Breast Cancer Risk and Screening: Essential Information for Transgender Individuals

Understanding breast cancer screening, such as mammography, can be a challenge for women. However, the conversation requires an extra level of nuance for transgender men and women whose breast cancer risk is complex and rarely discussed.

The U.S. Preventive Services Task Force (USPSTF) recently recommended amendments to its guidelines for screening mammography. They propose that women aged 40 to 74 years old, who have an average risk of breast cancer, undergo biannual screening.

These guidelines apply to cisgender women, nonbinary people, and trans men who were assigned female at birth.

The breast cancer risk for transgender individuals is slightly more nuanced. "There are populations within the LGBTQ+ community that are at a higher risk of developing breast cancer—specifically, male-to-female transgender individuals that have undergone five years of hormone replacement, and also female-to-male individuals that have not had top surgery," explained Robyn Roth, MD, a breast imaging specialist and podcast host, to Health.

Here's what experts recommend regarding transgender individuals and breast cancer, why this group often receives insufficient care, and what people of all gender identities should do to stay informed about their personal breast cancer risk:

Being transgender does not necessarily affect a person's physical health, but certain therapies can increase or decrease a person's breast cancer risk. In particular, people who have undergone gender-affirming care via hormone therapy or surgery may have a different level of breast cancer risk than what is expected for the gender they were assigned at birth.

Trans women who take hormones such as estrogen or progesterone are at a higher risk of developing breast cancer. "If you have a breast cancer, usually these occur because there's a mutation in the cells," said Edward Ray, MD, a plastic surgeon specializing in gender affirmation surgery at Cedars-Sinai. "Estrogen is linked to that process as well in many cases," he added. "So a lot of breast cancers grow faster and more aggressively if they're exposed to estrogen."

Though more research needs to be done on the subject, the opposite is valid for trans men who have undergone gender-affirming care, according to Dr. Ray. Androgen therapy, such as testosterone, may reduce the risk of developing estrogen receptor-positive breast cancer.

Breast cancer risk is also "substantially decreased" if a person has top surgery, which removes most of their breast tissue, according to Tami Rowen, MD, an obstetrician-gynecologist at the Center of Excellence for Transgender Health at the University of California, San Francisco.

However, it's essential to keep in mind that not all trans individuals are in this category. "If someone is transgender but has not used hormones or undergone surgery, they would have the same breast cancer risk as the cis population," Dr. Rowen stated. "You wouldn't screen or treat them any differently."

Dr. Roth added that many social factors could impact trans people's breast cancer risk. Past discomfort with doctors, being in areas designed primarily for cisgender men or women, and lifestyle factors such as nicotine and alcohol use disorders, all contribute to this. Also, trans men may be less likely to become pregnant or breastfeed, which would typically lower a person's risk long-term.

According to Dr. Roth, the current political climate could also be a medical concern—laws targeting transgender healthcare could make individuals less likely to seek medical care or be open to doctors about their gender identity and health issues.

"Our healthcare system is predominantly designed by and for cisgender heterosexual people," Dr. Roth remarked. "So we understand that the LGBTQ+ community—particularly concerning breast cancer—is more likely to have their symptoms ignored or dismissed."

The lack of clear guidelines for trans individuals and breast cancer risk is undoubtedly a worry. Although trans men are included in the USPSTF's planned screening mammography guidelines, trans women are not.

Dr. Ray explained breast cancer risk as a sort of hierarchy. Cisgender women have the highest risk, followed by trans women who’ve been taking estrogen for longer periods of time. Trans men who’ve had top surgery or who are taking testosterone would be next, and cisgender men have the lowest risk.

“[Trans women] still carry breast cancer risks and they should be screened. We just haven’t figured out timing and any other specifics about when to institute screening,” Dr. Ray said.

For trans men, who are included in the USPSTF draft guidelines, getting a mammogram every other year may not be necessary or even helpful. Trans men who’ve gotten top surgery are still at an elevated risk for breast cancer as compared to cisgender men, Dr. Rowen said, but it’s difficult to determine if that really warrants extra screening.

“There isn’t really a critical consensus,” she said. “Mammograms can be pretty dysphoric—they’re done for cis women. They’re not done for cis men, who also have breast tissue and breast cancer risk. So should we be treating [trans men] the same as we treat cis men, who still have the risks but don’t get screened because the cancer is rare? And that’s really an open question.”

The questions swirling around breast cancer screening for trans people hit at a core issue of cancer screening guidelines in general—breast cancer risk is individualized, and can depend on family history, genetics, or even a person’s race or type of breast tissue.

“[The USPSTF] can’t go into the nuance of every single person’s individual risk,” said Dr. Rowen.

Dr. Rowen recommends that providers and patients familiarize themselves with the World Professional Association for Transgender Health for more specific guidelines.

Though there are many unanswered questions about breast cancer risk for trans people, experts are confident that we’ll soon know more about best practices for keeping all people safe.

“There’s a lot of active research, especially now that we have larger patient populations who are going through these types of surgeries,” Dr. Ray said.

In the meantime, there are a few important things to keep in mind when it comes to breast cancer risk.

“Find a provider that you can trust, and [who] has cultural competency and experience,” Dr. Roth said. People can have open conversations with their doctor about whether mammography or other screening would be useful, depending on their gender-affirming care history.

Trans people who have a family history of breast cancer should also undergo genetic counseling, Dr. Ray said, just like any cisgender person. For certain trans women who are at a high risk of breast cancer, they’d want to speak with a doctor about how taking estrogen might heighten that risk, he said.

All people—regardless of gender—should also get into the habit of doing regular self-breast exams, experts agreed. If something seems off, it’s important to bring it up to a doctor right away.

“Everyone, at the end of the day, deserves equal access to the best breast cancer care, to give them the best outcomes possible—regardless of gender identity, sexual orientation, race, economic status, ethnicity,” Dr. Roth said. “We need to do our part to minimize breast cancer disparities at every level.”