Ask the Experts About LGBT Health
Q: Mammography for Transgender Breast Cancer Screening
Aside from evaluating a person's family history (especially maternal), are there any special recommendations for mammography screening among both male to female (MTF) and female to male (FTM) transgender people, given their different hormonal transitioning status? For example, if a MTF with strong maternal history is on hormones, is a mammogram recommended after age 40? What if they have a PATERNAL history? Thanks for any insights you can offer.
A: Response from Dr. Raney
There is little data on breast cancer risk in transgender people. It does seem logical, though, that anyone with breast tissue should be concerned about breast cancer, especially as we are seeing the rising incidence over the past decades.
We can only make guesses about breast cancer risk in transgender women from the existing data on natal women, most of which is from studies of postmenopausal women. It has become clear from various large studies around the world, that taking estrogen, with or without progesterone, causes a statistically significant increase in the risk of breast cancer in postmenopausal women. There is much less data for premenopausal natal women, but it looks from early studies that in younger, premenopausal women, naturally higher levels of circulating estradiol (and possibly testosterone) does correlate with increased rates of breast cancer. This is consistent also with observations that environmental pollutants, which are referred to as endocrine disrupting agents, are linked to breast cancers.
In the absence of data on transgender people, Fenway Health providers generally recommend that transgender women begin annual mammography screening after 5 years of estrogen therapy, after the age of 50.
But individual case consideration is also important. For example, a transgender female who has been on hormones since adolescence would be advised to begin screening at age 40 or 10 years prior to the earliest age a first degree relative was diagnosed. In general it is thought that transgender women have a higher risk of breast cancer than natal men but a lower risk than natal women. Because transgender women represent quite a diverse group, with varying estrogen exposure, a blanket guideline might miss higher risk transgender women.
There is conflicting data on whether testosterone is a mammary carcinogen. We recommend that transgender men who have not had top surgery should be screened according to the standard guidelines for natal women. Screening for transgender men who have a 1st degree relative with breast cancer (sibling or parent) should begin 10 years prior to the age of the diagnosis of their relative or age 40 whichever is first. After the baseline at age 40, continue screening every one to two years until age 50, then yearly until life expectancy is less than 5 more years. Transgender men who have had all breast tissue removed do not need mammograms.
When breast cancer shows up in a man it is most often due to genetic factors. So, I would approach the screening of a transgender patient with this family history the same way I would approach any other patient--which is to look at the genogram and determine whether genetic testing should be offered. Mammography screening should begin 10 years prior to the age at which the cancer was diagnosed in the first degree relative, or age 40 if hormones have been used for at least 5 years.
Breast self exam has never been shown to be an effective screening tool, and may even create anxiety, but a yearly clinical breast exam performed during routine heath screening should be done on all patients.
Download a fact sheet on breast cancer screening
A: Response from Dr. Raney
UPDATE
On November 16th, 2009 the United States Preventative Services Task Force released new recommendations for screening mammography, which it published in the Annals of Internal Medicine. One of the recommendations was "against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade C recommendation."
For the entire list of updated recommendations, please visit:
http://www.ahrq.gov/CLINIC/uspstf/uspsbrca.htm
The new recommendations are not without controversy. Currently, Fenway Health has not changed its recommendations or patient protocols as a result of this report. As always, an open conversation with your health care provider is crucial for determining the screening and care that are right for you.
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Forum Experts
 Harvey J. Makadon, MD is Clinical Professor of Medicine at Harvard Medical School and Director of Education and Training at The Fenway Institute at Fenway Health in Boston. He is a member of the Division of General Medicine at Beth Israel Deaconess Medical Center and is the lead editor of The Fenway Guide to LGBT Health, published by the American College of Physicians in 2007. He has long been involved in developing both educational and clinical programs to serve gay, lesbian, bisexual and transgender populations.  Patricia Raney, MD, is a staff physician at Fenway Health in Boston, Massachusetts. She is a graduate of the University of Massachusetts Medical School and is Board Certified in Family Medicine. Her clinical interests include women's health and wellness, primary care, preventive care and the health concerns of lesbians, bisexual women and transgender people. On a more personal note, she is an avid stone carver. |
