ArticleLiterature Review

Breast Cancer in Transgender Patients: A Systematic Review. Part 1: Male to Female

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Abstract

Male-to-Female (MtF) breast cancer events have been reported since 1968 however, MtF patients' risk of breast cancer remain unclear. Following PRISMA guidelines, electronic databases and grey literature were searched April 2018 to identify breast cancer events in MtF transgender persons. Screening and data extraction were independently performed in duplicate by two reviewers. Study quality was assessed using a component-based system. Qualitative analysis was performed on study characteristics, patient demographics, breast cancer characteristics, and breast cancer presentation and management. Eighteen articles met inclusion criteria representing 22 breast cancer events. Median age at breast cancer diagnosis was 51.5 years. The most common breast cancer type was adenocarcinomas (59.1%) and half of the breast cancers were hormone sensitive, with estrogen receptor positive status in 10 of 19 tested and progesterone receptor positive status in 5 of 14 tested. The most common presentation was breast lump (n = 6, 42.9%), two patients had palpable lymph nodes at presentation (14.3%), and six patients eventually developed metastases (42.9%). Seven patients had a recorded positive breast cancer family history and one was BRCA2 positive. Breast cancers were treated with mastectomies (simple, modified radical, and radical), wide local excision, lumpectomy, or were unclear. Four patients received hormone therapy (23.5%), two received radiation (11.8%), and seven received chemotherapy (41.2%). Breast cancer is present in MtF patients and commonly presents at a younger age with a palpable mass. Major gaps in the literature include lack of transgender population data and long term follow-up. This work highlights the need for screening recommendations.

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... A recent review analyzed 22 transgender women (individuals assigned as male at birth but identify as female) with breast cancer from 18 studies. 37 The median age of the 22 transgender patients with breast cancer was 51.5 years. Diagnosed breast cancers included 13 adenocarcinomas, 3 breast implant-associated anaplastic large cell lymphomas, 1 ductal carcinoma in situ, 1 secretory carcinoma, 1 malignant phyllodes, 1 Paget disease and invasive ductal carcinoma, and 2 were unspecified. ...
... Diagnosed breast cancers included 13 adenocarcinomas, 3 breast implant-associated anaplastic large cell lymphomas, 1 ductal carcinoma in situ, 1 secretory carcinoma, 1 malignant phyllodes, 1 Paget disease and invasive ductal carcinoma, and 2 were unspecified. 37 Ten of 19 tested cases had elevated levels of estrogen receptor present in the tissue (ie, estrogen receptor positive), and 5 of 14 tested cases had elevated levels of the progesterone receptor present in the tissue (ie, progesterone receptor positive). 37 Two of 8 reported cases had a positive human epidermal growth factor receptor 2 status, 7 patients had positive breast cancer family history, and 1 patient had a positive BRCA2 status. ...
... 37 Ten of 19 tested cases had elevated levels of estrogen receptor present in the tissue (ie, estrogen receptor positive), and 5 of 14 tested cases had elevated levels of the progesterone receptor present in the tissue (ie, progesterone receptor positive). 37 Two of 8 reported cases had a positive human epidermal growth factor receptor 2 status, 7 patients had positive breast cancer family history, and 1 patient had a positive BRCA2 status. 37 Of the 22 transgender patients with breast cancer, 20 reported taking cross-sex hormone therapy; the 2 remaining patients did not report whether they were Targeted therapy treatments used for hormone receptor-positive breast cancer include cyclindependent kinase 4 and 6 inhibitors and everolimus. ...
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.
... However, similar to natal females, continued mammographic and clinical screening for breast cancer is recommended in the transfeminine population. 66 Fortunately, many transgender women have been noted to be receptive to screening, viewing it as an opportunity to further embrace their femininity. 66,67 In addition to the lack of aesthetic and long-term outcomes, our study has a number of important limitations. ...
... 66 Fortunately, many transgender women have been noted to be receptive to screening, viewing it as an opportunity to further embrace their femininity. 66,67 In addition to the lack of aesthetic and long-term outcomes, our study has a number of important limitations. As with all studies using large databases, such as the ACS NSQIP, case selection is governed by diagnosis and procedural coding, and therefore comparisons of patients or operations are limited by the granularity of the specific codes. ...
Article
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Background: Breast augmentation in transgender women can be an important first step in addressing gender incongruence and improving psychosocial functioning. The aim of this study was to compare postoperative outcomes of augmentation mammoplasty in transgender and cisgender females. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2017 to establish 2 cohorts: (1) transgender females undergoing gender-affirming breast augmentation ("top surgery") and (2) cisgender females seeking cosmetic breast augmentation (CBA). Demographic characteristics and postoperative outcomes were compared between the 2 cohorts. Multivariable regression analysis was used to control for confounders. Results: A total of 1,360 cases were identified, of which 280 (21%) were feminizing top surgeries and 1,080 (79%) were CBA cases. The transfeminine cohort was significantly older, had a higher average body mass index, and was more racially diverse than the CBA cohort. Transfeminine patients also had higher rates of smoking, diabetes, and hypertension. The rates of all-cause complications were low in both cohorts, and differences were not significant (1.6% transfeminine versus 1.8% CBA, P = 0.890) for the first 30-days after operation. After controlling for confounding variables, transfeminine patients had postoperative complication profiles similar to their cisgender counterparts. Multivariable regression analysis revealed no statistically significant predictors for all-cause complications. Conclusions: Transfeminine breast augmentation is a safe procedure that has a similar 30-day complication profile to its cisgender counterpart. The results of this study should reassure and encourage surgeons who are considering performing this procedure.
... 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.
... According to a recent review, transgender female patients diagnosed with breast cancer tended to be diagnosed at a younger median age (51.5 years) compared to both cisgender female (60 years) and cisgender male (68 years) patients [17]. This suggests that transgender female patients may benefit from screening beginning at a younger age than their cisgender female counterparts, which is typically recommended starting at age 50 [18]. ...
... However, according to two cohort studies in transgender women, the incidence of breast cancer in this population remains low, between 4.1 and 20 per 100,000 patient years, when compared to cisgender females, in whom the incidence is as high as 170 cases per 100,000 patient years [11,19]. In addition, the review by Hartley et al, which included transgender female patients, demonstrated that only 13.6% of patients were diagnosed based upon screening mammography [17]. Albeit a small sample size, this rate is significantly less than the 43% rate seen in cisgender women. ...
... 10 In transgenders, the first two cases were reported in 1968 in two male to female (MtF) patients. 11 Among transgenders, transwomen (male to female) are at a higher risk of BC, as reported by de Block et al in a retrospective study. 10 In this report, we try to gain more insights into types of transgenders, GAHT, the risk associated with GAHT, patient presentation, and the dilemmas faced by this population in our society. ...
... 1,2 The length and dosage of estrogen treatment also play a role in the propagation of neoplastic breast epithelium. 11 Oral ethinylestradiol, an estrogen preparation, is not advised owing to the associated increased risks of blood clots and cardiovascular (CV) morbidity and mortality. However, transdermal estradiol patches or gel are safer to use as the risk of blood clotting is low. ...
Article
Full-text available
The molecular pathogenesis of breast cancer (BC), the second most common cancer, varies significantly between sexes, with minimal data in the transgender population. The overall prevalence of BC in transgenders is estimated to be 0.02%. Besides experiencing social disparities, transgenders have to face a lot of discrimination in the healthcare system. Adversities faced, along with the urge to identify with physical attributes to the gender felt by them, forces transgenders to use non-prescribed hormones. Gender affirming hormone therapy (GAHT) is a key feature of transition-related care, rehabbing mental health, and the quality of life of transgenders, but at the expense of their health. Studies have reported that GAHT is associated with severe health conditions such as cancer in transgenders. Estrogens and testosterone are associated with a moderate risk of developing BC. The types of BC diagnosed in transgenders after cross-sex hormone therapy include invasive ductal and neuroendocrine carcinoma, in addition to tubular adenocarcinoma. Although diagnosed at an age earlier compared with ciswomen, BC screening recommendations for transgenders are the same as for ciswomen. This review studies in detail the types of transgenders, their characteristics, different types of breast cancers associated, issues faced while treatment, and their best possible solutions. We also hope to have well-designed research in the future, which will fill the existing gaps in knowledge and provide scientific insight into the transgender population and issues related to their health. There are no international guidelines on screening and management of transgender patients but it appears that breast screening before cosmetic mastectomy, exposure to hormonal therapy for more than 5 years, and as per natal women screening guidelines should be offered to the patient with detailed discussion on the harms and benefits of the same.
... 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]. ...
... 32,33 More recently, textured implants have also been associated with the rare, but documented complication of BIA-ALCL. 34,35 Smooth implants were the implant of choice for the senior author. ...
Article
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Transgender women seeking gender-affirming breast augmentation often present with differences in preoperative chest measurements and contours in comparison with cisgender women. These include a more robust pectoralis muscle and limited glandular tissue, raising important considerations in determining the optimal anatomical plane for implantation. Abundant literature has described advantages and drawbacks of the available planes for breast augmentation in cisgender women. Certain drawbacks may be more pronounced for transgender women, given their distinct anatomy. The subfascial plane offers lower complication rates than the subglandular plane when using smooth implants, and avoids implant animation and displacement associated with the subpectoral plane. To our knowledge, existing studies have not yet addressed this discussion in the transfeminine population. The goal of this article is to highlight potential benefits of the subfascial plane for gender-affirming breast augmentation, utilizing a case series of 3 transfeminine patients, and to review the literature on surgical techniques and outcomes in this population. Methods: A retrospective chart review of patients presenting to a single surgeon for gender-affirming breast augmentation in 2019 was performed. A narrative literature review on surgical techniques and outcomes for gender-affirming breast augmentation was conducted. Results: Three cases of gender-affirming breast augmentation using subfascial implant placement are described. From the literature search, 12 articles inclusive of 802 transfeminine patients were identified. Conclusions: The subfascial plane represents an option for implant placement in gender-affirming breast augmentation that merits further investigation. There is a need for more research comparing surgical techniques and outcomes in the transfeminine population.
... To date, 22 cases of breast cancer in trans women and 20 cases in trans men have been published. [16][17][18][19] However, reliable estimations of the risk in transgender people are lacking because of the heterogeneity in the population and study cohorts. 20 To gain more insight into the risk of breast cancer in transgender people receiving hormone treatment and the influence of (exogenous) sex steroids on the development of breast cancer, we investigated the incidence and characteristics of breast cancer in a well documented cohort of transgender people receiving hormone treatment in the Netherlands, compared with the general Dutch population. ...
Article
Full-text available
Objective To investigate the incidence and characteristics of breast cancer in transgender people in the Netherlands compared with the general Dutch population. Design Retrospective, nationwide cohort study. Setting Specialised tertiary gender clinic in Amsterdam, the Netherlands. Participants 2260 adult trans women (male sex assigned at birth, female gender identity) and 1229 adult trans men (female sex assigned at birth, male gender identity) who received gender affirming hormone treatment. Main outcome measures Incidence and characteristics (eg, histology, hormone receptor status) of breast cancer in transgender people. Results The total person time in this cohort was 33 991 years for trans women and 14 883 years for trans men. In the 2260 trans women in the cohort, 15 cases of invasive breast cancer were identified (median duration of hormone treatment 18 years, range 7-37 years). This was 46-fold higher than in cisgender men (standardised incidence ratio 46.7, 95% confidence interval 27.2 to 75.4) but lower than in cisgender women (0.3, 0.2 to 0.4). Most tumours were of ductal origin and oestrogen and progesterone receptor positive, and 8.3% were human epidermal growth factor 2 (HER2) positive. In 1229 trans men, four cases of invasive breast cancer were identified (median duration of hormone treatment 15 years, range 2-17 years). This was lower than expected compared with cisgender women (standardised incidence ratio 0.2, 95% confidence interval 0.1 to 0.5). Conclusions This study showed an increased risk of breast cancer in trans women compared with cisgender men, and a lower risk in trans men compared with cisgender women. In trans women, the risk of breast cancer increased during a relatively short duration of hormone treatment and the characteristics of the breast cancer resembled a more female pattern. These results suggest that breast cancer screening guidelines for cisgender people are sufficient for transgender people using hormone treatment.
... 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.
... Other risk factors for breast cancer development in men include elevated oestrogens (imbalance of oestrogen and testosterone), liver cirrhosis, prostate cancer, age, obesity and smoking. In individuals who undergo male-tofemale gender reassignment, hormonal stimulation may promote breast cancer development 303 . Clinically, men with breast cancer present at older age (60-70 years) and with higher stage than women with breast cancer. ...
Article
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Breast cancer is the most frequent malignancy in women worldwide and is curable in ~70-80% of patients with early-stage, non-metastatic disease. Advanced breast cancer with distant organ metastases is considered incurable with currently available therapies. On the molecular level, breast cancer is a heterogeneous disease; molecular features include activation of human epidermal growth factor receptor 2 (HER2, encoded by ERBB2), activation of hormone receptors (oestrogen receptor and progesterone receptor) and/or BRCA mutations. Treatment strategies differ according to molecular subtype. Management of breast cancer is multidisciplinary; it includes locoregional (surgery and radiation therapy) and systemic therapy approaches. Systemic therapies include endocrine therapy for hormone receptor-positive disease, chemotherapy, anti-HER2 therapy for HER2-positive disease, bone stabilizing agents, poly(ADP-ribose) polymerase inhibitors for BRCA mutation carriers and, quite recently, immunotherapy. Future therapeutic concepts in breast cancer aim at individualization of therapy as well as at treatment de-escalation and escalation based on tumour biology and early therapy response. Next to further treatment innovations, equal worldwide access to therapeutic advances remains the global challenge in breast cancer care for the future.
... 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.
... In total, 10/19 breast cancers expressed estrogen receptors (ER+) and 5/14 were PR+. Family history of breast cancer was reported by seven patients (one BRCA2+) [24]. ...
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.
... Albeit studies remain scarce, the same discrepancy is observed for transgender male to female, where breast cancer is usually diagnosed at a younger age 51.5-year old while the incidence of breast cancer is increased by 46-fold when compared to male [13 , 14] . 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] . ...
Article
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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.
... To date, 22 cases of breast cancer in trans women and 20 cases in trans men have been published. [16][17][18][19] However, reliable estimations of the risk in transgender people are lacking because of the heterogeneity in the population and study cohorts. 20 To gain more insight into the risk of breast cancer in transgender people receiving hormone treatment and the influence of (exogenous) sex steroids on the development of breast cancer, we investigated the incidence and characteristics of breast cancer in a well documented cohort of transgender people receiving hormone treatment in the Netherlands, compared with the general Dutch population. ...
... Such as, breast cancer screening for women begins at 40 years old although Hartley et all revealed that transgender female had got breast cancer risk, too (while there's lack of literature). (16) The ignorance of female-to-female sex transmission is a problem not only for STDs but also for cervix cancer screening. (17) Maza et al revealed that cancer screening is also a problem for ...
Article
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Although most health issues affecting populations generally, individuals who define themselves as lesbian, gay, bisexual or gender incongruent (earlier named transsexual) (LGBT) reported that there are still disparities in healthcare. In a primary care setting not only for the management of chronic conditions but also to screen for the preventable diseases, Family Physicians (FPs) should not ignore to understand the patients’ sexual orientation and gender identity.
... Likewise, the concomitant administration of progesterone would reduce the potential risk of breast cancer and cardiovascular events, as described by Martinez Ramos [87]. Male-to-female (MtF) breast cancer cases have nevertheless been reported since 1968, but the breast cancer risk of MtF patients remained unknown at the moment in which Hartley [88] decided to study the subject by looking at literature updates. Among the conclusions, there was the fact that breast cancer is present in MtF patients, who typically present with a palpable mass at a younger age. ...
Article
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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.
... Cisgender women carry a 12% lifetime risk of breast cancer, while cisgender men carry only a 0.1% lifetime risk of breast cancer [2] . However, there is limited data and research regarding the risk and pathogenesis of breast cancer in transgender women undergoing CSH therapy [3] . This paucity of data is at least in part due to a lack of evidence-based consensus breast cancer screening recommendations offered to transgender women, poor subject follow-up, as well as barriers to care faced by the community, which include historical marginalization, reluctance to disclose, and lack of provider experience and resources [4 ,5] . ...
Article
Full-text available
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.
... Mammary development includes the formation of ducts, lobules, and acini, which is histologically identical to cisgender females and should not be referred to as gynecomastia [4,9,10]. There are Transgender Breast Cancer Screening published reports of benign breast entities, such as fibroadenomas, cysts, and lipomas [3,11], as well as breast malignancies that include ductal and lobular carcinomas and malignant phyllodes tumor [3,12]. ...
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.
... In addition, there are specific risks associated with implant surgery, such as capsular contracture [11] or breast implant-associated lymphoma (BIA-ALCL) [12,13]. Consideration should also be given to the potentially increased risk of developing breast cancer due to CSHT [14] and the limited validity of imaging due to the insertion of silicone implants [15]. ...
Article
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Background To achieve long-term improvement in health care of transgender women, it is necessary to analyze all aspects of gender-confirming surgery, especially the relation of risks and benefits occurring in these procedures. While there are many studies presenting data on the urologic part of the surgery, there are just few data about complications and satisfaction with breast augmentation. Methods This is a retrospective study using parts of the BREAST-Q Augmentation Questionnaire and additional questions for symptoms of capsular contracture and re-operations and analyzing archived patient records of all transwomen which were operated at University Hospital Essen from 2007 to 2020. Results 99 of these 159 patients (62%) completed the questionnaire after a median time of 4 years after surgery. Breast augmentation led to re-operations due to complications in 5%. The rate of capsular contracture (Baker Grad III–IV) in this population was 3%. Most patients (75%) rated high scores of satisfaction with outcome (more than 70 points) and denied to have restrictions due to their implants in their everyday life. All patients reported an improvement in their quality of life owing to breast augmentation. Conclusion Breast augmentation by inserting silicon implants is a safe surgical procedure which takes an important part in reducing 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.
Article
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Breast cancer in trans women is rare. Only 21 cases have been reported worldwide. Multidisciplinary teams must balance oncologic treatment with patient goals. Here we describe a case of invasive ductal carcinoma in a transgender woman who was found to have a BRCA2 gene mutation. A shared decision-making process led to the patient undergoing bilateral nipple-sparing mastectomy with immediate tissue expander placement. Later findings prompted discussions about adjuvant chemotherapy and radiation. Additionally, we discuss the complexities associated with reconstructing a transfeminine chest.
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.
Chapter
Gender-affirming surgeries are increasingly common in the United States. For many transgender and gender nonbinary (TGNB) patients, gender-affirming surgery is a critical aspect of their overall health and wellness, with a significant impact on mental health and social functioning. Primary care clinicians are in a unique position to guide TGNB patients seeking gender-affirming surgery. This chapter provides an overview of the preoperative assessment and perioperative management for the most common gender-affirming surgeries, from the perspective of a primary care clinician.
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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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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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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.
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The emergency department (ED) is the safety net for US healthcare. The Emergency Medical Treatment and Active Labor Act (EMTALA) mandates that EDs provide necessary care to every patient who presents for care, regardless of their ability to pay, their insurance status, or other factors. As a result, the ED population is often more vulnerable and at greater risk for disparate care than the general population, and at greater risk for poor health outcomes. An understanding of healthcare inequities and social determinants of health for diverse and vulnerable populations presenting to the ED is necessary for competent and effective care. Vulnerable populations are diverse and include racial and ethnic minorities, children, elderly, socioeconomic disadvantaged, underinsured/under-resourced, immigrants, lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ) persons, non-English speakers, prisoners, and those requiring accommodations for disabilities, among others.
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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.
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The risk of breast cancer in transgender women continues to be a topic of debate in the medical literature. Studies have theorized an increased risk in transgender women taking feminizing hormone therapy on the basis of established risk factors and histological characteristics in cisgender men and established increased risk in cisgender women on hormone replacement therapy. Historically, testing this theory has been challenging due to a relative lack of cases and large-scale, long-term studies reported in the literature. Studies to date have been contradictory, and a lack of medical consensus has led to inconsistencies in establishing universally accepted standards of care, including guidelines for screening. We hope to contribute to the ongoing discussion by presenting a case report of a transgender woman who had taken feminizing hormone therapy intermittently over 40 years and was subsequently diagnosed with breast cancer.
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Background: A growing number of transgender women present to plastic surgeons seeking breast augmentation. Despite some advocating their technical similarity, the authors have found substantially different planning and techniques are needed to obtain aesthetic results in transgender patients versus cosmetic breast augmentation. The authors sought to develop an approach for operative planning and technique to elucidate these differences and obtain consistent results. Methods: All patients who underwent breast augmentation at the Johns Hopkins Center for Transgender Health were included in this study. Anthropometric assessments were obtained and comparative statistics between operative and nonoperative cohorts were calculated. Outcomes were analyzed and a patient-reported survey was performed to evaluate patient satisfaction. Results: Fifty-nine consecutive transfemale patients presented for evaluation. Anthropometric measurements included base width (median, 15.0 ± 2.1 cm), notch-to-nipple distance (median, 22.0 cm), nipple-to-midline distance (median, 12.0 cm), areolar diameter (median, 3.5 ± 1.5 cm), and upper pole pinch (mean, 1.8 ± 1.1 cm). Thirty-six patients underwent augmentation mammaplasty. Postoperative complications (8.3 percent) included a minor hematoma and grade III capsular contracture in two patients. Patients were asked to complete a brief outcomes survey and reported an improvement in psychosocial well-being and high satisfaction rate (100 percent) with the overall cosmetic result. Conclusions: Transgender female patients represent a unique patient population requiring special consideration of anatomical differences in key planning decisions. The authors delineate the first systematic algorithm that addresses these differences, emphasizing maneuvers such as routine inframammary fold lowering. This can allow experienced augmentation surgeons to obtain excellent aesthetic and patient-reported outcomes in this population. As with cosmetic breast augmentation, patient satisfaction rates are high. Clinical question/level of evidence: Therapeutic, IV.
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Female transgender (male to female) is an individual assigned male sex at birth born but who identifies itself and desires to live as female. To achieve and maintain these characteristics, sometimes, it is necessary to undergo hormone therapy and/or surgical treatment. Benign lesions have been described including: fibroadenoma, lobular hyperplasia, pseudoangiomatous stromal hyperplasia, myofibroblastoma, angiolipoma and benign prosthesic reactions. And malignant pathology such as: ductal carcinoma in situ, Paget's disease, infiltrating carcinoma of non-special type (ductal, NOS), secretory adenocarcinoma, malignant phyllodes tumor and breast implant associated anaplastic large cell lymphoma. The described cases of each of these entities are reviewed. In conclusion, hormonal action or prosthesis implantation in female transgender can lead to associated pathologies in the mammary gland that follow a similar pattern to that found in the male breast. Although breast cancer is less frequent than in cisgender women, gynecological control or screening is recommended by some associations.
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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.
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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.
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Transgender women are increasingly evaluated in breast imaging centers. Radiologists should be familiar with a range of imaging findings related to feminizing hormone therapy and breast augmentations as well as benign and malignant lesions seen in this population. A growing body of literature has suggested that feminizing hormone therapy may increase the risk of breast cancer, prompting professional organizations to develop screening guidelines. The aim of this paper is to review common breast imaging findings in transgender women, recent data on the association between feminizing hormone therapy and breast cancer, and guidelines for breast cancer screening. Knowing these unique imaging features in transgender women is essential for providing competent care and reducing health care disparities.
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Management of a transgender (TG) woman's gender dysphoria is individualized to address the sources of her distress. This typically involves some combination of psychological therapy, hormone modulation, and surgical intervention. Breast enhancement is the most commonly pursued physical modification in this population. Because hormone manipulation provides disappointing results for most TG women, surgical treatment is frequently required to achieve the goal of a feminine chest. Creating a female breast from natal male chest anatomy poses significant challenges; the sexual dimorphism requires a different approach than that used in cisgender breast augmentation. The options and techniques used continue to evolve as experience in this field grows.
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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.
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Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare but serious complication in patients with breast implants, Patients are at risk of BIA-ALCL whether they receive breast implants for cosmetic reasons or for reconstructive purposes after surgery for breast cancer or prophylactic mastectomy. During the past decade, an increased number of reports have addressed BIA-ALCL. Herein, we describe BIA-ALCL in a transgender woman. The patient received breast implants as part of her gender transition and was diagnosed with BIA-ALCL 20 years later. The patient underwent several revisional operations in the 20 years after her primary breast surgery to treat unexplained pain with low-grade fever, severe capsular contracture (Baker grade III-IV), and several instances of implant rupture. In July 2016, the patient presented to our office with "late-onset" periprosthetic seroma 5 years after her last revisional breast surgery. She was diagnosed with BIA-ALCL without capsular invasion based on results of cytologic analysis of the periprosthetic seroma and histologic evaluation of the periprosthetic capsule. This diagnosis was verified further by results of immunohistochemical testing, which indicated expression of CD30 and T-cell markers in the periprosthetic seroma only. Our intentions with this case report are to demonstrate that all patients who undergo breast implantation, including transgender women, are at risk of BIA-ALCL and to highlight the importance of cytomorphologic and immunohistochemical screening of seroma fluid in patients with late-onset periprosthetic seroma. Level of evidence: 5.
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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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Importance Breast cancer is a leading cause of premature mortality among US women. Early detection has been shown to be associated with reduced breast cancer morbidity and mortality. Objective To update the American Cancer Society (ACS) 2003 breast cancer screening guideline for women at average risk for breast cancer.Process The ACS commissioned a systematic evidence review of the breast cancer screening literature to inform the update and a supplemental analysis of mammography registry data to address questions related to the screening interval. Formulation of recommendations was based on the quality of the evidence and judgment (incorporating values and preferences) about the balance of benefits and harms.Evidence Synthesis Screening mammography in women aged 40 to 69 years is associated with a reduction in breast cancer deaths across a range of study designs, and inferential evidence supports breast cancer screening for women 70 years and older who are in good health. Estimates of the cumulative lifetime risk of false-positive examination results are greater if screening begins at younger ages because of the greater number of mammograms, as well as the higher recall rate in younger women. The quality of the evidence for overdiagnosis is not sufficient to estimate a lifetime risk with confidence. Analysis examining the screening interval demonstrates more favorable tumor characteristics when premenopausal women are screened annually vs biennially. Evidence does not support routine clinical breast examination as a screening method for women at average risk.Recommendations The ACS recommends that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation). Women aged 45 to 54 years should be screened annually (qualified recommendation). Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation). Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation). Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation). The ACS does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).Conclusions and Relevance These updated ACS guidelines provide evidence-based recommendations for breast cancer screening for women at average risk of breast cancer. These recommendations should be considered by physicians and women in discussions about breast cancer screening.
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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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Incidence and prevalence of applications in Sweden for legal and surgical sex reassignment were examined over a 50-year period (1960-2010), including the legal and surgical reversal applications. A total of 767 people (289 natal females and 478 natal males) applied for legal and surgical sex reassignment. Out of these, 89 % (252 female-to-males [FM] and 429 male-to-females [MF]) received a new legal gender and underwent sex reassignment surgery (SRS). A total of 25 individuals (7 natal females and 18 natal males), equaling 3.3 %, were denied a new legal gender and SRS. The remaining withdrew their application, were on a waiting list for surgery, or were granted partial treatment. The incidence of applications was calculated and stratified over four periods between 1972 and 2010. The incidence increased significantly from 0.16 to 0.42/100,000/year (FM) and from 0.23 to 0.73/100,000/year (MF). The most pronounced increase occurred after 2000. The proportion of FM individuals 30 years or older at the time of application remained stable around 30 %. In contrast, the proportion of MF individuals 30 years or older increased from 37 % in the first decade to 60 % in the latter three decades. The point prevalence at December 2010 for individuals who applied for a new legal gender was for FM 1:13,120 and for MF 1:7,750. The FM:MF sex ratio fluctuated but was 1:1.66 for the whole study period. There were 15 (5 MF and 10 MF) regret applications corresponding to a 2.2 % regret rate for both sexes. There was a significant decline of regrets over the time period.
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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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Objectives: We estimated the prevalence and incidence of gender identity disorder (GID) diagnoses among veterans in the Veterans Health Administration (VHA) health care system and examined suicide risk among veterans with a GID diagnosis. Methods: We examined VHA electronic medical records from 2000 through 2011 for 2 official ICD-9 diagnosis codes that indicate transgender status. We generated annual period prevalence estimates and calculated incidence using the prevalence of GID at 2000 as the baseline year. We cross-referenced GID cases with available data (2009-2011) of suicide-related events among all VHA users to examine suicide risk. Results: GID prevalence in the VHA is higher (22.9/100 000 persons) than are previous estimates of GID in the general US population (4.3/100 000 persons). The rate of suicide-related events among GID-diagnosed VHA veterans was more than 20 times higher than were rates for the general VHA population. Conclusions: The prevalence of GID diagnosis nearly doubled over 10 years among VHA veterans. Research is needed to examine suicide risk among transgender veterans and how their VHA utilization may be enhanced by new VA initiatives on transgender care.
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Formal epidemiological studies on the incidence and prevalence of gender identity disorder (GID) or transsexualism have not been conducted. Accordingly, crude estimates of prevalence have had to rely on indirect methods, such as parental endorsement of behavioral items pertaining to GID on omnibus questionnaires for children and youth or the number of adult patients seeking contra-sex hormonal treatment or sex-transformative surgery at hospital- or university-based gender clinics. Data from child and adolescent parent-report questionnaires show that the frequent wish to be of the other sex is quite low but that periodic cross-gender behavior is more common. In the general population, cross-gender behavior is more common in girls than it is in boys but boys are referred to gender identity clinics more frequently than are girls. Prevalence estimates of GID in adults indicate that it is higher in natal males than in natal females although this may be accounted for by between-sex variation in sexual orientation subtypes. Prevalence estimates of GID in adults based on clinic-referred samples suggest an increase in more recent cohorts. It remains unclear whether this represents a true increase in prevalence or simply greater comfort in the seeking out of clinical care as professionals become more attuned to the psychosocial and biomedical needs of transgendered people.
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CLINICAL SCENARIO You are about to see a 76-year-old retired schoolteacher for the second time. You first saw her in the clinic a month ago because of cognitive problems. Your evaluation at that time included a Standardized Mini-Mental State Examination,1 on which she scored 18 out of a possible 30 points, and a physical examination that was normal including no focal neurological signs. You arranged investigations for the treatable causes of dementia that were negative, and you thus feel she has probable Alzheimer's disease.
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Introduction. Long-term effects and side effects of cross-sex hormone treatment in transsexual persons are not well known. Aim. The aim of this study is to describe the effects and side effects of cross-sex hormone therapy in both transsexual men and women. Main Outcome Measures. Hormone levels were measured by immunoassays. Physical health was assessed by physical examination and questionnaires on general health and specific side effects, areal bone parameters by dual energy X-ray absorptiometry. Methods. Single center cross-sectional study in 100 transsexual persons post-sex reassignment surgery and on average 10 years on cross-sex hormone therapy. Results. Transsexual men did not experience important side effects such as cardiovascular events, hormone-related cancers, or osteoporosis. In contrast, a quarter of the transsexual women had osteoporosis at the lumbar spine and radius. Moreover, 6% of transsexual women experienced a thromboembolic event and another 6% experienced other cardiovascular problems after on average 11.3 hormone treatment years. None of the transsexual women experienced a hormone-related cancer during treatment. Conclusion. Cross-sex hormone treatment appears to be safe in transsexual men. On the other hand, a substantial number of transsexual women suffered from osteoporosis at the lumbar spine and distal arm. Twelve percent of transsexual women experienced thromboembolic and/or other cardiovascular events during hormone treatment, possibly related to older age, estrogen treatment, and lifestyle factors. In order to decrease cardiovascular morbidity, more attention should be paid to decrease cardiovascular risk factors during hormone therapy management. Wierckx K, Mueller, S, Weyers S, Van Caenegem E, Roef G, Heylens G, and T'Sjoen G. Long-term evaluation of cross-sex hormone treatment in transsexual persons. J Sex Med **;**:**–**.
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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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Adverse effects of long-term cross-sex hormone administration to transsexuals are not well documented. We assessed mortality rates in transsexual subjects receiving long-term cross-sex hormones. A cohort study with a median follow-up of 18.5 years at a university gender clinic. Methods Mortality data and the standardized mortality rate were compared with the general population in 966 male-to-female (MtF) and 365 female-to-male (FtM) transsexuals, who started cross-sex hormones before July 1, 1997. Follow-up was at least 1 year. MtF transsexuals received treatment with different high-dose estrogen regimens and cyproterone acetate 100 mg/day. FtM transsexuals received parenteral/oral testosterone esters or testosterone gel. After surgical sex reassignment, hormonal treatment was continued with lower doses. In the MtF group, total mortality was 51% higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause. No increase was observed in total cancer mortality, but lung and hematological cancer mortality rates were elevated. Current, but not past ethinyl estradiol use was associated with an independent threefold increased risk of cardiovascular death. In FtM transsexuals, total mortality and cause-specific mortality were not significantly different from those of the general population. The increased mortality in hormone-treated MtF transsexuals was mainly due to non-hormone-related causes, but ethinyl estradiol may increase the risk of cardiovascular death. In the FtM transsexuals, use of testosterone in doses used for hypogonadal men seemed safe.
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An African American male to female transgender patient treated with estrogen detected a breast lump that was confirmed by her primary care provider. The patient refused mammography and 14 months later she was diagnosed with metastatic breast cancer with spinal cord compression. We used ethnographic interviews and observations to elicit the patient's conceptions of her illness and actions. The patient identified herself as biologically male and socially female; she thought that the former protected her against breast cancer; she had fears that excision would make a breast tumor spread; and she believed injectable estrogens were less likely than oral estrogens to cause cancer. Analysis suggests dissociation between the patient's social and biological identities, fear and fatalism around cancer screening, and legitimization of injectable hormones. This case emphasizes the importance of eliciting and interpreting a patient's conceptions of health and illness when discordant understandings develop between patient and physician.
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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.
Article
Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) is a rare peripheral T cell lymphoma. BIA-ALCL is a disease of the fibrous capsule surrounding the implant and occurs in patients after both breast reconstruction and augmentation. More than 300 cases have been reported so far, including two in a transgender patient. Here we describe BIA-ALCL presented with a mass in a transgender patient and the first case of BIA-ALCL in the Czech Republic. In 2007, a 33-year-old transgender male to female underwent bilateral breast augmentation as a part of his transformation to female. In June 2014, the patient developed a 5-cm tumorous mass in her left breast. Magnetic resonance imaging of the chest revealed a ruptured implant and a tumorous mass penetrating into the capsule and infiltrating the pectoral muscle. An R0 surgery was indicated—the implant, silicone gel and capsule were removed, and the tumorous mass was resected together with a part of the pectoral muscle. Histology revealed anaplastic large-cell lymphoma. The patient underwent standard staging procedures for lymphoma including a bone marrow trephine biopsy, which confirmed stage IE. The patient was treated with the standard chemotherapy for systemic ALCL—6 cycles of CHOP-21. The patient was tumor-free at the 2-year follow-up. BIA-ALCL has been reported mostly in women who received implants for either reconstructive or aesthetic augmentation. This is the third report of BIA-ALCL in a transgender person, the first in the Czech Republic. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Introduction: A systematic review and meta-analysis was conducted to evaluate how various definitions of transgender affect prevalence estimates. Aims: To evaluate the epidemiology of transgender and examine how various definitions of transgender affect prevalence estimates and to compare findings across studies that used different methodologies, in different countries, and over different periods. Methods: PubMed, EMBASE, and Medline were searched to identify studies reporting prevalence estimates of transgender in a population. All studies were grouped based on the case definition applied to the numerator. Summary estimates were derived using a random-effects model for total prevalence of transgender and for male-to-female and female-to-male subgroups. Overall and stratum-specific meta-prevalence estimates (mPs) and 95% confidence intervals (CIs) were accompanied by tests for heterogeneity and meta-regressions to assess sources of heterogeneity. Main outcome measures: The main outcome measure was population prevalence of transgender. Secondary outcomes included gender-specific prevalence estimates for male-to-female and female to male subgroups. Results: Thirty-two studies met the inclusion criteria for systematic review. Of those, 27 studies provided necessary data for a meta-analysis. Overall mP estimates per 100,000 population were 9.2 (95% CI = 4.9-13.6) for surgical or hormonal gender affirmation therapy and 6.8 (95% CI = 4.6-9.1) for transgender-related diagnoses. Of studies assessing self-reported transgender identity, the mP was 871 (95% CI = 519-1,224); however, this result was influenced by a single outlier study. After removal of that study, the mP changed to 355 (95% CI = 144-566). Significant heterogeneity was observed in most analyses. Conclusion: The empirical literature on the prevalence of transgender highlights the importance of adhering to specific case definitions because the results can range by orders of magnitude. Standardized and routine collection of data on transgender status and gender identity is recommended.
Article
Breast cancer is rare in male patients. Certain predisposing factors, be they genetic (e.g. BRCA2 gene mutations) or hormonal (imbalance between estrogen and androgen levels) have been implicated in male breast cancer pathophysiology. Male to female (MtF) transsexualism is a condition that generally involves cross-sex hormone therapy. Anti-androgens and estrogens are used to mimic the female hormonal environment and induce the cross-sex secondary characteristics. In certain situations, the change of the hormonal milieu can be disadvantageous and favor the development of hormone-dependent pathologies, such as cancer. We report a case of a MtF transgender (TG) patient who developed breast cancer after seven years of cross-sex hormonal therapy. The patient was found to be BRCA2 positive, and suffered recurrent disease. The patient was unaware of being a member of an established BRCA2 mutation positive kindred. This represents the first case of a BRCA2 mutation predisposing to breast cancer in a MtF transgender patient.
Article
CONTEXT: Despite decades of accumulated observational evidence, the balance of risks and benefits for hormone use in healthy postmenopausal women remains uncertain. OBJECTIVE: To assess the major health benefits and risks of the most commonly used combined hormone preparation in the United States. DESIGN: Estrogen plus progestin component of the Women's Health Initiative, a randomized controlled primary prevention trial (planned duration, 8.5 years) in which 16608 postmenopausal women aged 50-79 years with an intact uterus at baseline were recruited by 40 US clinical centers in 1993-1998. INTERVENTIONS: Participants received conjugated equine estrogens, 0.625 mg/d, plus medroxyprogesterone acetate, 2.5 mg/d, in 1 tablet (n = 8506) or placebo (n = 8102). MAIN OUTCOMES MEASURES: The primary outcome was coronary heart disease (CHD) (nonfatal myocardial infarction and CHD death), with invasive breast cancer as the primary adverse outcome. A global index summarizing the balance of risks and benefits included the 2 primary outcomes plus stroke, pulmonary embolism (PE), endometrial cancer, colorectal cancer, hip fracture, and death due to other causes. RESULTS: On May 31, 2002, after a mean of 5.2 years of follow-up, the data and safety monitoring board recommended stopping the trial of estrogen plus progestin vs placebo because the test statistic for invasive breast cancer exceeded the stopping boundary for this adverse effect and the global index statistic supported risks exceeding benefits. This report includes data on the major clinical outcomes through April 30, 2002. Estimated hazard ratios (HRs) (nominal 95% confidence intervals [CIs]) were as follows: CHD, 1.29 (1.02-1.63) with 286 cases; breast cancer, 1.26 (1.00-1.59) with 290 cases; stroke, 1.41 (1.07-1.85) with 212 cases; PE, 2.13 (1.39-3.25) with 101 cases; colorectal cancer, 0.63 (0.43-0.92) with 112 cases; endometrial cancer, 0.83 (0.47-1.47) with 47 cases; hip fracture, 0.66 (0.45-0.98) with 106 cases; and death due to other causes, 0.92 (0.74-1.14) with 331 cases. Corresponding HRs (nominal 95% CIs) for composite outcomes were 1.22 (1.09-1.36) for total cardiovascular disease (arterial and venous disease), 1.03 (0.90-1.17) for total cancer, 0.76 (0.69-0.85) for combined fractures, 0.98 (0.82-1.18) for total mortality, and 1.15 (1.03-1.28) for the global index. Absolute excess risks per 10 000 person-years attributable to estrogen plus progestin were 7 more CHD events, 8 more strokes, 8 more PEs, and 8 more invasive breast cancers, while absolute risk reductions per 10 000 person-years were 6 fewer colorectal cancers and 5 fewer hip fractures. The absolute excess risk of events included in the global index was 19 per 10 000 person-years. CONCLUSIONS: Overall health risks exceeded benefits from use of combined estrogen plus progestin for an average 5.2-year follow-up among healthy postmenopausal US women. All-cause mortality was not affected during the trial. The risk-benefit profile found in this trial is not consistent with the requirements for a viable intervention for primary prevention of chronic diseases, and the results indicate that this regimen should not be initiated or continued for primary prevention of CHD.
Chapter
Intensive epidemiological studies have identified a number of genetic risk factors associated with breast cancer, including evidence of BRCA1 and BRCA2 susceptibility genes, familiar history of cancer in the breast, ovary or endometrium and individual history of breast diseases [1]. An increased risk has also been associated with early onset of menstruation, nulliparity or delayed first childbirth, short duration of breast feeding, late menopause, use of hormone replacement therapy and increased bone density [2–4]. A principal culprit common for all these endocrine-related risk factors is the prolonged exposure to female sex hormones [5–8]. The hormonal influences have been mainly attributed to unopposed exposure to elevated levels of estrogens [5], as has been indicated for a variety of female cancers, namely, vaginal, hepatic and cervical carcinomas [9–11]. Exposure to estrogens, particularly during the critical developmental periods (e.g., in utero, puberty, pregnancy, menopause), also affects affective behaviors (e.g., depression, aggression, alcohol intake) and increases breast cancer risk [12].
Article
A 41-year-old male-to-female (MtF) transgender patient presented with a symptomatic tender lump in the left breast. There was no family history of breast cancer. She had been receiving estrogen therapy for 14 years to maintain her secondary sexual characteristics. Triple assessment revealed a 13 mm triple-negative grade 3 invasive ductal carcinoma. The tumour was completely excised following a left wide local excision and sentinel lymph node biopsy. There was no regional lymph node involvement. She was referred to the oncologist for adjuvant chemotherapy and radiotherapy. 2015 BMJ Publishing Group Ltd.
Article
Objective: The purposes of this article are to describe two cases of breast cancer in male-to-female transsexuals and to review eight cases previously reported in the literature. Conclusion: Breast cancer occurs in male-to-female transsexuals who receive high doses of exogenous estrogen and develop breast tissue histologically identical to that of a biologically female breast. This exposure to estrogen results in increased risk of breast cancer. The first patient described is a male-to-female transsexual with screening-detected ductal carcinoma in situ and a family history of breast cancer. The other patient is a male-to-female transsexual with invasive ductal carcinoma that was occult on diagnostic digital mammographic and ultrasound findings but visualized on digital breast tomosynthesis and breast MR images. The analysis of the eight previously reported cases showed that breast cancer in male-to-female transsexuals occurs at a younger age and is more frequently estrogen receptor negative than breast cancer in others born biologically male. Screening for breast cancer in male-to-female transsexuals should be undertaken for those with additional risk factors (e.g., family history, BRCA2 mutation, Klinefelter syndrome) and should be available to those who desire screening, preferably in a clinical trial.
Article
Importance Male-to-female (MTF) transsexual individuals take hormone treatment (HT) for acquisition and maintenance of female secondary sex characteristics. Rare but serious complications associated with long-term HT have been reported. While HT is usually initiated in specialized centers, long-term maintenance is often through more conveniently located primary care providers. Thus, clinicians should be familiar with the potential complications of long-term HT. Observations We present a case of a 60-year-old MTF transgender individual diagnosed with breast cancer after 8 years of HT. In addition, we summarize the related literature and briefly discuss the reported incidence of hormone-sensitive malignancies in MTF transgenders as well as recommendations for monitoring and screening on and off HT. Conclusions and Relevance: This case highlights several issues for MTF transgender patients. Physicians caring for these patients should discuss with them relevant cancer screening protocols. In addition, prolactin level should be monitored in subjects on long-term estrogen. An important unanswered question is the age at which cross-sex hormone administration can be responsibly discontinued without inducing an unacceptable risk of osteoporosis and bone fractures. Further reporting of cases such as ours should be encouraged as true insight can only come from reporting of adverse effects in the medical literature.
Article
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
There is limited published literature on the risk of breast cancer in transgender patients. We report a case of an aggressive triple negative inflammatory breast cancer in a male-to-female transsexual. This patient had a complicated psychiatric history with significant antipsychotic use, and the case raises several questions about the pathogenesis of this breast cancer. The literature on breast cancer in transgender patients and in relation to hyperprolactinaemia is reviewed. © 2013 The Authors. Internal Medicine Journal
Article
The Metamorphoses Greek myth includes a story about a woman raised as a male falling in love with another woman, and being transformed into a man prior to a wedding ceremony and staying with her. It is therefore considered that people who desire to live as though they have the opposite gender have existed since ancient times. People who express a sense of discomfort with their anatomical sex and related roles have been reported in the medical literature since the middle of the 19th century. However, homosexual, fetishism, gender identity disorder, and associated conditions were mixed together and regarded as types of sexual perversion that were considered ethically objectionable until the 1950s. The first performance of sex-reassignment surgery in 1952 attracted considerable attention, and the sexologist Harry Benjamin reported a case of 'a woman kept in the body of a man', which was called transsexualism. John William Money studied the sexual consciousness about disorders of sex development and advocated the concept of gender in 1957. Thereafter the disparity between anatomical sex and gender identity was referred to as the psychopathological condition of gender identity disorder, and this was used for its diagnostic name when it was introduced into DSM-III in 1980. However, gender identity disorder encompasses a spectrum of conditions, and DSM-III -R categorized it into three types: transsexualism, nontranssexualism, and not otherwise specified. The first two types were subsequently combined and standardized into the official diagnostic name of 'gender identity disorder' in DSM-IV. In contrast, gender identity disorder was categorized into four groups (including transsexualism and dual-role transvestism) in ICD-10. A draft proposal of DSM-5 has been submitted, in which the diagnostic name of gender identity disorder has been changed to gender dysphoria. Also, it refers to 'assigned gender' rather than to 'sex', and includes disorders of sexual development. Moreover, the subclassifications regarding sexual orientation have been deleted. The proposed DSM-5 reflects an attempt to include only a medical designation of people who have suffered due to the gender disparity, thereby respecting the concept of transgender in accepting the diversity of the role of gender. This indicates that transgender issues are now at a turning point.
Article
T h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 364;13 nejm.org march 31, 2011 1251 This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations. A healthy and successful 40-year-old man finds it increasingly difficult to live as a male. In childhood he preferred playing with girls and recalls feeling that he should have been one. Over time he has come to regard himself more and more as a female personality inhabiting a male body. After much agonizing, he has concluded that only sex reassignment can offer the peace of mind he craves. What would you advise? The Cl inic a l Probl em Gender identity is the sense one has of being male or female. 1,2 A significant incon-gruence between gender identity and physical phenotype is known as gender iden-tity disorder; the experience of this state, termed gender dysphoria, 1 is a source of chronic suffering. Manifestations of gender identity disorder range from simply living as a member of the opposite sex to partial or maximal physical adaptation through hormonal and surgical treatment. For most transsexuals (about 66%), the disorder has an early onset, in childhood; for the remainder, it develops much later in life. 3 For this older group of patients, usually men, the transition to a new sex from one they have lived in for many years is particularly difficult. 4 Traditionally, gender identity disorder has been viewed as a psychiatric condi-tion, and it will probably retain its classification as such in the Diagnostic and Statisti-cal Manual of Mental Disorders (DSM) (Table 1). 3,4 However, a substantial proportion of the transgender population does not have a clinically significant coexisting psychiatric condition, 2 and sex reassignment benefits this group. 5,6 The cause of gender identity disorder is unknown. Postmortem studies of small numbers of male-to-female transsexuals have shown a typically female pattern of sexual differentiation in two areas of the brain — the bed nucleus of the stria terminalis and the hypothalamic uncinate nucleus 7 — suggesting that gender identity disorder may be a sexual differentiation disorder affecting the brain. 8,9 Gender identity disorder cannot be explained by variations in chromosomal patterns or identifiable hormonal abnormalities. 8 Nor is there convincing evidence that psychological factors (being exposed to certain family dynamics or being raised as a member of the opposite sex) cause this condition. 10 The diagnosis relies on assessment by a mental health professional according to the criteria specified in the fourth edition (text revision) of the DSM (DSM-IV-TR) 4 (Table 1) and elabo-rated in clinical practice guidelines from the Endocrine Society. 11 The estimated prevalence of adult transsexualism in the Netherlands has been stable over time, at a rate of 1 case per 11,900 men and 1 per 30,400 women 12 ; similar or lower rates have been reported elsewhere. Estimates of the prevalence in North America are less precise, but the number of persons seeking help for gender identity disorder in North America has recently increased. 13 Among trans-The New England Journal of Medicine Downloaded from nejm.org at KAISER PERMANENTE on March 30, 2011. For personal use only. No other uses without permission.
Article
The challenges of managing breast cancer in women with augmented breasts include screening, diagnosis, oncologic and revisional surgery, and surveillance. In addition, women with augmented breasts frequently have greater expectations of cosmetic outcomes. More breast clinicians will be affected by these challenges as augmentation grows in popularity and women with implants reach the age range in which they are at higher risk of developing breast cancer. In the United States, more than 2 million women have undergone augmentation, making this the second most commonly performed cosmetic procedure. With a lifetime risk of developing breast cancer of 1 in 8, it is projected that more than 50,000 women who undergo augmentation each year in the United States will develop breast cancer at some point in their lives. This is a review of current practice based on an exhaustive literature search of PubMed, Google Scholar, and conference proceedings. A series of case studies is presented to illustrate mammographic changes and cosmetic outcomes in augmented breasts that have required treatment for breast cancer. An evidence-based summary of recommendations has been produced to guide breast surgeons in managing this particular group of patients. Management of breast cancer in previously augmented breasts presents a unique range of challenges. Patients can be reassured that the presence of an implant does not increase the risk of breast cancer developing or affect the prognosis if breast cancer does develop. Clinical judgement is made balancing surgical and oncologic principles to provide the best cosmetic outcome.
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
Data on the necessity of performing screening mammographies in transsexual women are lacking. The main objective of this study was to assess the possibility to perform mammography and breast sonography in transsexual women. Fifty Dutch-speaking transsexual women were interviewed about the following: attitude towards mammography and breast sonography, importance attributed to and satisfaction with breast appearance, opinion about the necessity of breast check-up, expectations regarding discomfort during the exams and knowledge about the breast surgery. A fasting blood sample, clinical breast exam, mammography and breast sonography were performed. At mammography the following parameters were noted: density, technical quality, location of the prostheses, presence of any abnormalities and painfulness. At sonography the following parameters were recorded: density, presence of cysts, visualisation of retro-areolar ducts or any abnormalities. Twenty-three percent of patients are not aware of the type of breast implants and 79% do not know their position to the pectoral muscles. Patient satisfaction with the appearance of their breasts was rather high (7.94 on a scale of 0-10). Mean expected and experienced pain from mammography was low (4.37 and 2.00 respectively). There was no statistically significant difference in expected pain between those who already had mammography and those who did not. There was a significant positive correlation between the expected and the experienced pain. Mammography and breast sonography were technically feasible and no gross anomalies were detected. Since both exams were judged as nearly painless, 98% of transsexual women intended to come back if they would be invited. Since breast cancer risk in transsexual women is largely unknown and breast exams are very well accepted, breast screening habits in this population should not differ from those of biological women.
Article
Transsexualism is the most extreme form of gender identity disorder and most transsexuals eventually pursue sex reassignment surgery (SRS). In transsexual women, this comprises removal of the male reproductive organs, creation of a neovagina and clitoris, and often implantation of breast prostheses. Studies have shown good sexual satisfaction after transition. However, long-term follow-up data on physical, mental and sexual functioning are lacking. To gather information on physical, mental, and sexual well-being, health-promoting behavior and satisfaction with gender-related body features of transsexual women who had undergone SRS. Fifty transsexual women who had undergone SRS >or=6 months earlier were recruited. Self-reported physical and mental health using the Dutch version of the Short-Form-36 (SF-36) Health Survey; sexual functioning using the Dutch version of the Female Sexual Function Index (FSFI). Satisfaction with gender-related bodily features as well as with perceived female appearance; importance of sex, relationship quality, necessity and advisability of gynecological exams, as well as health concerns and feelings of regret concerning transition were scored. Compared with reference populations, transsexual women scored good on physical and mental level (SF-36). Gender-related bodily features were shown to be of high value. Appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women obtained a good score (8 and 9, respectively). However, sexual functioning as assessed through FSFI was suboptimal when compared with biological women, especially the sublevels concerning arousal, lubrication, and pain. Superior scores concerning sexual function were obtained in those transsexual women who were in a relationship and in heterosexuals. Transsexual women function well on a physical, emotional, psychological and social level. With respect to sexuality, they suffer from specific difficulties, especially concerning arousal, lubrication, and pain.
Article
Gender identity disorder is defined as persistent feelings of gender discomfort and the inappropriateness of one's anatomical sex. To study the effects of androgens on female breast tissue, we examined mammary glands from female-to-male transsexual (FTMT) women using androgen therapy and from those not using androgen therapy. Female-to-male transsexual breast tissue is a rare specimen in surgical pathology and there are no well-defined guidelines for its examination. We evaluated the clinicopathologic findings of 186 FTMT mammary glands. The patients' ages at presentation ranged from 18 to 49 years (mean 27.4 years). We detected breast carcinoma in only 1 of 130 FTMT women who had not used androgen therapy and in none of 56 FTMT women who had used androgen therapy. We described the histopathological morphology of FTMT breast tissue. The frequency of carcinoma and hyperplasia did not differ significantly between FTMT women who had used androgen therapy and those who had not. These findings suggest that androgen does not alter the risk of carcinoma developing in the mammary glands of FTMT women.
Article
The clinicopathological findings in a patient who developed breast carcinoma ten years after male-to-female sexual reassignment are reported. Only two other cases of transsexual men with breast carcinoma have been reported previously. All three patients received oral estrogens for prolonged periods to maintain secondary female characteristics. The controversies relating to hormonal influences in the etiology of breast cancer in men are discussed herein.
Article
The optimum steroid hormone treatment regimes for transsexual subjects has not yet been established. We have investigated the mortality and morbidity figures in a large group of transsexual subjects receiving cross-sex hormone treatment. A retrospective, descriptive study in a university teaching hospital. Eight hundred and sixteen male-to-female (M-->F) and 293 female-to-male (F-->M) transsexuals. Subjects had been treated with cross-sex hormones for a total of 10,152 patient-years. Standardized mortality and incidence ratios were calculated from the general Dutch population (age- and gender-adjusted) and were also compared to side effects of cross-sex hormones in transsexuals reported in the literature. In both the M-->F and F-->M transsexuals, total mortality was not higher than in the general population and, largely, the observed mortality could not be related to hormone treatment. Venous thromboembolism was the major complication in M-->F transsexuals treated with oral oestrogens and anti-androgens, but fewer cases were observed since the introduction of transdermal oestradiol in the treatment of transsexuals over 40 years of age. No cases of breast carcinoma but one case of prostatic carcinoma were encountered in our population. No serious morbidity was observed which could be related to androgen treatment in the F-->M transsexuals. Mortality in male-to-female and female-to-male transsexuals is not increased during cross-sex hormone treatment. Transdermal oestradiol administration is recommended in male-to-female transsexuals, particularly in the population over 40 years in whom a high incidence of venous thromboembolism was observed with oral oestrogens. It seems that in view of the deep psychological needs of transsexuals to undergo sex reassignment, our treatment schedule of cross-sex hormone administration is acceptably safe.
Article
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Article
We describe a female-to-male trans-sexual, aged 33, who developed breast cancer 10 years after cosmetic bilateral subcutaneous mastectomy and nipple reimplantation. The complex hormonal pathways involved and the implications for women undergoing prophylactic mastectomy because of a high risk of familial breast cancer are discussed.
Article
Secretory carcinomas of the breast were first described as "juvenile carcinoma" by McDivitt and Stewart in a cohort of children. This term has been replaced by the term "secretory breast carcinoma", because the entity can occur at any time of life. Carcinoma of the male breast is uncommon and accounts for approximately 1% of all cancers in men. Recently, it has been reported that human secretory breast carcinoma expresses the ETV6-NTRK3 gene fusion that was previously cloned in pediatric mesenchymal cancers. We present the case of a 46-year-old male-to-female transsexual in whom a secretory breast carcinoma was an incidental finding. As confirmation of the histopathological diagnosis we detected the novel ETV6-NTRK3 gene fusion in this tumor.
Mammary fibroadenoma in a male-to-female transsexual.
  • Kanhai R.C.J.
  • Hage J.J.
  • Bloemena E.
  • Van Diest P.J.
  • Karim R.B.
Breast cancer in a transgender patient and role for screening mammography.
  • Kelley K.
Guidelines for the primary and gender-affirming care of transgender and gender non-binary people.
  • Deutsch M.B.