What Transgender Women and Transfeminine People Need to Know About Breast Cancer

Your risk may be affected by gender-affirming hormone therapy.

Transgender woman reading papers while working on a laptop.

Breast cancer screening may not be something you've thought about much if you were assigned male at birth, but it is possible for transfeminine people to develop breast cancer.

Unfortunately, until very recently, transfeminine people were often left out of cancer screening guidelines. But because the evidence indicates there is a risk, there has been an effort to develop guidelines for screening among transfeminine people. Here’s why it’s important to know your risk and to understand the recommendations for getting screened.

Knowing your breast cancer risk

People assigned male at birth in the United States have a 1 in 800 chance of being diagnosed with breast cancer at some point in their lives, according to data from the National Cancer Institute for the years 2015 to 2017. The risk for transfeminine people on gender-affirming hormone therapy (GAHT) is thought to be higher than that (though still lower than that of people assigned female at birth), based on a few factors. For starters, feminizing hormone therapy—which typically consists of estrogen along with testosterone-blocking medications—can lead to some breast growth.

"A transgender woman on hormone therapy develops breast tissue similar to a cisgender woman—the ducts and the lobules and parts of the breast that can be prone to breast cancer," says Ujas Parikh, MD, a radiologist and clinical fellow in the department of radiology and biomedical imaging at the University of California, San Francisco, and co-author of a 2019 article in the journal RadioGraphics on breast imaging in transgender patients.

What limited data there is on breast cancer in transfeminine people shows that the risk is not zero. Meanwhile, studies of postmenopausal cisgender women taking hormone therapy show an increased risk of breast cancer, which is something that could be extrapolated to transfeminine people on GAHT, explains Dr. Parikh.

Other risk factors for breast cancer also play a role, regardless of your gender. These include a personal or family history of breast or ovarian cancer, a genetic predisposition to breast cancer or a history of chest radiation.

Understanding the screening guidelines

In 2021, the American College of Radiology (ACR) published the first-ever ACR Appropriateness Criteria for Transgender Breast Cancer Screening. These guidelines offer recommendations based on a variety of factors, including age, hormone-therapy status, surgical history and one’s unique constellation of risk factors. They advise when breast imaging is usually appropriate, may be appropriate and usually not appropriate. Guidelines like these can give you a better idea of if and when you need to be screened and can help you have informed conversations with your HCP.

For example, the ACR says that it may be appropriate for a transfeminine person who is 40 years or older and has been on hormone therapy for five or more years to get screened for breast cancer. The guidelines also suggest that it is usually appropriate to get screened if you are younger than that but have a higher-than-average risk due to your personal or family medical history.

As with general breast cancer screening guidelines, which tend to vary by the organization providing them, the recommendations for transgender people aren't necessarily unanimous. The University of California, San Francisco's Transgender Care and Treatment Guidelines, for example, recommend mammograms for transfeminine people every two years starting at age 50 and only after being on hormone therapy for five to 10 years. 

As knowledge grows about the advantages of breast cancer screening in transfeminine people and researchers and medical associations continue making efforts to determine risks, guidelines are evolving. For now, the best thing you can do to navigate your own risk and screening is to have an open discussion of your risk factors and your hormone therapy with your HCP to determine the best plan for you.

“Despite the challenges of making recommendations, there has been increasing awareness of the importance of doing so," says Parikh, who cites the ACR’s guidelines for transgender individuals as an example of this trend.

Finding affirming care

People who are transgender, nonbinary or gender nonconforming often face stigma and discrimination in healthcare settings, which can make the prospect of seeking a mammogram as a transfeminine person especially challenging. The good news is that if you already have an HCP who provides sensitive and affirming care to gender-diverse patients, they can often recommend other providers who will be similarly competent. Parikh suggests asking affirming providers for recommendations for radiology imaging centers that are also knowledgeable in transgender health care.

If you don't already have a trusted, affirming primary care provider, you can search for one through online resources like Outcare and GLMA, word of mouth or local LGBTQ+ community resources. You can also call your local Planned Parenthood.

It's worth noting that if you're seeking breast cancer screening and your health insurance plan has your gender listed as male, you may need to ask your HCP for prior authorization or to use certain modifiers in order for screening to be covered. Making these phone calls before your appointment can save you time and stress in the event that your insurance company isn't cooperative.

"It's really exciting that we're trying to figure out the most effective and optimal ways to detect breast cancer in the transgender community," says Parikh. "I think there's still so much we need to do."

Article sources open article sources

National Cancer Institute. Breast Cancer Risk in American Women. Reviewed: December 16, 2020.
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. 2019;365:l1652.
American College of Radiology. ACR Appropriateness Criteria. Transgender Breast Cancer Screening. 2021.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Screening for breast cancer in transgender women. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.
Parikh U, Mausner E, Chhor CM, Gao Y, Karrington I, Heller SL. Breast imaging in transgender patients: what the radiologist should know. Radiographics. 2020;40(1):13-27.
Centers for Disease Control and Prevention. Breast Cancer Screening Guidelines for Women. Document reviewed September 22, 2020.

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