Transgender people and breast cancer awareness

October is Breast Cancer Awareness Month, but there is one group of people who should be screened that might be falling through the cracks, according to breast surgeon Naomi Kalliath, DO, at Cape Cod Healthcare Breast Surgery - Hyannis and Cape Cod Healthcare Breast Surgery - Falmouth.

“There’s very little outreach done for transgender people for breast cancer awareness,” she said.

That is something she would like to see changed.

Part of the problem is that there haven’t been very many studies on the estimated risk of breast cancer for transgender people, Dr. Kalliath said, pointing out that the breast cancer risk calculators used for cisgender people don’t appropriately take into account the exogenous hormones or gender-affirming surgery that trans people may experience.

The large population data sets like SEER (Surveillance, Epidemiology, and End Results Program) that are generally used to identify high-risk populations that may benefit the most from screening don’t include a subset for transgender and non-binary individuals. That makes identifying high-risk sub-populations within the transgender community very difficult.

“With the little data we do have, much demonstrates that transgender individuals are at elevated risk,” Dr. Kalliath said. “For instance, a 2019 study by the VU University Medical Centre in Amsterdam indicated that transgender women are 47 times more likely to develop breast cancer than cisgender men, likely from feminizing hormones, which makes sense.”

Hormone replacement therapy in post-menopausal women is a known risk for breast cancer and the general rule is to minimize the number of years women are on it. Transgender women may start taking hormones as early as their late teens, which means they take the hormones for decades, not years, she said. The same study showed that transgender men also show increased risk compared to cisgender men, but less risk than cisgender women.

“With any transgender individual, with or without implants or prior surgery, I begin with a clinical history, physical exam including clinical breast exam, and potentially breast imaging,” Dr. Kalliath said. “A mammogram, ultrasound, and MRI are all options when clinically indicated. Depending on their risk factors and family history, they could be recommended for genetic testing.”

No matter what your gender is, your whole life journey plays a role in breast cancer risk, she said, and contrary to popular belief, family history is only a small part of that. One in eight women get breast cancer and most of those women do not have a family history. That misconception stops a lot of people from being as vigilant about screening as they should be.

Genetic Testing & Risk Recommendations

When considering risk and possible recommendation for genetic testing, Dr. Kalliath said doctors take many things into consideration including:

• Sex assigned at birth,
• Current gender,
• Family history,
• History of breast biopsies and the results,
• History of radiation exposure,
• Hormone exposure,
• At what age menstruation began,
• At what age menopause occurred, and
• Age at the time of first birth (if applicable).

“Established guidelines for transgender-specific cancer screening recommendations really don’t exist, which is unfortunate, and it needs to change,” Dr. Kalliath said. “I really think it's important that trans people know their risk and feel comfortable coming in for consultation.”

The barriers to feeling comfortable with screening are numerous. Some transgender people feel like it’s a step backwards from their identity if they see a doctor like a gynecologist or breast specialist that is associated with their sex at birth. Others fear being turned away.

A National Institute of Health review of cancer screening in the transgender population revealed that 19 percent of people in one study reported a refusal of care. An additional 28 percent reported harassment, and 50 percent were turned off of the healthcare system due to a lack of gender nonconformity providers.

“Unfortunately, I do think there’s a political component to it sometimes,” Dr. Kalliath said. “It's not how it should be. The Hippocratic Oath doesn’t say for certain types of people to do no harm. That goes for all people.”

Dr. Kalliath assured that the staff at Cape Cod Healthcare Breast Surgery - Hyannis and Cape Cod Healthcare Breast Surgery - Falmouth. do not discriminate against anyone.

“That’s not how we operate, and I encourage anyone and everyone to come in for an open discussion and evaluation,” she said. “I really think treatment of gender dysphoria needs to be paired with outreach and screening for breast cancer, because I think access to healthcare begins with awareness.”