What transgender men and transmasculine people need to know about breast cancer

If you're a transgender man or transmasculine person wondering when and how often you should be screened for breast cancer, you're certainly not alone. Breast cancer screening can be hard to navigate, especially when your gender identity is often left out of the medical guidelines.

For transmasculine people on gender-affirming hormone therapy (GAHT) or who have had gender-affirming surgery to reduce or remove the breasts (also known as top surgery), the subject of breast health can be a complicated one.

After all, breast changes are often noticed through self-exams or annual exams. But for many transgender people, these are experiences that might cause distress due to gender dysphoria (the stress you might experience when you feel your gender identity doesn’t align with your physical or physiological characteristics). Discrimination and stigma can also lead many transgender people to avoid healthcare settings altogether.

"With increasing visibility of the transgender population, we need to be able to give exceptional care," says Ujas Parikh, MD, a radiologist at Cedars-Sinai in Los Angeles, California. "We must continue to increase our understanding of both breast cancer risk and appropriate imaging strategies in this population."

Because the risks of breast cancer for transmasculine people are not fully understood, it is even more important to know how your own risk factors and medical history can play a role. Fortunately, there are guidelines and experts who can provide advice on how best to pursue screening.

Knowing your breast cancer risk

An estimated 12.9 percent of people assigned female at birth in the United States will develop breast cancer at some point in their lives, according to figures compiled by the National Cancer Institute for the years 2015 to 2017. For people assigned male at birth in the U.S., the lifetime risk is 0.13 percent. The risk of breast cancer in transmasculine people is harder to measure due to limited research.

In addition to being assigned female at birth, factors that can raise your risk of breast cancer include being 55 years or older, having an inherited genetic mutation (especially in the BRCA1 or BRCA2 genes), having a family history of breast or ovarian cancer, having dense breast tissue, drinking alcohol, and being physically inactive.

But what about being on GAHT or having gender-affirming surgery?

Masculinizing hormone therapy doesn't seem to affect risk

Although there’s very little research on the topic, being on masculinizing hormone therapy—which typically involves taking some type of testosterone—appears not to increase or decrease breast cancer risk in transmasculine people.

That said, any hormone therapy, including testosterone, isn't recommended if you already have a hormone-sensitive cancer, like breast cancer. If you have a history of breast cancer, it's worth speaking to an oncologist (a medical doctor who specializes in treating cancer) before starting any hormone therapy, including testosterone.

Gender-affirming top surgery may decrease your risk

A bilateral mastectomy sought by a breast cancer patient to remove all breast tissue would significantly reduce the risk of breast cancer. But it’s unclear what breast cancer risk remains if you have gender-affirming top surgery, which may leave behind some breast tissue for aesthetic (appearance) or sculpting purposes. A review of research published in 2018 in the European Journal of Surgical Oncology indicated that the risk of breast cancer was lower in transgender men who had undergone top surgery than those who hadn’t. More data is needed to confirm these findings.

Don't assume you're not at risk for breast cancer after top surgery. It's still important for you and your healthcare provider (HCP) to discuss your surgical history and any other risk factors you might have.

Understanding the screening guidelines

If you're a transmasculine person who hasn't had top surgery, it's recommended that you follow the breast cancer screening guidelines for cisgender women. (Cisgender refers to a person whose gender identity corresponds with the sex they were identified as having at birth.) Those guidelines differ a bit depending on which medical organization provides them:

• The U.S. Preventive Services Task Force recommends cisgender women and people assigned female at birth get a mammogram every two years between the ages of 40 and 74.
• The American Cancer Society recommends that cisgender women get a mammogram every year between the ages of 45 and 54 and then every two years from age 55 to 74.
• The American College of Obstetricians and Gynecologists recommends that cisgender women decide along with their HCP whether to get a mammogram every year or every two years, as well as whether to start at age 40 or 50.
• The American College of Radiology recommends that cisgender women get a mammogram every year between the ages of 40 and 74.

With all of these recommendations, the decision to screen earlier, more frequently, or longer is left up to the patient and their HCP. It's also worth noting that these recommendations are for people at average risk of breast cancer. Having a genetic predisposition (or tendency toward a disease), for instance, will likely require earlier screening.

If you're wondering which guideline to follow, that's understandable. Having a trusted HCP who can help you navigate the recommendations while bearing in mind your personal risk factors is key. For more guidance specific to gender-diverse patients, the American College of Radiology (ACR) published their first-ever ACR Appropriateness Criteria for Transgender Breast Cancer Screening in 2021.

These guidelines are organized by gender identity, hormone therapy status, surgical history, and more. They advise when breast imaging is usually appropriate, may be appropriate, and usually not appropriate. Guidelines like these can give you a better idea about if and when you need to be screened and can help you have informed conversations with your HCP.

For example, the ACR criteria advise that it’s usually not appropriate for transmasculine people who have had top surgery to have mammograms. It is usually appropriate for transmasculine people at average risk of breast cancer who are 40 years old and over and who haven’t had top surgery to have mammograms.

What to do if you’ve had top surgery

For transmasculine people who’ve had top surgery, there is currently not enough data to make definitive screening recommendations. What’s more, a lack of breast tissue can make mammography difficult. Leading medical organizations for now ultimately suggest discussing with your HCP whether it makes sense for you to have regular chest wall exams or ultrasounds to screen for breast cancer.

"At this time, we currently just recommend clinical and physical examination and discussion with the clinician," explains Dr. Parikh.

This can be tricky if you don't already have a provider you see on a regular basis. But it's important to know that the risk of breast cancer after top surgery is likely not gone entirely and it depends on the type and extent of surgery you received. Being aware of breast and chest health is therefore an important part of the overall wellness plan you devise with your HCP.

What to expect from breast cancer screening

Seeking breast cancer screening as a transmasculine person can be a daunting and potentially traumatizing experience. This makes it worth trying to find a medical practice that is sensitive, affirming, and culturally competent and that ideally has experience treating gender-diverse patients. You can start with online resources like Outcare and GLMA, or you can ask for recommendations from friends or LGBTQ+ organizations in your area.

If you've had top surgery but are concerned about your breast cancer risk, Parikh suggests talking to your HCP about your surgical history. Ask them if they would recommend a physical exam, or an ultrasound or MRI if you don't have enough breast tissue for a mammogram.

Finally, it's also worth asking your HCP or the imaging center if you'll need prior authorization for a breast cancer screening if your health insurance plan has your gender listed as male. The ACR Appropriateness Criteria can be helpful in case HCPs or insurance companies call into question whether you need a mammogram as a transmasculine person.