An analysis of breast imaging center websites and a literature search for research articles on transgender breast health found that “issues related to transgender breast imaging are not well addressed in the radiology literature or in the radiology community, even though more transgender patients are presenting to breast centers.”1
Miriam David, MD
The study’s senior author, Miriam David, MD, Director of Breast Imaging Services, Advanced Imaging at Westchester Medical Center (WMC), said in an interview with The ASCO Post: “It is our hope at WMC, that this study will raise awareness and encourage radiologists and, more broadly, other health-care providers across many disciplines, to optimize our imaging services and how we share information with our patients, especially transgender people.” Dr. David is also Clinical Associate Professor of Radiology at New York Medical College, Valhalla, New York.
The impetus for the study “was a clear unmet need,” Dr. David said. “When I was attending community board meetings in the Bronx, community members asked what the breast radiology section was doing to reach out to transgender and male patients. I recognized they had identified an important need that I had the opportunity to address.”
Why Websites?
“For most patients, a breast imaging center’s website may be their first exposure to the practice. In particular, for transgender patients, a lack of information pertaining to their health on the website as well as gendered language and imagery may add to the alienation they experience in many aspects of health care,” Dr. David and her coauthors wrote. They selected 20 websites across the United States using a national consumer group listing of “America’s Best Breast Centers” and additional centers in two urban areas, New York and San Francisco, “that would have a higher likelihood of including transgender-related content,” the authors explained.
“For transgender patients, a breast imaging center’s website may be their first exposure to the practice.”— Miriam David, MD
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“Taken together, none of the 40 breast center websites that used the term ‘transgender’ mentioned breast imaging registries, screenings, or treatment of breast disease in transgender individuals or support groups for transgender individuals,” the researchers reported.
Scientific Literature Review
For the scientific literature review portion of their study, Dr. David and her colleagues “performed a PubMed search for all publications using the search phrases transgender breast cancer, LGBT [lesbian, gay, bisexual, transgender] breast cancer, and transgender breast imaging.” Of the 48 unique articles identified from 2010 to 2019, 11 were published in 2015, more than in the prior 5 years, and the number of new articles has fluctuated since then. However, “there has been continued research into this topic across multiple medical disciplines, suggesting that awareness of transgender breast health is increasing,” the authors noted.
Those multiple disciplines include surgery, medicine, and endocrinology, Dr. David said. “The use of hormone therapy and its duration may impact screening guidelines and even cancer prevention.”
Screening Guidelines
The study results “indicate that while research in transgender breast health is increasing, it is still insufficient to address the challenge in developing evidence-based guidelines for breast screening, especially as more transgender patients may present to breast centers for imaging,” the authors wrote. Breast cancer screening guidelines for transgender individuals are a work in progress, complicated by the lack of consensus for overall breast cancer screening guidelines in this population. “It is important to realize that we are dovetailing into an area that is already full of conflict and controversy,” Dr. David noted.
“Despite a potential benefit of screening, studies have shown conflicting results as to whether the transgender population should undergo mammography screening at the same rate as the cisgender population,” according to the study report.
“While research in transgender breast health is increasing, it is still insufficient to address the challenge in developing evidence-based guidelines for breast screening.”— Miriam David, MD
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“We do have guidelines in place,” Dr. David said, with the most commonly used being those from the [University of California, San Francisco (UCSF)] Center of Excellence for Transgender Health.2 The UCSF guidelines for transgender women generally call for starting screening at age 50 if there has been hormone use for more than 5 years, with more specific recommendations based on BRCA status, family history, radiation exposure, and some other factors, Dr. David explained.
“While it is important to have evidence-based screening guidelines, we try to personalize our recommendations by considering these additional risk factors as well as breast density,” Dr. David continued. She also noted there are different types of screening, not just mammography, but ultrasound and magnetic resonance imaging.
Absolute Risk Is Low
The results of a recently reported Dutch study “showed an increased risk of breast cancer in transgender women compared with cisgender men” and “suggested that breast cancer screening guidelines for cisgender people are sufficient for transgender people using hormone treatment.”3
“As the Dutch study really pointed out,” Dr. David said, “the goal isn’t to screen more people unnecessarily. The absolute risk of breast cancer in transgender people, in studies to date, is still quite low.” Awareness of that risk “is more important than simply initiating screening programs,” she continued.
Another important point mentioned in the Dutch study, she added, was that raising awareness “may lead to preventive programs. For example, discontinuing hormone treatment in older transgender patients might decrease their risk of breast cancer.”
Other Concerns
Not knowing when and where to undergo breast cancer screening may put transgender people at higher risk for delayed diagnosis and worse outcomes, as Dr. David noted in a Reuters article about the study.4
Another issue of particular concern to the transgender community, Dr. David added, was raised in a 2017 case report of breast implant-associated analastic large cell lymphoma in a transgender woman.5 This report points out that “an estimated 60% to 70% of individuals who undergo male-to-female transition require breast implantation. Therefore, breast implant–associated anaplastic large cell lymphoma may be diagnosed more frequently in transgender women in the coming years.”
The authors of that study concluded: “Physicians must recognize that all patients with breast implants, including transgender women, are at risk of breast implant–associated anaplastic large cell lymphoma. Cytohistologic and immunohistochemical analyses of aspirated seroma fluid constitute the most sensitive screening and diagnostic approach for patients with breast implants who present with late-onset periprosthetic seroma.”
More Research Needed
“More research, with input from radiologists, is vital” to the development of evidence-based breast screening guidelines for transgender patients, Dr. David stressed. According to a recent article on what radiologists should know about breast imaging in transgender patients,6 “evidence-based data on breast imaging and outcomes in transgender individuals are currently scant; prospective larger and longer-term studies are necessary to delineate the exact risk of breast cancer in the transgender population and, therefore, to create more robust guidelines for screening. More generally, radiologists must be aware of the needs of transgender individuals undergoing breast imaging and understand the health-care barriers that many face so optimal care can be delivered.”
“Additional data, specifically from prospective longitudinal follow-up of transgender individuals electing breast cancer radiologic surveillance, [are] needed to understand breast cancer risk in this population and to develop appropriate risk-adapted screening protocols,” stated Sonnenblick et al.7
DISCLOSURE: Dr. David reported no conflicts of interest.
REFERENCES
1. Huang SY, Zhang M, David M: Radiology’s engagement with transgender breast imaging: Review of radiology practice websites and publications. Journal of Breast Imaging. January 30, 2020 (early release online).
2. Deutsch MB: Screening for breast cancer in transgender women. Available at https://transcare.ucsf.edu/guidelines/breast-cancer-women. Accessed March 2, 2020.
3. de Blok CJM, Wiepjes CM, Nota NM, et al: Breast cancer risk in transgender people receiving hormone treatment: Nationwide cohort study in the Netherlands. BMJ 365:I1652, 2019.
4. Rapaport L: Trans patients may struggle to access breast cancer screening. Health News, Reuters, February 13, 2020.
5. de Boer M, van der Sluis WB, de Boer JP, et al: Breast implant-associated anaplastic large-cell lymphoma in a transgender woman. Aesthetic Surg J 37:NP83-NP87, 2017.
6. Parikh U, Mausner E, Chhor CM, et al: Breast imaging in transgender patients: What the radiologist should know. Radiographics 40:13-27, 2020.
7. Sonnenblick EB, Shah AD, Goldstein Z, et al: Breast imaging of transgender individuals: A review. Curr Radiol Rep 6:1, 2018.
