Breast Cancer Screening and the Transgender Community
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1 Breast Cancer Screening and the Transgender Community Evidence Based Clinical Considerations Author: Mr David Finkelde - Clinical Director Presenter: Dr Nick Repin - Designated Radiologist
2 Three Important Questions What do we know about breast cancer risk for transgender individuals - Male to Female and Female to Male? Is there evidence that population screening provides the best surveillance for transgender individuals? How do we ensure the best clinical care for transgender people with respect to breast cancer?
3 Breast Cancer Risk in the Transgender Community Two distinct populations Transgender female (natal male) Transgender male (natal female) Marked heterogeneity in each group Very little published evidence Recognised potential for institutional bias in those few papers that have been published
4 Transgender Women 2 published reports : Gooren et al: 2 probable cases amongst 2307 Transgender females between 1975 and 2011 with >5years of cross sex hormone (CSH)use Brown: 3 cases in Transgender females in a review of 5135 Transgender veterans In each study the incidence of breast cancer approximates risk of natal male population rather than known female risk level
5 Transgender Women (2) Limited true data 13 cases of breast cancer arising in Transgender females in the English language medical literature up to 2015 No evidence that cross-sex hormones (CSH) result in a greater incidence of breast cancer than in the natal (male) population Wide variation in patterns of CSH use, make analysis of risk difficult No evidence that breast augmentation with silicon prostheses is associated with an increased risk of breast cancer
6 Transgender Men Risk of breast cancer almost entirely related to amount of retained breast parenchyma Where no breast glandular tissue removed, breast cancer risk is similar to natal females, ~12%, irrespective of hormonal manipulation (Phillips) Surgical removal of breast glandular tissue covers a spectrum from reduction mammoplasty to subcutaneous mastectomy
7 Risk Summary Transgender Women Risk more closely matches natal males than natal females No proven effects of CSH for developing breast cancer - but the data is poor Transgender Men Baseline risk level is equivalent to natal females Only documented means to reduce risk is bilateral mastectomy No evidence that CSH will decrease risk in this population
8 Screening Mammography for Transgender People What evidence is there of benefit from mammographic screening? What risks might there be from mammographic screening? How practical is mammographic screening? Does a population based screening program meet the clinical needs of the transgender community?
9 Screening Mammography for Transgender People (2) What we do know? Value of screening mammography is based on studies of natal females in defined populations (age, interval, asymptomatic) A mass Population Based Screening program is not designed for diverse clinical needs
10 Screening Mammography for Transgender People (3) What are the risks? Radiation exposure False positive findings Inappropriate biopsy or intervention False negative findings False level of reassurance Risks need to be proportionate to the benefit
11 Screening Mammography for Transgender People (4) Is mammography possible for Transgender women? Technically possible - sometimes: Adequate imaging and tolerance from Dutch study (Weyers et al) High proportion of implants
12 Screening Mammography for Transgender People (5) Is mammography possible for Transgender men? Technically yes, for those who have not undergone breast reduction surgery Utility related to amount of residual breast glandular parenchyma Distribution of residual glandular tissue after subcutaneous mastectomy may not be suitable for mammography How to sensitively determine who has sufficient tissue for mammography within the constraints of a screening program?
13 Does a population based screening program meet the clinical needs of the Transgender community? Probably not Insufficient data or evidence on the need for screening within the respective groups Insufficient data on the effectiveness of a screening program for either Transgender men or Transgender women
14 Does a population based screening program meet the clinical needs of the Transgender community? (2) Surveillance should be customised to the individual s level of gender transition Absence of proven benefit, but definite risks: - Unnecessary/overexposure to radiation - Evidence shows the level of risk for Transgender females is extremely low, and screening has not demonstrated benefit. - Individuals are not at Population level risk - Mass screening program not equipped to manage individual psycho-social needs of transgender individuals.
15 What is the best way of monitoring the risk of breast cancer in the Transgender community? Individualised care - Imaging (multi-modality) matched to the objective level of risk for the individual - Education for the Transgender community of risk level - Education of the responsible members of respective medical teams
16 What is the best way of monitoring the risk of breast cancer in the Transgender community? (2) Clinical Trials, but - Heterogeneity of population with respect to surgery / CSH use - Large numbers needed - Long surveillance period to obtain meaningful results and demonstrate any advantage of a screening program - Cost
17 What is the best way of managing the risk of breast cancer in the Transgender community? (3) Agree a clinical solution tailored to individual need and risk, and based on evidence Informed consent Alternative access to appropriate imaging?specific Medicare item for imaging surveillance of those not suitable for BSA but with specific risks
18 References: Madeline B. Deutsch, MD, MPH, Editor; Guidelines for the Primary Care of Transgender and Gender Nonbinary People, Director of Clinical Services; UCSF Center of Excellence for Transgender Health Gooren LJ, van Trotsenburg MAA, Giltay EJ, and van Diest PJ. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. Journal of Sexual Medicine (2013), 10: Cancer Incidence in Australia 2017, AIHW Brown, GR & Jones KT, Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Research and Treatment (2015) 149: Brown GR, Breast Cancer in Transgender Veterans: A ten-case series. LGBT Health (2015) 2(1):77-80 Canadian Cancer Society: Get Screened Education Module for healthcare providers. Phillips J, Fein-Zachary VJ, Mehta TS, Littlehale N, Venkataraman S, and Slanetz PJ, Breast imaging in the transgender patient. AJR (2014) 202:
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