeded that reported for smaller European studies of transsexual patients that were longer in duration. Although definitive conclusions cannot be made regarding breast cancer incidence in TG veterans who did or did not receive VA CSH due to the sample size and duration of observation, it appears that TG veterans do not display an increase in breast cancer incidence. This is consistent with European studies of longer duration that conclude that CSH treatment in gender dysphoric patients of either birth sex does not result in a greater incidence than the general population.
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Introduction: Transsexual people receive cross-sex hormones as part of their treatment, potentially inducing hormone-sensitive malignancies. Aim: To examine the occurrence of breast cancer in a large cohort of Dutch male and female transsexual persons, also evaluating whether the epidemiology accords with the natal sex or the new sex. Main outcome measure: Number of people with breast cancer between 1975 and 2011. Methods: We researched the occurrence of breast cancer among transsexual persons 18-80 years with an exposure to cross-sex hormones between 5 to >30 years. Our study included 2,307 male-to-female (MtF) transsexual persons undergoing androgen deprivation and estrogen administration (52,370 person-years of exposure), and 795 female-to-male (FtM) subjects receiving testosterone (15,974 total years of exposure). Results: Among MtF individuals one case was encountered, as well as a probable but not proven second case. The estimated rate of 4.1 per 100,000 person-years (95% confidence interval [CI]: 0.8-13.0) was lower than expected if these two cases are regarded as female breast cancer, but within expectations if viewed as male breast cancer. In FtM subjects, who were younger and had shorter exposure to cross-sex hormones compared with the MtF group, one breast cancer case occurred. This translated into a rate of 5.9 per 100,000 person-years (95% CI: 0.5-27.4), again lower than expected for female breast cancer but within expected norms for male breast cancer. Conclusions: The number of people studied and duration of hormone exposure are limited but it would appear that cross-sex hormone administration does not increase the risk of breast cancer development, in either MtF or FtM transsexual individuals. Breast carcinoma incidences in both groups are comparable to male breast cancers. Cross-sex hormone treatment of transsexual subjects does not seem to be associated with an increased risk of malignant breast development.
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The incidence of breast carcinoma following prophylactic mastectomy is probably less than 2%. We present a 43-year-old female to male transsexual who developed breast cancer 1 year after bilateral nipple- sparing subcutaneous mastectomy as part of female to male gender reassignment surgery. In addition to gender reassignment surgery, total abdominal hysterectomy with bilateral salpingo-oophorectomy (to avoid the patient from entering menopause and to eliminate any subsequent risk of iatrogenic endometrial carcinoma), colpocleisys, metoidioplasty, phalloplasty, urethroplasty together with scrotoplasty/placement of testicular prosthesis and perineoplasty were also performed. Before the sex change surgery, the following diagnostic procedures were performed: breast ultrasound and mammography (which were normal), lung radiography (also normal) together with abdominal ultrasound examination, biochemical analysis of the blood and hormonal status. According to medical literature, in the last 50 years only three papers have been published with four cases of breast cancer in transsexual female to male patients. All hormonal pathways included in this complex hormonal and surgical procedure of transgender surgery have important implications for women undergoing prophylactic mastectomy because of a high risk of possible breast cancer.
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Background: False-positive mammography results are common. Biennial screening may decrease the cumulative probability of false-positive results across many years of repeated screening but could also delay cancer diagnosis. Objective: To compare the cumulative probability of false-positive results and the stage distribution of incident breast cancer after 10 years of annual or biennial screening mammography. Design: Prospective cohort study. Setting: 7 mammography registries in the National Cancer Institute-funded Breast Cancer Surveillance Consortium. Participants: 169,456 women who underwent first screening mammography at age 40 to 59 years between 1994 and 2006 and 4492 women with incident invasive breast cancer diagnosed between 1996 and 2006. Measurements: False-positive recalls and biopsy recommendations stage distribution of incident breast cancer. Results: False-positive recall probability was 16.3% at first and 9.6% at subsequent mammography. Probability of false-positive biopsy recommendation was 2.5% at first and 1.0% at subsequent examinations. Availability of comparison mammograms halved the odds of a false-positive recall (adjusted odds ratio, 0.50 [95% CI, 0.45 to 0.56]). When screening began at age 40 years, the cumulative probability of a woman receiving at least 1 false-positive recall after 10 years was 61.3% (CI, 59.4% to 63.1%) with annual and 41.6% (CI, 40.6% to 42.5%) with biennial screening. Cumulative probability of false-positive biopsy recommendation was 7.0% (CI, 6.1% to 7.8%) with annual and 4.8% (CI, 4.4% to 5.2%) with biennial screening. Estimates were similar when screening began at age 50 years. A non-statistically significant increase in the proportion of late-stage cancers was observed with biennial compared with annual screening (absolute increases, 3.3 percentage points [CI, -1.1 to 7.8 percentage points] for women age 40 to 49 years and 2.3 percentage points [CI, -1.0 to 5.7 percentage points] for women age 50 to 59 years) among women with incident breast cancer. Limitations: Few women underwent screening over the entire 10-year period. Radiologist characteristics influence recall rates and were unavailable. Most mammograms were film rather than digital. Incident cancer was analyzed in a small sample of women who developed cancer. Conclusion: After 10 years of annual screening, more than half of women will receive at least 1 false-positive recall, and 7% to 9% will receive a false-positive biopsy recommendation. Biennial screening appears to reduce the cumulative probability of false-positive results after 10 years but may be associated with a small absolute increase in the probability of late-stage cancer diagnosis. Primary funding source: National Cancer Institute.
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Testosterone is important for the development of secondary sexual characteristics in female-to-male (FtM) transsexuals, but it may increase breast cancer risk. To date, only one breast cancer case has been reported in the literature in a FtM transsexual after 10 years of testosterone therapy. We describe 2 cases of breast cancers diagnosed in FtM transsexuals who have been treated with supraphysiological doses of testosterone. Our 2 cases demonstrate the unique issues that concern the management of FtM transsexuals with breast cancer and examine possible roles of testosterone in the development of breast cancer.
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Adverse effects of long-term cross-sex hormone administration to transsexuals are not well documented. We assessed mortality rates in transsexual subjects receiving long-term cross-sex hormones. A cohort study with a median follow-up of 18.5 years at a university gender clinic. Methods Mortality data and the standardized mortality rate were compared with the general population in 966 male-to-female (MtF) and 365 female-to-male (FtM) transsexuals, who started cross-sex hormones before July 1, 1997. Follow-up was at least 1 year. MtF transsexuals received treatment with different high-dose estrogen regimens and cyproterone acetate 100 mg/day. FtM transsexuals received parenteral/oral testosterone esters or testosterone gel. After surgical sex reassignment, hormonal treatment was continued with lower doses. In the MtF group, total mortality was 51% higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause. No increase was observed in total cancer mortality, but lung and hematological cancer mortality rates were elevated. Current, but not past ethinyl estradiol use was associated with an independent threefold increased risk of cardiovascular death. In FtM transsexuals, total mortality and cause-specific mortality were not significantly different from those of the general population. The increased mortality in hormone-treated MtF transsexuals was mainly due to non-hormone-related causes, but ethinyl estradiol may increase the risk of cardiovascular death. In the FtM transsexuals, use of testosterone in doses used for hypogonadal men seemed safe.
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Fewer surgical procedures have a history as fascinating and as terrifying as breast augmentation. Initial efforts at augmentation involved injection of substances such as paraffin or oil into the breast tissue, or the implantation of substances including ivory or glass balls, or rubber. More recent efforts have included the injection of liquid silicone or polyacrylamide hydrogel. The current paper reviews four distinct eras of breast augmentation, and provides the current status of these injection materials. A case report is presented on a woman whose breasts were injected with polyacrylamide hydrogel in Iran. The current status of this group of materials is also presented. During the past 110 years, history has repeated itself during each of the four eras of injection.
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An African American male to female transgender patient treated with estrogen detected a breast lump that was confirmed by her primary care provider. The patient refused mammography and 14 months later she was diagnosed with metastatic breast cancer with spinal cord compression. We used ethnographic interviews and observations to elicit the patient's conceptions of her illness and actions. The patient identified herself as biologically male and socially female; she thought that the former protected her against breast cancer; she had fears that excision would make a breast tumor spread; and she believed injectable estrogens were less likely than oral estrogens to cause cancer. Analysis suggests dissociation between the patient's social and biological identities, fear and fatalism around cancer screening, and legitimization of injectable hormones. This case emphasizes the importance of eliciting and interpreting a patient's conceptions of health and illness when discordant understandings develop between patient and physician.
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For people who are transgender, transsexual, or transitioned (trans), access to primary, emergency, and transition-related health care is often problematic. Results from Phase I of the Trans PULSE Project, a community-based research project in Ontario, Canada, are presented. Based on qualitative data from focus groups with 85 trans community members, a theoretical framework describing how erasure functions to impact experiences interacting with the health care system was developed. Two key sites of erasure were identified: informational erasure and institutional erasure. How these processes work in a mutually reinforcing manner to erase trans individuals and communities and produce a system in which a trans patient or client is seen as an anomaly is shown. Thus, the impetus often falls on trans individuals to attempt to remedy systematic deficiencies. The concept of cisnormativity is introduced to aid in explaining the pervasiveness of trans erasure. Strategies for change are identified.
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To evaluate the rate of over-diagnosis of breast cancer 15 years after the end of the Malmö mammographic screening trial. Follow-up study. Malmö, Sweden. 42 283 women aged 45-69 years at randomisation. Screening for breast cancer with mammography or not (controls). Screening was offered at the end of the randomisation design to both groups aged 45-54 at randomisation but not to groups aged 55-69 at randomisation. Rate of over-diagnosis of breast cancer (in situ and invasive), calculated as incidence in the invited and control groups, during period of randomised design (period 1), during period after randomised design ended (period 2), and at end of follow-up. In women aged 55-69 years at randomisation the relative rates of over-diagnosis of breast cancer (95% confidence intervals) were 1.32 (1.14 to 1.53) for period 1, 0.92 (0.79 to 1.06) for period 2, and 1.10 (0.99 to 1.22) at the end of follow-up. Conclusions on over-diagnosis of breast cancer in the Malmö mammographic screening trial can be drawn mainly for women aged 55-69 years at randomisation whose control groups were never screened. Fifteen years after the trial ended the rate of over-diagnosis of breast cancer was 10% in this age group.
Article
Objective: To review the history, current status, and future trends related to breast cancer screening. Data sources: Peer-reviewed articles, web sites, and textbooks. Conclusion: Breast cancer remains a complex, heterogeneous disease. Serial screening with mammography is the most effective method to detect early stage disease and decrease mortality. Although politics and economics may inhibit organized mammography screening programs in many countries, the judicious use of proficient clinical and self-breast examination can also identify small tumors leading to reduced morbidity. Implications for nursing practice: Oncology nurses have exciting opportunities to lead, facilitate, and advocate for delivery of high-quality screening services targeting individuals and communities. A practical approach is needed to translate the complexities and controversies surrounding breast cancer screening into improved care outcomes.
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Cardiovascular diagnostic imaging tests are increasingly used in everyday clinical practice, but are often imperfect, just like any other diagnostic test. The performance of a cardiovascular diagnostic imaging test is usually expressed in terms of sensitivity and specificity compared with the reference standard (gold standard) for diagnosing the disease. However, evidence-based application of a diagnostic test also requires knowledge about the pre-test probability of disease, the benefit of making a correct diagnosis, the harm caused by false-positive imaging test results, and potential adverse effects of performing the test itself. To assist in clinical decision making regarding appropriate use of cardiovascular diagnostic imaging tests, we reviewed quantitative concepts related to diagnostic performance (e.g., sensitivity, specificity, predictive values, likelihood ratios), as well as possible biases and solutions in diagnostic performance studies, Bayesian principles, and the threshold approach to decision making.
Article
The main harm of overdiagnosis is overtreatment. However a form of overdiagnosis also occurs when foci of cancer are found by imaging in addition to the symptomatic lesion when this leads to additional treatment which does not benefit the patient. Even if overtreatment is avoided, knowledge of the diagnosis can still cause psychological harm. Overdiagnosis is an inevitable effect of mammographic screening as the benefit comes from diagnosing breast cancer prior to clinical detectability. Estimates of the rate of overdiagnosis at screening are around 10%. DCIS represents 20% of cancers detected by screening and is the main focus in the overdiagnosis debate. Detection and treatment of low grade DCIS and invasive tubular cancer would appear to represent overdiagnosis in most cases. Supplementary screening with tomosynthesis or US are both likely to increase overdiagnosis as both modalities detect predominantly low grade invasive cancers. MRI causes overdiagnosis because it is so sensitive that it detects real tumour foci which after radiotherapy and systemic therapy do not, in many cases go on and cause local recurrence if the women had had no MRI and undergone breast conservation and adjuvant therapy with these small foci left in situ.
Article
Breast cancer is rare in male patients. Certain predisposing factors, be they genetic (e.g. BRCA2 gene mutations) or hormonal (imbalance between estrogen and androgen levels) have been implicated in male breast cancer pathophysiology. Male to female (MtF) transsexualism is a condition that generally involves cross-sex hormone therapy. Anti-androgens and estrogens are used to mimic the female hormonal environment and induce the cross-sex secondary characteristics. In certain situations, the change of the hormonal milieu can be disadvantageous and favor the development of hormone-dependent pathologies, such as cancer. We report a case of a MtF transgender (TG) patient who developed breast cancer after seven years of cross-sex hormonal therapy. The patient was found to be BRCA2 positive, and suffered recurrent disease. The patient was unaware of being a member of an established BRCA2 mutation positive kindred. This represents the first case of a BRCA2 mutation predisposing to breast cancer in a MtF transgender patient.
Article
Background: In 2009, the U.S. Preventive Services Task Force recommended biennial mammography screening for women aged 50 to 74 years and selective screening for those aged 40 to 49 years. Purpose: To review studies of screening in average-risk women with mammography, magnetic resonance imaging, or ultrasonography that reported on false-positive results, overdiagnosis, anxiety, pain, and radiation exposure. Data sources: MEDLINE and Cochrane databases through December 2014. Study selection: English-language systematic reviews, randomized trials, and observational studies of screening. Data extraction: Investigators extracted and confirmed data from studies and dual-rated study quality. Discrepancies were resolved through consensus. Data synthesis: Based on 2 studies of U.S. data, 10-year cumulative rates of false-positive mammography results and biopsies were higher with annual than biennial screening (61% vs. 42% and 7% vs. 5%, respectively) and for women aged 40 to 49 years, those with dense breasts, and those using combination hormone therapy. Twenty-nine studies using different methods reported overdiagnosis rates of 0% to 54%; rates from randomized trials were 11% to 22%. Women with false-positive results reported more anxiety, distress, and breast cancer-specific worry, although results varied across 80 observational studies. Thirty-nine observational studies indicated that some women reported pain during mammography (1% to 77%); of these, 11% to 46% declined future screening. Models estimated 2 to 11 screening-related deaths from radiation-induced cancer per 100 000 women using digital mammography, depending on age and screening interval. Five observational studies of tomosynthesis and mammography indicated increased biopsies but reduced recalls compared with mammography alone. Limitations: Studies of overdiagnosis were highly heterogeneous, and estimates varied depending on the analytic approach. Studies of anxiety and pain used different outcome measures. Radiation exposure was based on models. Conclusion: False-positive results are common and are higher for annual screening, younger women, and women with dense breasts. Although overdiagnosis, anxiety, pain, and radiation exposure may cause harm, their effects on individual women are difficult to estimate and vary widely. Primary funding source: Agency for Healthcare Research and Quality.
Article
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data were collected by the National Cancer Institute (Surveillance, Epidemiology, and End Results [SEER] Program), the Centers for Disease Control and Prevention (National Program of Cancer Registries), and the North American Association of Central Cancer Registries. Mortality data were collected by the National Center for Health Statistics. In 2016, 1,685,210 new cancer cases and 595,690 cancer deaths are projected to occur in the United States. Overall cancer incidence trends (13 oldest SEER registries) are stable in women, but declining by 3.1% per year in men (from 2009-2012), much of which is because of recent rapid declines in prostate cancer diagnoses. The cancer death rate has dropped by 23% since 1991, translating to more than 1.7 million deaths averted through 2012. Despite this progress, death rates are increasing for cancers of the liver, pancreas, and uterine corpus, and cancer is now the leading cause of death in 21 states, primarily due to exceptionally large reductions in death from heart disease. Among children and adolescents (aged birth-19 years), brain cancer has surpassed leukemia as the leading cause of cancer death because of the dramatic therapeutic advances against leukemia. Accelerating progress against cancer requires both increased national investment in cancer research and the application of existing cancer control knowledge across all segments of the population. CA Cancer J Clin 2016. © 2016 American Cancer Society.
Article
The incidence of breast cancer in female-to-male (FTM) transsexuals who received mastectomy and sex reassignment surgery is very rare. In fact, there is only one previous medical report of such a case. We experienced a case of an FTM transsexual who developed breast cancer 12 years after mastectomy and hysterectomy with bilateral salpingo-oophorectomy. Because he had been continuously receiving testosterone during the last 15 years and because histopathological examination revealed positive estrogen receptor and androgen receptor expression, we suggest that exogenous testosterone may have initiated the development of breast cancer via two distinct pathways. We describe the clinical course and condition of the patient and recommend that medical personnel consider the possibility of hormone-related cancer in FTM transsexuals receiving cross-sex hormones.
Article
CONTEXT: Despite decades of accumulated observational evidence, the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain. OBJECTIVE: To assess the major health benefits and risks of the most commonly used combined hormone preparation in the United States. DESIGN: Estrogen plus progestin component of the Women's Health Initiative, a randomized controlled primary prevention trial (planned duration, 8.5 years) in which 16608 postmenopausal women aged 50-79 years with an intact uterus at baseline were recruited by 40 US clinical centers in 1993-1998. INTERVENTIONS: Participants received conjugated equine estrogens, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, in 1 tablet (n = 8506) or placebo (n = 8102). MAIN OUTCOMES MEASURES: The primary outcome was coronary heart disease (CHD) (nonfatal myocardial infarction and CHD death), with invasive breast cancer as the primary adverse outcome. A global index summarizing the balance of risks and benefits included the 2 primary outcomes plus stroke, pulmonary embolism (PE), endometrial cancer, colorectal cancer, hip fracture, and death due to other causes. RESULTS: On May 31, 2002, after a mean of 5.2 years of follow-up, the data and safety monitoring board recommended stopping the trial of estrogen plus progestin vs placebo because the test statistic for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits. This report includes data on the major clinical outcomes through April 30, 2002. Estimated hazard ratios (HRs) (nominal 95% confidence intervals [CIs]) were as follows: CHD, 1.29 (1.02-1.63) with 286 cases; breast cancer, 1.26 (1.00-1.59) with 290 cases; stroke, 1.41 (1.07-1.85) with 212 cases; PE, 2.13 (1.39-3.25) with 101 cases; colorectal cancer, 0.63 (0.43-0.92) with 112 cases; endometrial cancer, 0.83 (0.47-1.47) with 47 cases; hip fracture, 0.66 (0.45-0.98) with 106 cases; and death due to other causes, 0.92 (0.74-1.14) with 331 cases. Corresponding HRs (nominal 95% CIs) for composite outcomes were 1.22 (1.09-1.36) for total cardiovascular disease (arterial and venous disease), 1.03 (0.90-1.17) for total cancer, 0.76 (0.69-0.85) for combined fractures, 0.98 (0.82-1.18) for total mortality, and 1.15 (1.03-1.28) for the global index. Absolute excess risks per 10 000 person-years attributable to estrogen plus progestin were 7 more CHD events, 8 more strokes, 8 more PEs, and 8 more invasive breast cancers, while absolute risk reductions per 10 000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures. The absolute excess risk of events included in the global index was 19 per 10 000 person-years. CONCLUSIONS: Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal US women. All-cause mortality was not affected during the trial. The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases, and the results indicate that this regimen should not be initiated or continued for primary prevention of CHD.
Article
We used retrospective (2012–2013) chart review to examine breast cancer screening among transgender persons and sexual minority women (n = 1263) attending an urban community health center in Massachusetts. Transgender were less likely than cisgender patients and bisexuals were less likely than heterosexuals and lesbians to adhere to mammography screening guidelines (respectively, adjusted odds ratios = 0.53 and 0.56; 95% confidence intervals = 0.31, 0.91 and 0.34, 0.92) after adjustment for sociodemographics. Enhanced cancer prevention outreach is needed among gender and sexual minorities.
Article
Age-specific effects of mammographic screening, and the timing of such effects, are a matter of debate. The results of the UK Age trial, which compared the effect of invitation to annual mammographic screening from age 40 years with commencement of screening at age 50 years on breast cancer mortality, have been reported at 10 years of follow-up and showed no significant difference in mortality between the trial groups. Here, we report the results of the UK Age trial after 17 years of follow-up. Women aged 39-41 from 23 UK NHS Breast Screening Programme units years were randomly assigned by individual randomisation (1:2) to either an intervention group offered annual screening by mammography up to and including the calendar year of their 48th birthday or to a control group receiving usual medical care (invited for screening at age 50 years and every 3 years thereafter). Both groups were stratified by general practice. We compared breast cancer incidence and mortality by time since randomisation. Analyses included all women randomly assigned who could be traced with the National Health Service Central Register and who had not died or emigrated before entry. The primary outcome measures were mortality from breast cancer (defined as deaths with breast cancer coded as the underlying cause of death) and breast cancer incidence, including in-situ, invasive, and total incidence. Because there is an interest in the timing of the mortality effect, we analysed the results in different follow-up periods. This trial is registered, number ISRCTN24647151. Between Oct 14, 1990, and Sept 25, 1997, 160 921 participants were randomly assigned; 53 883 women in the intervention group and 106 953 assigned to usual medical care were included in this analysis. After a median follow-up of 17 years (IQR 16·8-18·8), the rate ratio (RR) for breast cancer mortality was 0·88 (95% CI 0·74-1·04) from tumours diagnosed during the intervention phase. A significant reduction in breast cancer mortality was noted in the intervention group compared with the control group in the first 10 years after diagnosis (RR 0·75, 0·58-0·97) but not thereafter (RR 1·02, 0·80-1·30) from tumours diagnosed during the intervention phase. The overall breast cancer incidence during 17 year follow-up was similar between the intervention group and the control group (RR 0·98, 0·93-1·04). Our results support an early reduction in mortality from breast cancer with annual mammography screening in women aged 40-49 years. Further data are needed to fully understand long-term effects. Cumulative incidence figures suggest at worst a small amount of overdiagnosis. National Institute for Health Research Health Technology Assessment programme and the American Cancer Society. Past funding was received from the Medical Research Council, Cancer Research UK, the UK Department of Health, and the US National Cancer Institute. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
A 41-year-old male-to-female (MtF) transgender patient presented with a symptomatic tender lump in the left breast. There was no family history of breast cancer. She had been receiving estrogen therapy for 14 years to maintain her secondary sexual characteristics. Triple assessment revealed a 13 mm triple-negative grade 3 invasive ductal carcinoma. The tumour was completely excised following a left wide local excision and sentinel lymph node biopsy. There was no regional lymph node involvement. She was referred to the oncologist for adjuvant chemotherapy and radiotherapy. 2015 BMJ Publishing Group Ltd.
Article
Cross-sex hormone treatment of transsexual people may be associated with the induction and growth stimulation of hormone-related malignancies. We report here five cases of breast cancer, three in female-to-male (FtoM) transsexual subjects and two in male-to-female (MtoF) transsexual subjects. In the general population the incidence of breast cancer increases with age and with duration of exposure to sex hormones. This pattern was not recognised in these five transsexual subjects. Tumours occurred at a relatively young age (respectively, 48, 41, 41, 52 and 46 years old) and mostly after a relatively short span of time of cross-sex hormone treatment (9, 9-10 but in one after 30 years). Occurrence of breast cancer was rare. As has been reported earlier, breast tumours may occur in residual mammary tissue after breast ablation in FtoM transsexual people. For adequate treatment and decisions on further cross-sex hormone treatment it is important to have information on the staging and histology of the breast tumour (type, grade and receptor status), with an upcoming role for the androgen receptor status, especially in FtoM transsexual subjects with breast cancer who receive testosterone administration. This information should be taken into account when considering further cross-sex hormone treatment. © 2015 Blackwell Verlag GmbH.
Article
Objective: The purposes of this article are to describe two cases of breast cancer in male-to-female transsexuals and to review eight cases previously reported in the literature. Conclusion: Breast cancer occurs in male-to-female transsexuals who receive high doses of exogenous estrogen and develop breast tissue histologically identical to that of a biologically female breast. This exposure to estrogen results in increased risk of breast cancer. The first patient described is a male-to-female transsexual with screening-detected ductal carcinoma in situ and a family history of breast cancer. The other patient is a male-to-female transsexual with invasive ductal carcinoma that was occult on diagnostic digital mammographic and ultrasound findings but visualized on digital breast tomosynthesis and breast MR images. The analysis of the eight previously reported cases showed that breast cancer in male-to-female transsexuals occurs at a younger age and is more frequently estrogen receptor negative than breast cancer in others born biologically male. Screening for breast cancer in male-to-female transsexuals should be undertaken for those with additional risk factors (e.g., family history, BRCA2 mutation, Klinefelter syndrome) and should be available to those who desire screening, preferably in a clinical trial.
Article
Importance Male-to-female (MTF) transsexual individuals take hormone treatment (HT) for acquisition and maintenance of female secondary sex characteristics. Rare but serious complications associated with long-term HT have been reported. While HT is usually initiated in specialized centers, long-term maintenance is often through more conveniently located primary care providers. Thus, clinicians should be familiar with the potential complications of long-term HT. Observations We present a case of a 60-year-old MTF transgender individual diagnosed with breast cancer after 8 years of HT. In addition, we summarize the related literature and briefly discuss the reported incidence of hormone-sensitive malignancies in MTF transgenders as well as recommendations for monitoring and screening on and off HT. Conclusions and Relevance: This case highlights several issues for MTF transgender patients. Physicians caring for these patients should discuss with them relevant cancer screening protocols. In addition, prolactin level should be monitored in subjects on long-term estrogen. An important unanswered question is the age at which cross-sex hormone administration can be responsibly discontinued without inducing an unacceptable risk of osteoporosis and bone fractures. Further reporting of cases such as ours should be encouraged as true insight can only come from reporting of adverse effects in the medical literature.
Article
IntroductionMale-to-female transgender persons (trans-women) receive livelong cross-sex hormonal treatment in order to induce and maintain secondary female characteristics. One of the concerns of long-term estrogen treatment is the induction of carcinomas of estrogen-sensitive tissues such as the breast. BRCA1 mutations have been shown to account for a large proportion of inherited predispositions to breast cancer.AimThe aim of this case report is to discuss the hormonal and surgical options in the treatment of trans-women with a genetic predisposition for breast cancer.Method We describe a case of a trans-woman who was found to be a carrier of a BRCA1 mutation.ResultsThe patient underwent a breast augmentation. She refused a prophylactic mastectomy followed by a primary breast reconstruction. She also underwent a vaginoplasty and a bilateral castration. Androgen blocking treatment was stopped after surgery; estradiol treatment however was continued.Conclusions This case points to the importance of routine investigation of family history in trans-women. Trans-women with BRCA mutations should be carefully monitored and if cancers develop, this should be reported. Follow-up should be according to the guidelines for breast cancer screening in biological women, and the guidelines for prostate cancer and colon cancer screening in men. Colebunders B, T'Sjoen G, Weyers S, and Monstrey S. Hormonal and surgical treatment in trans-women with BRCA1 mutations: A controversial topic. J Sex Med **;**:**–**.
Article
Introduction: There is a dearth of studies to quantify the use of illicit fillers by transwomen. Case studies of illicit filler injections have pointed to an array of serious health complications, including death. Aims: The aims of this study were to determine the population prevalence and identify correlates of filler use among transwomen in San Francisco, CA. Methods: An analysis of data collected in 2013 with a population-based sample of 233 transwomen recruited using respondent-driven sampling (RDS). We used RDS weights to conduct bivariate and multivariate analyses of correlates of filler use. Main outcome measures: Main outcome measures were an RDS-weighted population prevalence of filler use among transwomen and differences in demographic characteristics, transition-related care factors, and self-esteem related to appearance. Results: Weighted filler prevalence among transwomen was 16.7%. Being a transwoman between 30 and 49 years of age, owning/renting or living with a partner/family/friend, having had and planning to have surgery in the future, and having used nonprescribed hormones were all significantly associated with filler use. HIV was not associated with filler use. Conclusions: This study provides the first known estimate to date of the prevalence of filler use in a population-based sample of transwomen in San Francisco. Accessing illicit fillers may be the only choice available for many transwomen to make changes to their appearance due to the high cost of legal surgeries and other cosmetic procedures. An important next step in this research is to determine the overall prevalence and long-term consequences of filler use among transwomen, to explore how the use of fillers is protective to the safety and well-being of transwomen, and to find safe and affordable alternatives to this method that meet important gender-related appearance needs.
Article
There is limited published literature on the risk of breast cancer in transgender patients. We report a case of an aggressive triple negative inflammatory breast cancer in a male-to-female transsexual. This patient had a complicated psychiatric history with significant antipsychotic use, and the case raises several questions about the pathogenesis of this breast cancer. The literature on breast cancer in transgender patients and in relation to hyperprolactinaemia is reviewed. © 2013 The Authors. Internal Medicine Journal
Article
Current guidelines recommend mammography every 1 or 2 years starting at age 40 or 50 years, regardless of individual risk for breast cancer. To estimate the cost-effectiveness of mammography by age, breast density, history of breast biopsy, family history of breast cancer, and screening interval. Markov microsimulation model. Surveillance, Epidemiology, and End Results program, Breast Cancer Surveillance Consortium, and the medical literature. U.S. women aged 40 to 49, 50 to 59, 60 to 69, and 70 to 79 years with initial mammography at age 40 years and breast density of Breast Imaging Reporting and Data System (BI-RADS) categories 1 to 4. Lifetime. National health payer. Mammography annually, biennially, or every 3 to 4 years or no mammography. Costs per quality-adjusted life-year (QALY) gained and number of women screened over 10 years to prevent 1 death from breast cancer. Biennial mammography cost less than $100,000 per QALY gained for women aged 40 to 79 years with BI-RADS category 3 or 4 breast density or aged 50 to 69 years with category 2 density; women aged 60 to 79 years with category 1 density and either a family history of breast cancer or a previous breast biopsy; and all women aged 40 to 79 years with both a family history of breast cancer and a previous breast biopsy, regardless of breast density. Biennial mammography cost less than $50,000 per QALY gained for women aged 40 to 49 years with category 3 or 4 breast density and either a previous breast biopsy or a family history of breast cancer. Annual mammography was not cost-effective for any group, regardless of age or breast density. Mammography is expensive if the disutility of false-positive mammography results and the costs of detecting nonprogressive and nonlethal invasive cancer are considered. Results are not applicable to carriers of BRCA1 or BRCA2 mutations. Mammography screening should be personalized on the basis of a woman's age, breast density, history of breast biopsy, family history of breast cancer, and beliefs about the potential benefit and harms of screening. Eli Lilly, Da Costa Family Foundation for Research in Breast Cancer Prevention of the California Pacific Medical Center, and Breast Cancer Surveillance Consortium.
Article
To evaluate gene expression signatures of breast tissue in female-to-male (FtM) transsexuals under cross-sex hormone therapy (HT). Prospective cohort study. Academic research institution. Five hormone-naïve FtM transsexuals before and after HT. Breast tissue biopsy before and after 2 years of intramuscular testosterone undecanoate (1,000 mg every 12 wk) and oral lynestrenole (5 mg daily), and gene signature analysis by global gene expression array covering 28,869 genes. Differential regulation of specific genes and gene expression signatures. We identified 2,250 differentially expressed probe sets. One hundred twenty probe sets showed >2-fold change, of which 77 (64.2%) were up-regulated and 43 (35.8%) down-regulated. Genes involved in transcription were most overrepresented, with 43 out of 97 (44.3%) annotated probes, e.g., the transcription factor complex activator protein 1, including all three Jun genes (c-Jun, JunB, and JunD), two Fos genes (c-Fos and FosB), and activating transcription factor 3. In a Database for Annotation, Visualization, and Integrated Discovery analysis of the 2,007 down-regulated probe sets, proteins of the ribosome pathway and of two pathways involved in protein degradation, i.e., proteasome- and ubiquitin-mediated proteolysis, were significantly down-regulated. We identified eight breast cancer-associated gene expression signatures significantly overlapping with differentially regulated probe sets after cross-sex HT. Cross-sex HT in FtM transsexuals leads to the up-regulation and down-regulation of 243 and 2,007 distinct genes, respectively, and is associated with breast cancer-related gene expression signatures.
Article
Understanding breast cancer treatment options can help family physicians care for their patients during and after cancer treatment. This article reviews typical treatments based on stage, histology, and biomarkers. Lobular carcinoma in situ does not require treatment. Ductal carcinoma in situ can progress to invasive cancer and is treated with breast-conserving surgery and radiation therapy without further lymph node exploration or systemic therapy. Stages I and II breast cancers are usually treated with breast-conserving surgery and radiation therapy. Radiation therapy following breast-conserving surgery decreases mortality and recurrence. Sentinel lymph node biopsy is considered for most breast cancers with clinically negative axillary lymph nodes, and it does not have the adverse effects of arm swelling and pain that are associated with axillary lymph node dissection. Choice of adjuvant systemic therapy depends on lymph node involvement, hormone receptor status, ERBB2 (formerly HER2 or HER2/neu) overexpression, and patient age and menopausal status. In general, node-positive breast cancer is treated systemically with chemotherapy, endocrine therapy (for hormone receptor-positive cancer), and trastuzumab (for cancer overexpressing ERBB2). Anthracycline- and taxane-containing chemotherapeutic regimens are active against breast cancer. Stage III breast cancer typically requires induction chemotherapy to downsize the tumor to facilitate breast-conserving surgery. Inflammatory breast cancer, although considered stage III, is aggressive and requires induction chemotherapy followed by mastectomy, rather than breastconserving surgery, as well as axillary lymph node dissection and chest wall radiation. Prognosis is poor in women with recurrent or metastatic (stage IV) breast cancer, and treatment options must balance benefits in length of life and reduced pain against harms from treatment.
Article
Data on the necessity of performing screening mammographies in transsexual women are lacking. The main objective of this study was to assess the possibility to perform mammography and breast sonography in transsexual women. Fifty Dutch-speaking transsexual women were interviewed about the following: attitude towards mammography and breast sonography, importance attributed to and satisfaction with breast appearance, opinion about the necessity of breast check-up, expectations regarding discomfort during the exams and knowledge about the breast surgery. A fasting blood sample, clinical breast exam, mammography and breast sonography were performed. At mammography the following parameters were noted: density, technical quality, location of the prostheses, presence of any abnormalities and painfulness. At sonography the following parameters were recorded: density, presence of cysts, visualisation of retro-areolar ducts or any abnormalities. Twenty-three percent of patients are not aware of the type of breast implants and 79% do not know their position to the pectoral muscles. Patient satisfaction with the appearance of their breasts was rather high (7.94 on a scale of 0-10). Mean expected and experienced pain from mammography was low (4.37 and 2.00 respectively). There was no statistically significant difference in expected pain between those who already had mammography and those who did not. There was a significant positive correlation between the expected and the experienced pain. Mammography and breast sonography were technically feasible and no gross anomalies were detected. Since both exams were judged as nearly painless, 98% of transsexual women intended to come back if they would be invited. Since breast cancer risk in transsexual women is largely unknown and breast exams are very well accepted, breast screening habits in this population should not differ from those of biological women.
Article
The clinicopathological findings in a patient who developed breast carcinoma ten years after male-to-female sexual reassignment are reported. Only two other cases of transsexual men with breast carcinoma have been reported previously. All three patients received oral estrogens for prolonged periods to maintain secondary female characteristics. The controversies relating to hormonal influences in the etiology of breast cancer in men are discussed herein.
Article
Rudolf, KaaksTheron, JohnsonKaja, TikkDisorn, SookthaiAnne, TjønnelandNina, RoswallKim, OvervadFrançoise, Clavel-ChapelonMarie-Christine, Boutron-RuaultLaure, DossusSabina, RinaldiIsabelle, RomieuHeiner, BoeingMadlen, SchützeAntonia, TrichopoulouPagona, LagiouDimitrios, TrichopoulosDomenico, PalliSara, GrioniRosario, TuminoCarlotta, SacerdoteSalvatore, PanicoGenevieve, BucklandMarcial, ArgüellesMaría-José, SánchezPilar, AmianoMaria-Dolores, ChirlaqueEva, ArdanazH. Bas, Bueno-de-MesquitaCarla H., van GilsPetra H., PeetersAnne, AnderssonMalin, SundElisabete, WeiderpassInger Torhild, GramEiliv, LundKay-Tee, KhawNick, WarehamTimothy J., KeyRuth C., TravisMelissa A., MerrittMarc J., GunterElio, RiboliAnnekatrin, Lukanova. (2014) Insulin-like growth factor I and risk of breast cancer by age and hormone receptor status-A prospective study within the EPIC cohort. International Journal of Cancer 134:10.1002/ijc.v134.11, 2683-2690 CrossRef
Article
We describe a female-to-male trans-sexual, aged 33, who developed breast cancer 10 years after cosmetic bilateral subcutaneous mastectomy and nipple reimplantation. The complex hormonal pathways involved and the implications for women undergoing prophylactic mastectomy because of a high risk of familial breast cancer are discussed.
Article
To characterize reports of adverse events occurring during mammography to women with breast implants submitted to the Food and Drug Administration (FDA). We searched the adverse events database for any report on silicone gel breast implants or saline breast implants that included the word "mammography" or "mammogram"in the text. We also searched adverse event reports for mammographic equipment that included the term "breast implant" in the text. We retrieved 714 adverse event reports using this strategy. Sixty-six of these reports detailed an adverse event that occurred during mammography or described breast implant interference with mammography. The majority of these reports, 41 of 66 (62.1%), described breast implant rupture during mammography. Other adverse events reported included mammographic compression crushing implants, pain during mammography attributed to implants, inability to perform mammography because of capsular contracture or fear of implant rupture, and delayed detection of cancer attributed to implants. It is important that women considering breast implants be informed of these potential risks and that clinicians, radiologists, and mammographic technicians keep them in mind when imaging women with implants.
Article
Levels of endogenous hormones have been associated with the risk of breast cancer among postmenopausal women. Little research, however, has investigated the association between hormone levels and tumor receptor status or invasive versus in situ tumor status. Nor has the relation between breast cancer risk and postmenopausal progesterone levels been investigated. We prospectively investigated these relations in a case-control study nested within the Nurses' Health Study. Blood samples were prospectively collected during 1989 and 1990. Among eligible postmenopausal women, 322 cases of breast cancer (264 invasive, 41 in situ, 153 estrogen receptor [ER]-positive and progesterone receptor [PR]-positive [ER+/PR+], and 39 ER-negative and PR-negative [ER-/PR-] disease) were reported through June 30, 1998. For each case subject, two control subjects (n = 643) were matched on age and blood collection (by month and time of day). Endogenous hormone levels were measured in blood plasma. We used conditional and unconditional logistic regression analyses to assess associations and to control for established breast cancer risk factors. We observed a statistically significant direct association between breast cancer risk and the level of both estrogens and androgens, but we did not find any (by year) statistically significant associations between this risk and the level of progesterone or sex hormone binding globulin. When we restricted the analysis to case subjects with ER+/PR+ tumors and compared the highest with the lowest fourths of plasma hormone concentration, we observed an increased risk of breast cancer associated with estradiol (relative risk [RR] = 3.3, 95% confidence interval [CI] = 2.0 to 5.4), testosterone (RR = 2.0, 95% CI = 1.2 to 3.4), androstenedione (RR = 2.5, 95% CI = 1.4 to 4.3), and dehydroepiandrosterone sulfate (RR = 2.3, 95% CI = 1.3 to 4.1). In addition, all hormones tended to be associated most strongly with in situ disease. Circulating levels of sex steroid hormones may be most strongly associated with risk of ER+/PR+ breast tumors.
Article
Secretory carcinomas of the breast were first described as "juvenile carcinoma" by McDivitt and Stewart in a cohort of children. This term has been replaced by the term "secretory breast carcinoma", because the entity can occur at any time of life. Carcinoma of the male breast is uncommon and accounts for approximately 1% of all cancers in men. Recently, it has been reported that human secretory breast carcinoma expresses the ETV6-NTRK3 gene fusion that was previously cloned in pediatric mesenchymal cancers. We present the case of a 46-year-old male-to-female transsexual in whom a secretory breast carcinoma was an incidental finding. As confirmation of the histopathological diagnosis we detected the novel ETV6-NTRK3 gene fusion in this tumor.
Article
To describe the sonographic and mammographic features of patients whose breasts have been injected with silicone. Between July 1997 and August 1999, 14 patients with a history of breast injection of liquid silicone underwent physical, mammographic, and sonographic examination. Mammographic findings were classified as macronodular, micronodular, or mixed striated patterns. Sonographic appearances were classified as macronodular, micronodular, mixed, or snowstorm patterns. Eighty-six percent of the patients had abnormal physical examination. Well-defined nodules were palpable in 4 patients, 6 patients had diffusely heterogeneous breasts on palpation, and 2 patients had a combination of heterogeneous texture with dominant nodules. Sonographic examination revealed the presence of marked echogenicity (i.e., snowstorm pattern) in all 14 patients; in 11 patients it was associated with macronodules and/or micronodules, whereas in 3 patients only snowstorm appearance was noted. Mammographic patterns were macronodular in 7 patients and mixed macronodular and micronodular in 6 patients. Both mammography and sonography can help identify free silicone injected directly into the breast.
Article
Cosmetic breast enlargement surgery has become common in Japan. There are some reports suggesting that implants can interfere with mammography (MMG) and may lead to delayed breast cancer diagnosis, even when implant-displaced MMG (Eklund technique) is performed. Screening MMG was recommended in a notification issued by the Japanese Ministry of Health, Labor and Welfare in 1999, and MMG is just coming into widespread use in Japanese breast cancer screening. Recent reports suggest that screening MMG may not be appropriate in augmented women, but breast self-examination may be effective in these women. Ultrasonography (US) may be useful in screening augmented women without risk of rupturing the implant. In appropriate cases, magnetic resonance imaging should be considered as an adjunct to MMG and US. The question of whether augmented women should not undergo core needle biopsy because of the possibility of damage to the implant should be considered. This review discusses diagnostic methods for augmented women and suggests the optimal screening method for augmented women. The challenge of the screening and diagnosis of breast cancer in augmented women is important in order to detect more of their cancer at a preclinical stage, because we can expect to see breast cancer in augmented women with increasing frequency over the next decade.
Article
Five false-positive gonorrhea test results from a private laboratory using a nucleic acid amplification test led to an investigation by the Hawaii State Department of Health. No unexplained increase or variation in the laboratory's positive gonorrhea test results was detected. The proportion of positive gonorrhea test results among tests performed in the population was 1.06%. The calculated positive predictive value (PPV) of the test in this setting was 60%. Documentation of sexual histories was lacking for all cases. It is imperative to obtain a sexual history for both assessing sexually transmitted disease (STD) risk and interpreting STD test results. The possibility that positive test results may be false should be considered when patients have unanticipated positive test results. Clinicians who perform STD screening tests should know the approximate prevalence of STDs in the population being screened and have a conceptual understanding of PPV and the impact of low prevalence on screening tests with imperfect specificity.
Canadian Task Force on Preventive Health Care
  • Ctf Care
  • Ph
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