- The adult transgender population in the US is estimated to be 0.6% of the population:
- At least 1.4 million people
- Cross sex hormonal therapy:
- Is androgen based for people transitioning female to male:
- This results in decreased breast glandular tissue
- The pathological histology of the breast tissue:
- Is similar to a postmenopausal cis female
- If the breast tissue remains intact, there is the same risk of benign and malignant disease as natal females
- Is androgen based for people transitioning female to male:
- “Top surgery” is:
- Bilateral subcutaneous mastectomies
- Chest contouring
- Repositioning of the nipple areolar complex
- Guidelines for imaging prior to top surgery:
- Generally follow established guidelines for cis gendered females
- The American Society of Plastic Surgeons recommends:
- Pre-operative screening:
- Based on age and risk factors per these existing guidelines
- For high-risk patients:
- This may include mammography and MRI
- For average risk patients under the age of 40:
- There are no defined guidelines, and this is left to surgeon discretion
- Pre-operative screening:
- The risk of breast cancer following top surgery:
- Has been shown to decrease risk when compared to natal female risk or when no top surgery is done
- For Female to Male (F to M) patients who have not had top surgery:
- Their risk is based on gender genotype and is same as cis gender women
- The goal of top surgery is chest contouring:
- Thus, there is residual breast tissue over a standard nipple sparing mastectomy done for risk reduction or oncological purposes
- Top surgery does decrease breast cancer risk:
- Studies have shown this risk is similar to natal males
- Because there is likely residual breast tissue, it is imperative that physicians counsel patients about risk and self-awareness
- Testosterone therapy:
- While theorized to undergo aromatization to estrogen and thus cause increased risk:
- Has not been shown in this population to increase overall risk of development of breast cancer
- While theorized to undergo aromatization to estrogen and thus cause increased risk:
- Cross sex hormone therapy:
- Does not appear to alter breast cancer risk
- Currently screening guidelines from the American College of Radiology state:
- That for transgender men who have not had top surgery, or had breast reduction only:
- Guidelines for cisgender females should be followed:
- Imaging is “not usually appropriate” in transmasculine patients of any age or risk if they had bilateral mastectomies (top surgery):
- It is important to note that there are no longitudinal studies evaluating the efficacy of screening in this population
- Imaging is “not usually appropriate” in transmasculine patients of any age or risk if they had bilateral mastectomies (top surgery):
- Guidelines for cisgender females should be followed:
- That for transgender men who have not had top surgery, or had breast reduction only:
- References:
- Hayward J. Updates in Transgender Breast Imaging. Seminars in Ultrasound CT and MRI. Published online November 2022. doi:https://doi.org/10.1053/j.sult.2022.10.002
- Choosing Wisely: An Initiative of the ABIM Foundation. http://www.choosingwisely.org. Accessed September 27, 2023. https://www.choosingwisely.org/wp-content/uploads/2015/02/ASPS-choosing-wisely-list.pdf
- Meggetto O, Peirson L, Yakubu M, et al. Breast cancer risk and breast screening for trans people: an integration of 3 systematic reviews. CMAJ Open. 2019;7(3):E598-E609. doi:https://doi.org/10.9778/cmajo.20180028
Gooren LJ, van Trotsenburg MAA, Giltay EJ, van Diest PJ. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. The journal of sexual medicine. 2013;10(12):3129-3134. doi:https://doi.org/10.1111/jsm.12319 - Brown A, Lourenco AP, Niell BL, et al. ACR Appropriateness Criteria® Transgender Breast Cancer Screening. Journal of the American College of Radiology. 2021;18(11):S502-S515. doi:https://doi.org/10.1016/j.jacr.2021.09.005
- Pivo S, Montes J, Schwartz S, et al. Breast Cancer Risk Assessment and Screening in Transgender Patients. Clinical Breast Cancer. 2017;17(5):e225-e227. doi:https://doi.org/10.1016/j.clbc.2016.08.003
Rodrigo Arrangoiz MS, MD, FACS, FSSO 