ArticleLiterature Review

Breast Cancer in Transgender Patients: A Systematic Review. Part 2: Female to Male

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Abstract

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.

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... The median age of patients at diagnosis was 44.5 years; there were 8 cases of invasive ductal carcinoma, 2 cases of tubular carcinomas, and 7 unrecorded types of breast cancer. 38 The hormone status of 14 tumors was known; 12 of these tumors were estrogen receptor positive, of which 9 also were progesterone receptor positive. 38 Three patients had a family history of breast cancer, and none were BRCA1 or BRCA2 positive. ...
... 38 The hormone status of 14 tumors was known; 12 of these tumors were estrogen receptor positive, of which 9 also were progesterone receptor positive. 38 Three patients had a family history of breast cancer, and none were BRCA1 or BRCA2 positive. 38 Cross-sex hormone therapy in transgender men includes taking androgens (male hormones). ...
... 38 Three patients had a family history of breast cancer, and none were BRCA1 or BRCA2 positive. 38 Cross-sex hormone therapy in transgender men includes taking androgens (male hormones). High levels of androgens circulating in the blood is associated with an elevated risk of breast cancer in postmenopausal cisgender women, and thus cross-sex therapy might increase breast cancer risk in transgender men who have not undergone a mastectomy. ...
Article
Breast cancer occurs in about 1% of men, but the number of men receiving a diagnosis is increasing. Data on male breast cancer (MBC) is limited, and treatment for men is based primarily on treatments used for women. However, some argue that breast cancer in men is a different disease than breast cancer in women. Multiple risk factors, including those with genetic and environmental origins, affect the likelihood of men receiving a breast cancer diagnosis. This article discusses types of MBC, risk factors, treatment options, and ethical concerns men encounter after they receive a breast cancer diagnosis.
... We have read with interest the review of Stone and colleagues on breast cancer incidence in female-to-male (FTM) transgender patients, henceforth considered as transmen [1]. The currently available literature was analysed, which identified seventeen transmen with breast cancer. ...
... The analysis pointed out the limitations of these reports concerning the presentation and extent of disease, the incidence of loco-regional and distant metastases, the potentially adverse effects of cross-sex hormonal treatment and the challenges of general management of breast cancer in transmen. Stone et al. discerned three patients with breast cancer diagnosis upon routine histopathological examination of mastectomy specimens after gender-confirming surgery [1]. We would like to emphasize the role of the histopathologist in incidental breast cancer diagnosis in these patients. ...
... Stone and colleagues conjecture the use of routine histopathological examination of FTM mastectomy specimens [1]. We strongly support their proposal, as currently available evidence suggests a breast cancer incidence of approximately 0,3e0,5% in transmen at the time of chest-contouring surgery. ...
... Historically, transgender individuals have had poor access to medical care; perceived and real discrimination in the health care setting is well documented by several studies and often leads to inadequate preventative health care and delayed presentation to treatment. 15,16 Breast cancer is the most common cancer in women and the second leading cause of cancer mortality, with a 1 in 8 lifetime risk for natal female individuals. Breast tumors in transmen are relatively rare. ...
... Breast tumors in transmen are relatively rare. 16,17 The estimated incidence rate of BC in these individuals was 5.9 per 100,000 person-years. For comparison, the expected incidence of BC would be 154.7 per 100,000 person-years for cis women and 1.1 per 100,000 person-years for cis men. ...
... [20][21][22][23] Unlike in cis women, the cases of BC observed in transmen occurred at a younger age (transmen median age of 44.5 years vs. cis women median age of 62 years) and after relatively short spans of estrogen exposure and showed similarities to BC in men. 16,24 Transmen are an ideal model to examine the effects of T on the breast tissue because they are biologically female individuals subjected to long-term exposure to exogenous T. 8 A recent study revealed a significant histological finding in 51/68 cases (75%) of cases of transmen gender-affirming breast surgery. The main histological effect was a benign breast disease, in particular a fibrocystic change with marked reduction of glandular mammary gland tissues and increased fibrous connective tissue, 25 followed by gynecomastoid change, fibrotic stage 22 cases (32.4%), and fibroadenomatoid change 11 cases (16.2%) including 1 case (1.5%) of flat epithelial atypia. ...
... It is less clear however, what risk breast cancer poses to the transgender individual and how, if at all, physicians should screen these patients. Reports of transgender men breast cancer have been mentioned in the medical literature [5]. Number on the incidences of breast cancer in trans women receiving GAHT remains vague. ...
... Various deep learning models such as Radial Basis Function Network (RBFN), K-Nearest Neighbors (KNN), Probability Neural Network (PNN), Support Vector Machine (SVM), ResNet50, SeResNet50, V Net, Bayes Net, Convolutional Neural Networks (CNN), Convolutional and De-Convolutional Neural Networks (C-DCNN), VGG-16, Hybrid (ResNet-50 and V-Net), ResNet101, DenseNet and Incep-tionV3 were analyzed to process thermographic images of breast cancer. Some research works discussed the breast cancer in transgender patients [5,31]. The qualitative analysis was performed on patient demographics, breast cancer characteristics, breast cancer presentation and management. ...
... How breast cancer detection using deep learning is different from the other approaches? [31] 2018 [5] 2018 ...
Article
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Breast cancer is a common health problem in women, with one out of eight women dying from breast cancer. Many women ignore the need for breast cancer diagnosis as the treatment is not secure due to the exposure of radioactive rays. The breast cancer screening techniques suffer from non-invasive, unsafe radiations, and specificity of diagnosis of tumor in the breast. The deep learning techniques are widely used in medical imaging. This paper aims to provide a detailed survey dealing with the screening techniques for breast cancer with pros and cons. The applicability of deep learning techniques in breast cancer detection is studied. The performance measures and datasets for breast cancer are also investigated. The future research directions associated with breast cancer are studied. The primary aim is to provide a comprehensive study in this field and to help motivate the innovative researchers.
... In our case, expressions of ER, PR, and AR were all negative however HER-2 expression was positive. Some case reports of breast cancer development in transgender men receiving testosterone therapy noted increased expression of HER-2 but the mechanism of testosterone-related overexpression of HER-2 is unknown [3,11]. Of the cases revealed in the literature, the types of breast cancer were variable, consisting of invasive ductal carcinoma, neuroendocrine carcinoma, and tubular adenocarcinoma [3][4][5][6][7]11]. ...
... Some case reports of breast cancer development in transgender men receiving testosterone therapy noted increased expression of HER-2 but the mechanism of testosterone-related overexpression of HER-2 is unknown [3,11]. Of the cases revealed in the literature, the types of breast cancer were variable, consisting of invasive ductal carcinoma, neuroendocrine carcinoma, and tubular adenocarcinoma [3][4][5][6][7]11]. The strongest correlation of androgen levels and risk of breast cancer was in hormone receptor positive tumors including ER/PR and androgen receptor (AR) positivity [2,3]. ...
... No consistent guidelines exist regarding the continuation of GAHT following breast cancer treatment in transgender men [3][4][5][6][7]10]. Published reports suggest that most patients are restarted on low-dose testosterone therapy with or without an aromatase inhibitor to prevent peripheral conversion of testosterone to estrogens [3,4,6,7,11]; however the available evidence on the risk of breast cancer recurrence with continuation of masculinizing GAHT is conflicting. Prophylactic use of aromatase inhibitors is currently under investigation and its effectiveness is unknown [3][4][5][6][7]. ...
Article
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Context To describe a case of invasive ductal carcinoma of the breast in a transgender male receiving testosterone therapy for gender-affirming treatment. Case Description A 28-year-old transgender male receiving intramuscular testosterone was found to have a breast mass on ultrasound after self-exam revealed a palpable breast lump. Ultrasound-guided breast biopsy revealed estrogen receptor/progesterone receptor (ER/PR) negative, human epidermal growth factor receptor-2 (HER-2) positive, invasive ductal carcinoma of the left breast. He underwent neoadjuvant and adjuvant chemotherapy along with bilateral mastectomy. At patient request, his testosterone injections were permanently discontinued. Conclusion Fewer than 20 cases of breast cancer in transgender male patients have been reported in medical literature. While studies have shown increased risk of breast cancer in postmenopausal women with higher testosterone levels, data regarding premenopausal women is conflicting and little is known about breast cancer risk in transgender individuals receiving gender-affirming hormone therapy (GAHT), with inconclusive results regarding correlation between testosterone therapy and breast cancer. More research is required to evaluate whether a possible increased risk of breast cancer exists for transgender men receiving gender-affirming therapy.
... The goal of chest contouring is to create an aesthetic appearance of the male breast, which can involve removal of breast tissue and excess skin and obliteration of the inframam-mary fold (52). In these patients, some residual breast tissue may remain, including preservation of the nipple-areolar complex (53,54). It is important for both the clinician and patient to be aware of the specific surgery performed to make individual decisions for screening and treatment. ...
... In the previously described studies, Gooren et al (30,33) found the incidence of breast cancer to be 20.4 per 100 000 personyears for transgender men, which is significantly lower than that for cisgender women (154 per 100 000 person-years). However, these data may be complicated by the inclusion of patients who undergo elective top surgery, which is known to reduce cancer risk, and the limited duration of follow-up (53). More robust studies are needed to delineate the effects of exogenous testosterone therapy on breast cancer risk. ...
... In transgender men who have undergone top surgery, the risk of breast cancer in residual breast tissue is unclear (34,53). While there have been cases of breast cancer in the transgender male population after top surgery, there are no data at this time to support imaging-based screening (53,60,61). ...
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.
... The transition from male to female relies on antiandrogens and estrogen therapies, which increase the risk of breast cancer [14] . A younger age of diagnosis at 44.5 years of age is also observed for individuals transitioning from female to male [15] . If bilateral nipple-sparing mastectomies are performed in the surgical transition to men, the risk of breast cancer is decreased with a standardized incidence ratio of 0.3 when compared to the natal females [13] . ...
... If bilateral nipple-sparing mastectomies are performed in the surgical transition to men, the risk of breast cancer is decreased with a standardized incidence ratio of 0.3 when compared to the natal females [13] . However, if any breast tissue is conserved, the risk of cancer increased and is similar to natal females for transgender men who did not undergo top surgery [15] . ...
Article
Full-text available
The cellular heterogeneity of breast cancers still represents a major therapeutic challenge. The latest genomic studies have classified breast cancers in distinct clusters to inform the therapeutic approaches and predict clinical outcomes. The mammary epithelium is composed of luminal and basal cells, and this seemingly hierarchical organization is dependent on various stem cells and progenitors populating the mammary gland. Some cancer cells are conceptually similar to the stem cells as they can self-renew and generate bulk populations of nontumorigenic cells. Two models have been proposed to explain the cell of origin of breast cancer and involve either the reprogramming of differentiated mammary cells or the dysregulation of mammary stem cells or progenitors. Both hypotheses are not exclusive and imply the accumulation of independent mutational events. Cancer stem cells have been isolated from breast tumors and implicated in the development, metastasis, and recurrence of breast cancers. Recent advances in single-cell sequencing help deciphering the clonal evolution within each breast tumor. Still, few clinical trials have been focused on these specific cancer cell populations.
... Twelve out of 14 cancers were ER+ and 9 were PR+. A breast lump was the most common presentation [25]. In the experience of the senior author (ECR), one such FTM patient was incidentally diagnosed with lobular carcinoma in situ at the time of gender-affirming mastectomy after 20+ years of androgen use, but many others were found to exhibit atypia or hyperplasia of their breast tissue. ...
... Both patient populations are at some risk for developing breast cancer and deserve surveillance guidelines to establish the best screening tools and the frequency of testing [85]. Mammography is difficult in this population, as most FTM patients do not have sufficient breast tissue for standard mammographic procedures to be useful [25]. In an analogous sense, MTF patients undergoing genderaffirming "bottom surgery" (e.g., penectomy, orchiectomy, and vaginoplasty) typically still have a prostate gland with the potential to develop future malignancy. ...
Article
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Purpose: Hormone replacement therapy (HRT) has become a mainstay medical treatment option for management of gender dysphoria in transgender patients of both biologic sexes. Very little is known about the long-term effects of steroid hormone modulation on breast tissue in this population. Most of the data available on the effects of HRT on breast and reproductive tissues come from studies of postmenopausal cisgender women. Therapeutic regimens are often provider-dependent, and there, are no uniform guidelines in place for cancer surveillance in transgender patients. In this review, we present what forms of hormone therapy and hormone modulation are available to transgender patients, what is known about their effects on male and female breast tissue, and what other endogenous and exogenous factors contribute to the macroscopic and cellular changes observed. Methods: A search for the existing literature focusing on therapeutic regimens and the effects of HRT on breast tissue provided the most current information available for this review. Recent evidence-based reports (since the year 2000) and reviews were given priority over anecdotal evidence and expert opinions when conflicting information was encountered. Older resources were considered when primary sources were needed. Given the paucity of available articles on this subject, all resources were given careful consideration. Results: Information about the risks associated with HRT in the current literature and in this setting is limited and often conflicting, due to a scarcity of long-term studies tracking breast pathology among transgender men and women. Conclusions: We conclude that the long-term effects of off-label pharmaceutical use for modulation of hormone levels and sexual characteristics in transgender patients have not been well studied. The tendency of steroid hormones to promote the growth of certain cancers also raises questions about the safety of differing doses and drug combinations. Further clinical and laboratory study is needed to better establish safety and dosing guidelines in transgender patients.
... Current evidence consists primarily of case reports and several cohort studies, all of which are retrospective. However, a younger age at the time of breast cancer diagnosis has been reported in transgender people [1][2][3][4][5]. ...
... Gender-affirming therapy can influence an individual's risk of developing certain cancers, including breast cancer [5,6]. Transgender patients may undergo either gender-affirming hormone treatment (previously known as crosssex hormone treatment), surgical treatment, or a combination thereof as part of their transition. ...
Article
Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
... The risk of breast cancer is thought to be low, but cases have been reported. 42,43 After male chest construction has been completed, mammograms might not be feasible, and self-or provider-initiated chest exams might be used for screening purposes. 42,43 Cancer rates and monitoring in TGD persons incorporates preexisting endogenous hormone exposures and anatomy. ...
... 42,43 After male chest construction has been completed, mammograms might not be feasible, and self-or provider-initiated chest exams might be used for screening purposes. 42,43 Cancer rates and monitoring in TGD persons incorporates preexisting endogenous hormone exposures and anatomy. ...
Article
Increasing numbers of transgender and gender diverse (TGD) youth are presenting for medical care, including seeking more information and access to services from gynecologic and reproductive health experts. Such experts are well positioned to provide affirming, comprehensive services, including education, hormonal interventions, menstrual management, contraception, and various gynecological procedures. Early medical guidance and support for the TGD community has been associated with long-term positive emotional and physical health outcomes. In this article medical interventions that reproductive health experts can offer to their TGD patients are discussed.
... 2,3 It is theorized that this may be due to risk reduction as a result of prior gender-affirming mastectomy, as well as potential estrogen suppression by gender-affirming testosterone therapy. 4 However, in transmasculine individuals who have not undergone these interventions, the rates of breast cancer would be expected to approximate those in 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. ...
... Social and psychological obstacles remain far too common for transmasculine individuals seeking medical care, particularly for historically gendered conditions such as breast cancer. 4 When performed in a multidisciplinary and collaborative setting with breast surgeons and gender-affirming plastic surgeons, oncologic mastectomy can be performed safely while concurrently offering patient an aesthetic genderaffirming reconstructive outcome. ...
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.
... This is, however, far below the incidence of 154 per 100,000 in cis women. 6,11 In the publication of Vujovic et al, no BCa occurred during a 20-year follow-up among the 62 trans men who underwent GAS and who had been on testosterone therapy for at least 12 months. 12 The authors assumed that testosterone therapy combined with mastectomy in some patients could diminish the risk of BCa in the trans men population. ...
Article
Full-text available
Bilateral prophylactic mastectomy reduces the risk of breast cancer in the general population by more than 90%. Most trans men patients undergo bilateral mastectomy as part of sex reassignment. However, clear data on the incidence of breast cancer in this population are lacking, as well as screening guidelines. Only five cases of breast cancer after bilateral mastectomy in trans men have been reported in the literature so far. In this report, we present the case of a 28-year old transgender man diagnosed with grade 3 invasive breast carcinoma two years after bilateral mastectomy. The patient had a negative family history of cancer and had been on testosterone therapy for 2.5 years. We critically discuss the potential impact of hormone therapy on breast cancer development in trans men under androgen treatment. We also present a comprehensive literature review of previous reports on breast cancer in trans men population after mastectomy. Due to the scarcity of this cancer occurrence, and considering the psychological impact of such diagnosis, it is crucial to report such cases and gather epidemiologic data. Raising awareness on breast cancer in transgender patients will allow us to optimize screening and to provide better management guidelines.
... Zudem finden sich bei LSBTIQ-Personen häufiger Risikofaktoren für kardiovaskuläre Erkrankungen wie Stress, Schlafprobleme, Übergewicht und Adipositas, ein höherer Tabak-, Alkohol-und Suchtmittelkonsum sowie eine geringere körperliche Aktivität [26,32]. Auch nehmen sie medizinische und psychologische Hilfe tendenziell seltener oder zeitlich verzögert in Anspruch [26,[33][34][35][36][37]. Gründe können erwartete oder erfahrene Diskriminierung im Gesundheitssystem sowie fehlende Informationen aufseiten der Gesundheitsberufe sein [38][39][40][41]. ...
Article
Zusammenfassung Die Gesundheitsberichterstattung (GBE) informiert über die gesundheitliche Lage von Frauen und Männern. Geschlechtergruppen werden derzeit eher homogen dargestellt. Unterschiede innerhalb der Gruppen und auch das Thema der geschlechtlichen und sexuellen Vielfalt finden bislang wenig Beachtung. Die GBE steht daher vor der Frage, wie sozial und geschlechterbezogen angemessen differenziert werden kann. Das Potenzial des Ansatzes der Intersektionalität soll künftig auf seine Nutzbarkeit in der GBE geprüft werden.
... The topics of breast screening and the effect of CSHs on breast cancer outcomes among trans people have not been rigorously and thoroughly researched. Previous reviews on similar topics 6,10,[33][34][35][36] have largely summarized published case reports and series on breast cancer in trans people, as well as the studies included in our 2 reviews of primary research. ...
Article
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Background: Trans people face uncertain risk for breast cancer and barriers to accessing breast screening. Our objectives were to identify and synthesize primary research evidence on the effect of cross-sex hormones (CSHs) on breast cancer risk, prognosis and mortality among trans people, the benefits and harms of breast screening in this population, and existing clinical practice recommendations on breast screening for trans people. Methods: We conducted 2 systematic reviews of primary research, 1 on the effect of CSHs on breast cancer risk, prognosis and mortality, and the other on the benefits and harms of breast screening, and a third systematic review of guidelines on existing screening recommendations for trans people. We searched PubMed, MEDLINE, Embase, CINAHL, the Cochrane Database of Systematic Reviews and grey literature sources for primary research, guidelines and position statements published in English between 1997 and 2017. Citations were screened by 2 independent reviewers. One reviewer extracted data and assessed methodological quality of included articles; a second reviewer verified these in full. The results were synthesized narratively. Results: Four observational studies, 6 guidelines and 5 position statements were included. Observational evidence of very low certainty did not show an effect of CSHs on breast cancer risk in trans men or trans women. Among trans women, painfulness of mammography and ultrasonography was low. There was no evidence on the effect of CSHs on breast cancer prognosis and mortality, or on benefits and other harms of screening. Existing clinical practice documents recommended screening for distinct trans subpopulations; however, recommendations varied. Interpretation: The limited evidence does not show an effect of CSHs on breast cancer risk. Although there is insufficient evidence to determine the potential benefits and harms of breast screening, existing clinical practice documents generally recommend screening for trans people; further large-scale prospective comparative research is needed.
... A recent systematic review 107 reported 15 cases of breast cancer in TM taking testosterone therapy. 100,[107][108][109][110][111][112][113] Van Renterghem and colleagues 114 reported no invasive cancer in mastectomy specimens of 148 TM, although apocrine metaplasia was seen in 23.6%, lactational changes in 2%, columnar cell changes in 37.2%, sclerosing adenosis in 4.7%, fibroadenoma in 4.1%, usual ductal hyperplasia in 27%, flat epithelial atypia in 0.7%, and atypical ductal hyperplasia in 3.4%. Gooren and colleagues 100 reported a lower incidence of breast cancer in TM, compared with cisgender women (5.9 vs 155 per 100.000 ...
Article
Prescribing gender-affirming hormonal therapy in transgender men (TM) not only induces desirable physical effects but also benefits mental health. In TM, testosterone therapy is aimed at achieving cisgender male serum testosterone to induce virilization. Testosterone therapy is safe on the short term and middle term if adequate endocrinological follow-up is provided. Transgender medicine is not a strong part of the medical curriculum, although a large number of transgender persons will search for some kind of gender-affirming care. Because hormonal therapy has beneficial effects, all endocrinologists or hormone-prescribing physicians should be able to provide gender-affirming hormonal care.
... Le neoplasie correlate alla terapia ormonale F to M rappresentano degli eventi rari. Tuttavia, sono stati descritti in letteratura tre casi di tumore mammario (entrambi con somministrazione di testosterone a dosaggi eccessivamente elevati) e tre casi ci carcinoma ovarico in pazienti F to M [10,11]. La chirurgia, tappa "complementare" e/o finale del percorso, ha il compito di rimuovere i caratteri sessuali secondari presenti (caratteristiche massiccio-faciali, genitali e ghiandole mammarie) e "ricostruirne" di congruenti al genere esperito. ...
Article
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Sommario La disforia di genere è una condizione in cui il non riconoscersi nell’aspetto determinato dal proprio genere biologico causa sofferenza, malessere, emarginazione. Nel 2017 gli ultimi standard di cura per la terapia ormonale si sono posti il duplice obiettivo di ridurre i caratteri secondari biologici e promuovere quelli del genere atteso, garantendo la salute dei soggetti con controlli seriati nel tempo.
... Persons who elect chest masculinization ("top") surgery may have reduced risk as glandular tissue is removed [8]. Residual breast tissue is known to remain after oncologic mastectomy, which is a more extensive procedure aimed at removing all breast tissue to prevent cancer recurrence [12]. ...
Article
Full-text available
Purpose of Review The purpose of this review is to summarize the current knowledge base for sex-trait related cancer risks and screening guidelines as applied in transgender and gender diverse (TGD) populations with an emphasis on the potential impact of gender-affirming hormonal and surgical therapies. Additionally, this review will address access to screening services and patient-friendly adaptations to screening approaches for this population. Recent Findings While breast cancer incidence is higher among transfeminine persons relative to genotypic males, it still remains significantly lower than that of genotypic females. As chest masculinization surgery performed in transmasculine persons may leave behind breast tissue, there is still a cancer risk. Mammography may not be feasible in a contoured chest and alternative approaches should be considered. Endometrial and ovarian cancers do not appear to have increased incidence in transmasculine persons who receive testosterone. Gender-affirming hormone therapy may be protective in prostate cancer risk in transfeminine persons. Lastly, prevalent societal constraints and outright discrimination of TGD persons in health care settings may limit patients from seeking necessary screening examinations. Some may opt out of screening because of emotional or physical discomfort associated with incongruence between screened anatomy and gender identity. Summary Overall, the incidence of sex steroid–influenced cancers among TGD persons appears to be low, but gender-affirming therapies may influence cancer risk. Additionally, the patient experience and potential barriers in access should also be considered in the development of TGD-specific screening guidelines.
... Zudem finden sich bei LSBTIQ-Personen häufiger Risikofaktoren für kardiovaskuläre Erkrankungen wie Stress, Schlafprobleme, Übergewicht und Adipositas, ein höherer Tabak-, Alkohol-und Suchtmittelkonsum sowie eine geringere körperliche Aktivität [26,32]. Auch nehmen sie medizinische und psychologische Hilfe tendenziell seltener oder zeitlich verzögert in Anspruch [26,[33][34][35][36][37]. Gründe können erwartete oder erfahrene Diskriminierung im Gesundheitssystem sowie fehlende Informationen aufseiten der Gesundheitsberufe sein [38][39][40][41]. ...
... For example, in the Health and Retirement Study (HRS), only those who identify as women are asked questions about breast cancer (Jenkins, Ofstedal, & Weir, 2008). Yet, not all who have breast cancer identify as women, and hormone treatments and other practices like breast-binding Downloaded from https://academic.oup.com/gerontologist/advance-article/doi/10.1093/geront/gnaa107/5896611 by State Univ NY at Stony Brook user on 09 September 2020 A c c e p t e d M a n u s c r i p t 4 carry unknown risks to breast health (Maycock & Kennedy, 2014; J. P. Stone, Hartley, & Temple-Oberle, 2018). The result of this lack of questioning is that the experiences of trans individuals are not well documented or described. ...
Article
Information on transgender people's health, and especially their experiences of aging, is lacking, including from major longitudinal studies of aging like the Health and Retirement Study and its sister studies in the Gateway to Global Aging Data project. This paper surveys the state of gender-data collection among major longitudinal studies and finds that all but one fail to collect adequate information on participants' gender to determine participants' gender identities. It identifies the unique challenges that population-wide longitudinal data-collection poses to current best practices for identifying transgender survey participants and proposes a modified "two-question model": one question for sex assigned at birth, and a second for gender identity, both of which offer three responses.
... Female breast carcinoma and malignant tumors of the reproductive system pose a serious threat to the health and lives of women across the world. [1][2][3] Although several treatment options are available in the form of surgery, endocrine therapy, radiotherapy, chemotherapy, and targeted therapy for treating such patients, much needs to be done in relation to prognosis for late patients and of those experiencing metastasis. [4] The reason for the high mortality of women with advanced breast cancer and reproductive system tumors is the lack of effective treatment options. ...
Article
Background:. The prognostic value of SPRY4-Intronic transcript 1 (SPRY4-IT1) in women suffering from breast carcinoma and malignant tumors of the reproductive system remains to be ascertained. Therefore, this paper attempted to assess the relationship between SPRY4-IT1 with the clinicopathological indicators and survival analysis in women suffering from breast carcinoma and malignant tumors of their reproductive organs through meta-analysis. Method:. Related literature retrieved from Cochrane Library, Ovid, Embase, PubMed, the CNKI, and the Web of Science databases were reviewed. The latest article search was updated to September 1, 2021. The outcome indicators included as effective measures in the study were hazard ratio (HR), odds ratio (OR), and 95% confidence interval (CI). The Stata 12.0 software was used to analyze the data. Results:. The elevated SPRY4-IT1 levels were indicative of poor overall survival (OS) [HR = 2.44, 95% CI = 1.35–4.43, P
... Oestrogen and progesterone are related to the risk of developing some breast cancers, but even among people who are biologically female at birth, the relationship between these hormones and the mechanisms of developing breast cancer is poorly understood (Tian et al., 2018;Yue et al., 2010). The relationship between sex hormones and breast cancer development among people who are transgender is even less well understood, with limited emerging evidence about hormone-related cancer risks for both female to male and male to female transgender people Meggetto et al., 2019;Stone et al., 2018). While male to female transgender people appear experience greater risk of breast cancer (de Blok et al., 2019), which also presents at younger ages , the further work necessary to fully determine transgender peoples' risk of developing breast cancer and correspondingly how to best screen, treat, care for and support transgender people in relation to breast cancer is just as necessary as the additional evidence necessary to support overall equity in terms of transgender health. ...
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Aim To develop evidence-based recommendations for provision of culturally safe, high-quality services for breast cancer screening for transgender people. Design The scoping review will follow the JBI methodological guidance for scoping reviews. Methods A search using MEDLINE (PubMed), Embase (Ovid), Scopus, the Cochrane Library, including the Cochrane Methodology Register, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and the World Health Organization, Australia Government Department of Health and Google Scholar will be undertaken. The review will include people of any age and ethnicity defined in the source of evidence as transgender. The review will include individuals who have used gender-affirming interventions or not and sources of evidence that report information relevant to the provision of culturally safe, high-quality breast cancer screening services for transgender people. English language sources of evidence published from database inception with information from any country will be eligible for inclusion. Sources will be screened for inclusion by three independent reviewers. Results will be extracted using a purpose-built tool and presented in relation to the review questions and objective in the final report using tables, figures and corresponding narrative. Project funding was approved by the Australian Government Department of Health in June 2020. Discussion There are a range of factors that impact on the equity of health access and outcomes for people who are not cisgender. Transgender people are at risk of breast cancer but there is relatively little evidence about how their risks may or may not differ substantially from cis-gendered individuals and little guidance for health providers to ensure inclusive, culturally safe, high-quality breast cancer screening services for both transgender males, transgender females and gender diverse people who may not identify as male or as female. Impact It is important to provide culturally safe, high-quality services for breast cancer screening for transgender people.
... Finally, she discussed the unknown future risk of breast cancer and the need to evaluate suspicious lumps, because all of the breast tissue may not be removed. 24 The patient's mother was present at both visits. In this context, the same plastic surgeon who had seen the patient in the emergency room obtained his assent and his mother's permission for top surgery. ...
Article
Mastectomy for chest masculinization is a commonly performed gender-affirming surgery in minor patients, a vulnerable population with unique developmental and psychosocial needs. We aimed to use principles of medical ethics (eg, autonomy, beneficence, nonmaleficence, and justice) as a framework to analyze preoperative clinical decision making by pediatric plastic surgeons who work with transmasculine and nonbinary adolescents designated female at birth presenting for chest masculinization. Two patients were selected for inclusion in this case series based on the senior author's (J.F.C.) clinical experience. A retrospective chart review was conducted to extract relevant psychosocial and clinical information from clinic notes and supplemental documentation (eg, letters from outside providers) available in the electronic medical record. In case A, a 17-year-old patient presented to a plastic surgery clinic with mixed parental support and restrictive insurance requirements. In case B, a 16-year-old patient presented to the emergency room after an attempt to remove his own breasts. The cases highlight the role of the plastic surgeon in advocating for adolescent autonomy and justice by facilitating shared family decision making and navigating barriers to care. In addition, we recommend multidisciplinary care, including trusted, transcompetent mental health professionals, to ensure beneficence and nonmaleficence by providing timely care when appropriate.
... Breast cancer is the leading cause of cancer in women [1] . Cisgender women carry a 12% lifetime risk of breast cancer, while cisgender men carry only a 0.1% lifetime risk of breast cancer [2] . ...
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We report a case of breast cancer in a transgender woman (assigned male sex at birth, gender identity female) of Ashkenazi Jewish descent with BRCA2 mutation who had been taking cross-sex hormone therapy for 2 years. In addition to demonstrating breast cancer imaging findings and risk factors, this case draws attention to the paucity of research and data regarding breast cancer in transgender women and exemplifies the need for evidence-based consensus breast cancer screening recommendations for transgender women.
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Purpose of Review There are over 1.4 million individuals who identify as transgender in the USA, and these individuals are frequently treated with cross-sex hormonal therapy (CSH) to acquire their desired phenotype. Simultaneously, breast cancer is one of the most common cancers in the USA, and there are mixed data on how CSH may influence breast cancer development in transgender individuals. Here, we review the barriers that exist to health access in this population, the current evidence of breast cancer risk in transgender individuals, and breast cancer screening guidelines for both transgender women and men. Recent Findings A large portion of the transgender population report barriers that exist to accessing appropriate healthcare, some of which are directly related to poor interactions with healthcare providers. From both systemic reviews and large retrospective studies, it appears that while transgender females have a lower rate of breast cancer development compared to cis-gender females, transgender males have a higher rate of breast cancer development compared to cis-gender males. While several organizations have released screening guidelines for transgender persons, there is a lack of consensus on optimal screening regimens. In addition, there are no formal recommendations by the American Cancer Society or the United States Preventative Task Force for breast cancer screening in transgender persons. Summary The risk of breast cancer development in transgender individuals is different compared to that of the cis-gender population. Further prospective data are needed to appropriately quantify these risks and to assess what is the appropriate breast cancer screening recommendations for this population.
Chapter
Gender affirming hormonal treatment (GAHT) in transgender men consists of testosterone treatment in different formulations. The main goal of testosterone treatment is to achieve cisgender male serum testosterone levels in order to induce virilization. The desired effects include increased facial and body hair, deepening of the voice, cessation of menses, fat redistribution and increased lean mass and strength, as well as improvement of psychological well-being. However, testosterone treatment may induce potential undesired effects and risks, such as acne, androgenetic alopecia, increase in systolic blood pressure, haematocrit and changes in lipid profile. GAHT in transgender men is considered safe on the short term and middle term, although several aspects, such as long-term cardiovascular and oncological safety, need to be adequately assessed in the future through long-term prospective studies.
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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.
Article
Transgender and gender diverse (TGD) individuals may undergo a wide range of care during gender transition including mental health counseling, gender-affirming hormonal therapy, and various surgeries. Hormone therapy effectively converts the hormonal milieu into that of the affirmed gender and produces measurable alterations in serum markers for coronary artery disease and other hematologic conditions (eg, erythrocytosis, venous thrombosis). Although illegal in the United States, some transgender women may receive silicone injections for breast and soft tissue augmentation, which can lead to devastating local complications, as well as silicone migration, pulmonary embolism, systemic reactions, and death. Smoking rates are higher among transgender and sexual minority populations, placing them at elevated risk of smoking-related diseases, including lung cancer. Some opportunistic infections may be more common in the TGD populations, attributable to higher rates of coexisting infection with human immunodeficiency virus. Radiologists should be aware that these patients may develop cancer of their natal organs (eg, breast, prostate), especially as some of these tissues are not completely removed during gender-affirming surgery, which may manifest with thoracic involvement by secondary neoplasia. As more TGD patients seek medical care, thoracic radiologists can reasonably expect to interpret imaging performed in this population and should be aware of possible disease processes and potential complications of hormonal and surgical therapies.
A review of new resources to support the provision of evidence-based care for women and infants.
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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
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
The term transgender youth commonly refers to those whose gender identity, or personal core sense of self as a particular gender, differs from their assigned sex at birth; this is often designated by what external genitalia are present. These youths are presenting to multidisciplinary clinics worldwide at exponentially higher rates than in decades past, and clinics themselves have grown in number to meet the specialized demands of these youth. Additionally, the scientific and medical community has moved towards understanding the construct of gender dimensionally (i.e., across a spectrum from male to female) as opposed to dichotomous or binary "male or female" categories. This is reflected in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM 5); in this publication, the diagnostic classification of gender dysphoria, GD, (which has two subtypes: childhood and adolescence/adulthood) provides a set of criteria that many transgender people meet. GD describes the affective distress that arises as a result of the incongruence between gender identity and sex anatomy. The DSM uses language to indicate that a person may identify as another gender instead of the other gender, which further captures the complexity of the human experience of gender. Also, research regarding how current adolescents are describing their identity development and experience along this spectrum within today's society is only now being addressed in the literature. Therefore, the clinical needs of the transgender population have outpaced medical training and scientific advancement, which has opened up gaps on how to define best practices. This article provides current concepts of evaluation and management for transgender persons with emphasis on hormonal therapy (i.e., puberty blockers and gender affirming hormone therapy). Other management issues are briefly considered including gender confirming surgery and changes in the face as well as voice.
Article
OBJECTIVE. The purpose of this article is to provide an overview of common gender affirmation surgical therapies, define key anatomy, and describe select complications using multidisciplinary, multimodality approaches. CONCLUSION. Gender affirmation therapy may be tailored to the needs of each individual patient. There are three major categories of gender affirmation surgery: genital reconstruction (comprising vaginoplasty and either metoidioplasty or phalloplasty), body contouring, and maxillofacial contouring (facial feminization or masculinization). If encountered in diagnostic imaging, routine evaluation should take into consideration normal postsurgical anatomy and key associated unique complications.
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.
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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.
Article
The transgender and nonbinary (TGNB) population is a significant minority, comprising at least 0.6% of the population. Visibility is growing rapidly, especially in younger generations. Gender affirming health care must adapt to this population's needs. Demographic data regarding TGNB health care are limited, but several disparities are clear, stemming from sociopolitical factors, such as external discrimination and insensitive and/or uninformed care. Most self-identifying TGNB patients receive some type of nonsurgical care, including hormonal and/or mental health. Gender-affirming surgery is highly prevalent as well, with at least one-quarter of TGNB people having had some combination of the procedures in this category.
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Mastectomy and augmentation are one of the first steps in gender affirming surgery. The breasts as a secondary sexual characteristic pose a significant social handicap for transmen and transwomen. Creating a new male-like or woman-like personality physically as well as emotionally helps transgender patients to improve their psychological state of mind. In recent international publications the term top surgery can be very frequently found. The aim of this study is to show the current status of chest wall gender affirming masculinizing or feminizing procedures in cases of a psychologically confirmed gender dysphoria.
Article
The Society of Surgical Oncology is committed to reducing health disparities adversely affecting sexual and gender minorities. Transgender persons represent a socially disadvantaged group who frequently experience discrimination and receive disparate care, resulting in suboptimal cancer outcomes. The rate of breast cancer development in transgender individuals differs from rates observed in their cisgender counterparts, however there is little evidence to quantify these differences and guide evidence-based screening and prevention. There is no consensus for breast cancer screening guidelines in transgender patients. In this review, we discuss barriers to equitable breast cancer care, risk factors for breast cancer development, and existing data to support breast cancer screening in transgender men and women.
Chapter
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.
Article
The preventive health care needs of transgender persons are nearly identical to the rest of the population. Special consideration should be given, however, to the impact of gender-affirming hormone regimens and surgical care on preventive screenings. Providers should integrate a more comprehensive view of health when caring for transgender persons and address the impact of social determinants and other barriers to accessing affirming, inclusive health care. In individual interactions, providers must consider the unique impact that a gender identity and expression different from the assigned gender at birth affects patient-provider interactions, including the history, physical examination, and diagnostic testing.
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Background Breast asymmetry is a common post‐operative outcome for women with breast cancer. Quality of cosmetic result is viewed clinically as a critical endpoint of surgery. However, research suggests that aesthetic standards governing breast reconstruction can be unrealistic and may problematically enforce feminine appearance norms. The aim of reconstructive procedures is to help women live well with and beyond breast cancer. Therefore, understanding how patients and clinicians talk about surgical outcomes is important. However, we lack evidence about such discussions. Objective To examine clinical communication about breast symmetry in real‐time consultations in a breast cancer clinic. Design Seventy‐three consultations between 16 clinicians and 47 patients were video‐recorded, transcribed and analysed using conversation analysis. Results In most cases, patients do considerable interactional work to persuade clinicians of the validity of their concerns regarding breast asymmetry, and clinicians legitimize these concerns, aligning with patients. In a significant minority of cases, patients appear more accepting of their treatment outcome, but clinicians prioritize symmetry or treat symmetry with the presence of breast tissue as normative, generating misalignment between clinician and patient. Conclusion Current clinical communication guidelines and practices may inadvertently reinforce culturally normative assumptions regarding the desirability of full, symmetrical breasts that are not held by all women. Clinicians and medical educators may benefit from detailed engagement with recordings of clinical communication like those analysed here, to reflect on which communicative practices may work best to attend to a patient's individual stance on breast symmetry, and optimize doctor‐patient alignment.
Article
A 54-year-old postmenopausal woman with gender identity disorder was administered androgen as part of the female-to-male transformation. Right breast calcification was detected during breast cancer screening, and she underwent physical examination at a local hospital. She was diagnosed with mucinous carcinoma via needle biopsy under stereotactic guidance. With a pre-operative diagnosis of T1N0M0 Stage IA, she underwent a total mastectomy with sentinel lymph node biopsy. Histological examination revealed mucinous carcinoma (pT1cN0M0 Stage IA), ER (score 5), PgR (score 5), HER2 (1+), and Ki-67 index (1%). At the patient's request, androgen supplementation was re-started after the surgery. The occurrence of breast cancer during androgen administration for gender identity disorder is extremely rare. The mechanism and clinical outcome will be evaluated after further data collection.
Article
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
We have searched the literature for information on the risk of breast cancer (BC) in relation to gender, breast development, and gonadal function in the following 8 populations: 1) females with the Turner syndrome (45, XO); 2) females and males with congenital hypogonadotropic hypogonadism and the Kallmann syndrome; 3) pure gonadal dysgenesis (PGD) in genotypic and phenotypic females and genotypic males (Swyer syndrome); 4) males with the Klinefelter syndrome (47, XXY); 5) male-to-female transgender individuals; 6) female-to-male transgender individuals; 7) genotypic males, but phenotypic females with the complete androgen insensitivity syndrome, and 8) females with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome (müllerian agenesis). Based on this search, we have drawn 3 major conclusions. First, the presence of a Y chromosome protects against the development of BC, even when female-size breasts and female-level estrogens are present. Second, without menstrual cycles, BC hardly occurs with an incidence comparable to males. There is a strong correlation between the lifetime number of menstrual cycles and the risk of BC. In our populations the BC risk in genetic females not exposed to progesterone (P4) is very low and comparable to males. Third, BC has been reported only once in genetic females with MRKH syndrome who have normal breasts and ovulating ovaries with normal levels of estrogens and P4. We hypothesize that the oncogenic glycoprotein WNT family member 4 is the link between the genetic cause of MRKH and the absence of BC women with MRKH syndrome.
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Male breast cancers are uncommon, as men account for less than 1 percent of all breast carcinomas. Among the predisposing risk factors for male breast cancer, the following appear to be significant: (a) breast/chest radiation exposure, (b) estrogen use, diseases associated with hyper-estrogenism, such as cirrhosis or Klinefelter syndrome, and (c) family health history. Furthermore, there are clear familial tendencies, with a higher incidence among men who have a large number of female relatives with breast cancer and (d) major inheritance susceptibility. Moreover, in families with BRCA mutations, there is an increased risk of male breast cancer, although the risk appears to be greater with inherited BRCA2 mutations than with inherited BRCA1 mutations. Due to diagnostic delays, male breast cancer is more likely to present at an advanced stage. A core biopsy or a fine needle aspiration must be performed to confirm suspicious findings. Infiltrating ductal cancer is the most prevalent form of male breast cancer, while invasive lobular carcinoma is extremely uncommon. Male breast cancer is almost always positive for hormone receptors. A worse prognosis is associated with a more advanced stage at diagnosis for men with breast cancer. Randomized controlled trials which recruit both female and male patients should be developed in order to gain more consistent data on the optimal clinical approach.
Article
In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.
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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Breast cancer is a major public health issue and it can impact individual’s lives in different dimensions. Although women are the ones most affected by this illness, there are other minority groups, such as men and transgender people, that are also affected and frequently ignored in healthcare approaches. People affected by breast cancer can face societal oppressions that puts them into a vulnerable situation where they need to deal with the suffering involved in have a serious illness and the societal expectations of the body. This situation can negatively influence an individual’s sense of identity and views of the body. As a result, it becomes necessary to dismantle the monolithic constructions on this collective, since these groups not only carry their gender identity but also the identities forged by social and cultural experiences. Thus, this article is a philosophical reflection to critically examine conceptual understandings of the body for individuals affected by breast cancer, to understand the influence of social interactions in this process based on the feminist philosophy, and to explore how nurses and healthcare professionals can help tackling this issue. Feminist thinking has become a crucial component of both political and sanitary philosophy and theory, and it is promoting a real "refoundation" of the political, philosophical, and theoretical dimensions. Therefore, it is important to healthcare professionals to use a philosophical feminist approach to breast cancer to help empowering these individuals and disassemble the constructions on this collective.
Article
Many transgender and gender nonconforming individuals have undergone, or plan to pursue, gender-affirming surgery as part of their transition. While not all gender-affirming surgeries are provided by Obstetrics and Gynecologists (OBGYNs), OBGYNs are uniquely skilled to perform certain gender-affirming surgeries such as hysterectomies, bilateral oophorectomies, and vaginectomies. OBGYNs are also well positioned to provide anatomy-specific cancer screening as dictated by patient's hormonal and surgical status, and to address postsurgical or natal vulvovaginal concerns.
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Purpose This review will inform radiologists about the evidence base regarding radiographic imaging for transgender individuals and considerations for providing culturally sensitive care for this population. Findings Transgender individuals are increasingly referred for both screening and diagnostic breast imaging. It is important that the clinic environment is welcoming, the medical staff utilize accepted terminology and patients are able to designate their gender and personal history to ensure appropriate care. Hormone and surgical treatments used for transition by many transgender women and men may change the approach to imaging. Summary Although not yet evidence-based, screening mammography is currently suggested for transgender women with risk factors, including those receiving hormone treatment over 5 years. The risk for breast cancer in transgender individuals is still being defined.
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Importance Nipple-sparing mastectomy (NSM) offers superior cosmetic outcomes and has been gaining wide acceptance; however, its role among patients with BRCA mutations remains controversial. Objective To report on the oncologic safety of NSM and provide evidence-based data to patients and health care professionals regarding preservation of the nipple-areolar complex during a risk-reducing mastectomy in a population with BRCA mutations. Design, Setting, and Participants We retrospectively reviewed the outcomes of 9 institutions’ experience with prophylactic NSM from 1968 to 2013 in a cohort of patients with BRCA mutations. Patients with breast cancer were included if they underwent contralateral risk-reducing mastectomy; however, only the prophylactic side was considered in the analysis. Patients found to have an occult primary breast cancer at the time of risk-reducing mastectomy, those having variant(s) of unknown significance, and those undergoing free nipple grafts were excluded. Main Outcomes and Measures The primary outcome measure was development of a new breast cancer after risk-reducing NSM. Three reference data sources were used to model the expected number of events, and this was compared with our observed number of events. Results A total of 548 risk-reducing NSMs in 346 patients were performed at 9 institutions. The median age at NSM was 41 years (interquartile range, 34.5-47.5 years). Bilateral prophylactic NSMs were performed in 202 patients (58.4%), and 144 patients (41.6%) underwent a unilateral risk-reducing NSM secondary to cancer in the contralateral breast. Overall, 201 patients with BRCA1 mutations and 145 with BRCA2 mutations were included. With median and mean follow-up of 34 and 56 months, respectively, no ipsilateral breast cancers occurred after prophylactic NSM. Breast cancer did not develop in any patients undergoing bilateral risk-reducing NSMs. Using risk models for BRCA1/2 mutation carriers, approximately 22 new primary breast cancers were expected without prophylactic NSM. Prophylactic NSM resulted in a significant reduction in breast cancer events (test of observed vs expected events, P < .001). Conclusions and Relevance Nipple-sparing mastectomies are highly preventive against breast cancer in a BRCA population. Although the follow-up remains relatively short, NSM should be offered as a breast cancer risk–reducing strategy to appropriate patients with BRCA mutations.
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Women with a BRCA1/2 gene mutation and others with a high breast cancer risk may opt for bilateral prophylactic mastectomy. To allow for immediate breast reconstruction the skin envelope is left in situ with or without the nipple-areola complex (NAC). Although possibly leading to a more natural aesthetic outcome than the conventional total mastectomy, so-called skin-sparing mastectomies (SSM) and nipple-sparing mastectomies (NSM) may leave some breast glandular tissue in situ. The oncological risk associated with remaining breast glandular tissue is unclear. We present a case of primary breast cancer after prophylactic mastectomy followed by a review of the literature on remaining breast glandular tissue after various mastectomy techniques and oncological safety of prophylactic mastectomies.
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Systematic reviews should build on a protocol that describes the rationale, hypothesis, and planned methods of the review; few reviews report whether a protocol exists. Detailed, well-described protocols can facilitate the understanding and appraisal of the review methods, as well as the detection of modifications to methods and selective reporting in completed reviews. We describe the development of a reporting guideline, the Preferred Reporting Items for Systematic reviews and Meta-Analyses for Protocols 2015 (PRISMA-P 2015). PRISMA-P consists of a 17-item checklist intended to facilitate the preparation and reporting of a robust protocol for the systematic review. Funders and those commissioning reviews might consider mandating the use of the checklist to facilitate the submission of relevant protocol information in funding applications. Similarly, peer reviewers and editors can use the guidance to gauge the completeness and transparency of a systematic review protocol submitted for publication in a journal or other medium.
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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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Breast cancer is the most common malignancy in women with 6.6% of cases diagnosed in young women below the age of 40. Despite variances in risk factors, Age Standardized Incidence Rates of breast cancer in young women vary little between different countries. Review of modifiable risk factors shows that long-term use of oral contraceptives, low body mass index (BMI) and high animal fat diet consumption are associated with increased risk of premenopausal breast cancer. Decreased physical activity and obesity increase risks of breast cancer in postmenopausal women, but data on premenopausal women rather shows that high BMI is associated with decreased risk of breast cancer. Non-modifiable risk factors such as family history and genetic mutations do account for increased risks of breast cancer in premenopausal women. Breast cancer in young women is associated with adverse pathological factors, including high grade tumors, hormone receptor negativity, and HER2 overexpression. This has a significant negative impact on the rate of local recurrence and overall survival. Moreover, younger women often tend to present with breast cancer at a later stage than their older counterparts, which further explains worse outcome. Despite these factors, age per se is still being advocated as an independent role player in the prognosis. This entails more aggressive treatment modalities and the need for closer monitoring and follow-up.
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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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Members of the transgender community have identified healthcare access barriers, yet a corresponding inquiry into healthcare provider perspectives has lagged. Our aim was to examine physician perceptions of barriers to healthcare provision for transgender patients. This was a qualitative study with physician participants from Ontario, Canada. Semi-structured interviews were used to capture a progression of ideas related to barriers faced by physicians when caring for trans patients. Qualitative data were then transcribed verbatim and analysed with an emergent grounded theory approach. A total of thirteen (13) physician participants were interviewed. Analysis revealed healthcare barriers that grouped into five themes: Accessing resources, medical knowledge deficits, ethics of transition-related medical care, diagnosing vs. pathologising trans patients, and health system determinants. A centralising theme of "not knowing where to go or who to talk to" was also identified. The findings of this study show that physicians perceive barriers to the care of trans patients, and that these barriers are multifactorial. Access barriers impede physicians when referring patients to specialists or searching for reliable treatment information. Clinical management of trans patients is complicated by a lack of knowledge, and by ethical considerations regarding treatments-which can be unfamiliar or challenging to physicians. The disciplinary division of responsibilities within medicine further complicates care; few practitioners identify trans healthcare as an interest area, and there is a tendency to overemphasise trans status in mental health evaluations. Failure to recognise and accommodate trans patients within sex-segregated healthcare systems leads to deficient health policy. The findings of this study suggest potential solutions to trans healthcare barriers at the informational level-with increased awareness of clinical guidelines and by including trans health issues in medical education-and at the institutional level, with support for both trans-focused and trans-friendly primary care models.
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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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Androgens have important physiological effects in women while at the same time they may be implicated in breast cancer pathologies. However, data on the effects of androgens on mammary epithelial proliferation and/or breast cancer incidence are not in full agreement. We performed a literature review evaluating current clinical, genetic and epidemiological data regarding the role of androgens in mammary growth and neoplasia. Epidemiological studies appear to have significant methodological limitations and thus provide inconclusive results. The study of molecular defects involving androgenic pathways in breast cancer is still in its infancy. Clinical and nonhuman primate studies suggest that androgens inhibit mammary epithelial proliferation and breast growth while conventional estrogen treatment suppresses endogenous androgens. Abundant clinical evidence suggests that androgens normally inhibit mammary epithelial proliferation and breast growth. Suppression of androgens using conventional estrogen treatment may thus enhance estrogenic breast stimulation and possibly breast cancer risk. Addition of testosterone to the usual hormone therapy regimen may diminish the estrogen/progestin increase in breast cancer risk but the impact of this combined use on mammary gland homeostasis still needs evaluation.
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The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence, which was low or very low. Committees and members of The Endocrine Society, European Society of Endocrinology, European Society for Paediatric Endocrinology, Lawson Wilkins Pediatric Endocrine Society, and World Professional Association for Transgender Health commented on preliminary drafts of these guidelines. Transsexual persons seeking to develop the physical characteristics of the desired gender require a safe, effective hormone regimen that will 1) suppress endogenous hormone secretion determined by the person's genetic/biologic sex and 2) maintain sex hormone levels within the normal range for the person's desired gender. A mental health professional (MHP) must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children. We recommend treating transsexual adolescents (Tanner stage 2) by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.
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Background: The medical transition undergone by a transgender person may influence their risk of breast or reproductive cancer. Objectives: To assess breast and reproductive cancer prevalence in the transgender population. To elucidate any associations between gender-affirming hormones and risk of these cancers. Search strategy: Following registration of review protocol with PROSPERO, five databases were searched. Selection criteria: Included studies investigated breast, ovarian, uterine, cervical, vaginal, neovaginal, testicular and prostate cancer in the transgender population. Secondary studies, opinions, editorials and conference abstracts were excluded. No date, language or setting restrictions were applied. Data collection and analysis: Two reviewers conducted literature searches and applied inclusion and exclusion criteria to the results. Studies were categorised, aggregated and analysed by study population (transmen/ transwomen) and type of cancer. Main results: Literature searching produced 228 articles. 43 were included. The overall evidence quality was very-low to low. Reported in transgender women were 20 breast cancer cases, two neovaginal cancer cases, one testicular cancer case, and eight prostate cancer cases. Reported in transgender men were 18 breast cancer cases, five ovarian cancer cases, four uterine/cervical cancer cases, and one vaginal cancer case. Conclusions: There is insufficient evidence to estimate breast or reproductive cancer prevalence in the transgender population. Gender-affirming hormones have not been shown to affect cancer risk, but there is a clear need for well-designed robust studies to confirm or refute this. This article is protected by copyright. All rights reserved.
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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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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.
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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
Transgender and gender nonconforming people face stigma and discrimination from a wide variety of sources and through numerous social realms. Stigma and discrimination originating from biomedicine and health care provision may impact this group's access to primary care. Such stigma and discrimination may originate not only from direct events and past negative experiences, but also through medicine's role in providing treatments of transitioning, the development of formal diagnoses to provide access to such treatments, and the medical language used to describe this diverse group. This paper examines the postponement of primary curative care among this marginalized group of people by drawing from the National Transgender Discrimination Survey, one of the largest available datasets for this underserved group. This paper also proposes an innovate categorization system to account for differences in self-conceptualization and identity, which has been of considerable concern for transgender and gender nonconforming communities but remains underexplored in social and health research. Results suggest that experience, identity, state of transition, and disclosure of transgender or gender nonconforming status are associated with postponement due to discrimination. Other findings suggest that postponement associated with primary place of seeking care and health insurance has ties to both discrimination and affordability. These findings highlight the importance of combating stigma and discrimination generated from within or experienced at sites of biomedicine or health care provision in improving access to care for this group of people. Improving access to care for all gender variant people requires a critical evaluation of existing research practices and health care provision to ensure that care is tailored as needed to each person's perspective in relation to larger social processes.
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The transgender community is arguably the most marginalized and underserved population in medicine. A special issue focusing on men’s health would be incomplete without mention of this vulnerable population, which includes those transitioning to and from the male gender. Transgender patients face many barriers in their access to healthcare including historical stigmatization, both structural and financial barriers, and even a lack of healthcare provider experience in treating this unique population. Historical stigmatization fosters a reluctance to disclose gender identity, which can have dire consequences for long-term outcomes due to a lack of appropriate medical history including transition-related care. Even if a patient is willing to disclose their gender identity and transition history, structural barriers in current healthcare settings lack the mechanisms necessary to collect and track this information. Moreover, healthcare providers acknowledge that information is lacking regarding the unique needs and long-term outcomes for transgender patients, which contributes to the inability to provide appropriate care. All of these barriers must be recognized and addressed in order to elevate the quality of healthcare delivered to the transgender community to a level commensurate with the general population. Overcoming these barriers will require redefinition of our current system such that the care a patient receives is not exclusively linked to their sex but also considers gender identity.
Article
Background: Reduction mammoplasty (RM) continues to be popular. The reported incidence of occult breast carcinoma in these specimens varies between 0.05 and 1.8 %. Literature review reveals a wide discrepancy in study methodology, outcome measures, and even what is constituted as a "significant" result. We set out to identify RM patients at increased risk of occult significant pathological findings to engender a systematic improvement in efficiency of those specimens sent for histopathological examination. Methods: A single-centre retrospective study of the pathology results for 1,388 consecutive RM patients was undertaken. Patients were divided into three groups according to indication for surgery: group 1, macromastia; group 2, developmental asymmetry; and group 3, symmetrising surgery after breast cancer reconstructive surgery. Results: Nine cases of occult carcinoma were found among the 1,388 women (0.65 %), all in patients over 35 years of age. Forty percent of all patients were under 35 years old. Histopathological analysis of 59 % of patients revealed nonsignificant findings. Patients with a breast cancer history were 4.3 times more likely to have occult breast cancer. Patients under 30 years of age had a significantly higher chance of nonsignificant findings than those over 30 (relative risk = 2.5). Conclusions: Although the overall incidence of occult breast cancer in reduction mammaplasty patients remains low, specific subgroups with a higher risk are identified. It is recommended that histological analysis of specimens should be restricted to high-risk patients and those over 30 years of age as significant pathology is uncommon in younger patients. These results will promote health-care-related economic benefits and a reduction of the burden placed on histopathology departments. Level of evidence iv: This journal requires that authors assign a level of evidence to each article.
Article
With the evolution of breast reconstruction and oncoplastic techniques, more aesthetic mastectomies are being offered to patients. Nipple-sparing mastectomy (NSM) has been controversial, but an expanding body of published experience has allowed this concept to gain momentum. The authors review their experience with NSM. From 2007 to 2009, 112 consecutive patients (204 breasts) who were candidates for NSM presented to one of two private plastic surgery practices. All patients underwent preoperative magnetic resonance imaging to assess the size of the tumor, its distance from the nipple, and any additional disease within the ipsilateral/contralateral breast or axillae. Exclusion criteria included tumors larger than 3 cm, clinical invasion of the nipple-areolar complex, tumors within 2 cm of the nipple, evidence of multicentric disease, a positive intraoperative retroareolar frozen section, or nodal disease (excluding isolated immunohistochemistry positivity). Fourteen patients were excluded from the study for one of these reasons, leaving a total of 98 patients (186 breasts) who underwent NSM. Risk-reducing mastectomies were performed on 45 patients. Therapeutic mastectomies were performed for Stage 0 cancer (ductal carcinoma in situ) in 26 patients, for Stage 1A in 24 patients, and for Stage 1B in three patients. Disease-free survival was calculated from the date of surgery to any local, regional, or distant relapse (whichever occurred first). As of the writing of this article, follow-up ranged from nine months to three years, and there has been no local or regional recurrence in any patient. NSM is evolving and should be considered a good treatment option in carefully-selected patients. These findings add to the growing body of evidence showing that, with proper patient selection and operative technique, NSM is a safe and effective intervention for patients requiring therapeutic or prophylactic mastectomy.
Article
Transgender (TG) persons have had historically difficult interactions with health care providers, leading to limited care and risks for a broad spectrum of health problems. This is of particular concern for TG persons with or at risk for HIV infection. This article discusses care providers' roles in establishing TG-friendly clinical care sites; conducting appropriate and thorough physical examinations for TG patients; managing hormones, especially in conjunction with antiretroviral therapy; and engaging TG persons in education about prevention and treatment of HIV.
Article
Subcutaneous mastectomy was performed in 12 cadaver breasts and in two patients. Biopsies of the margins of resection disclosed breast tissue not only in the areolar area, as expected, but in unpredictable locations in 10 of the 12 cadaver breasts and in one of the two patients. Because subcutaneous mastectomy does not routinely remove all breast tissue, it cannot be considered completely prophylactic. The authors advocate multiple biopsies of all margins of resection prior to insertion of implants in order to detect and remove any apparent remaining breast tissue so that the ideal of total mastectomy can be more nearly achieved. A careful follow up of all patients who have had subcutaneous mastectomies and the establishment of a national registry to evaluate accurately, over a long period of time, the value of the procedure is proposed.
Article
Intuitively, breast tissue mass should be directly related to a woman's risk of breast cancer, simply because having more cells at risk would seem to increase the potential for malignant transformation. However, studies attempting to link breast size with breast cancer risk have been inconsistent. Limitations include crude measures of breast size, the inability to distinguish glandular from adipose tissue, and the confounding influence of co-factors such as obesity. A nationwide study in Denmark was undertaken to investigate the effect of breast reduction surgery on the subsequent risk of breast cancer, including an evaluation of the patterns of risk by age and time since surgery. The Danish Hospital Discharge Registry was used to identify women who underwent reduction mammaplasty between 1977 and 1992. Linkage based on personal identification numbers with the Danish Cancer Registry provided information on cancer incidence. Expected numbers of cancers were calculated from rates in the general population. Among 7,720 women whose breasts were surgically reduced, 182 cancers were subsequently observed cf 209 expected (standardized incidence ratio [SIR] = 0.9;95 percent confidence interval [CI] = 0.7-1.0). Breast cancer was significantly reduced by nearly 50 percent (29 observed cf 53.9 expected, SIR = 0.5, CI = 0.4-0.8), and accounted for the overall deficit in cancer. The risk reductions were related inversely to age at surgery, with significant deficits apparent only among women 40 years of age and older at surgery and especially among those over age 50 (SIR = 0.3). No clear trend was apparent with increasing years post-surgery. The findings indicate that breast reduction surgery among women over age 40 is associated with a lower subsequent risk of breast cancer, but the surgery and presumably glandular mass appear less closely related to breast cancer risk among younger women.
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.
Clinicopathological study of breast tissue in female-to-male transsexuals.
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