What Trans People Need to Know About Breast Cancer Risk and Screening

Understanding breast cancer screening, like mammography, can often be difficult for women to understand. But the conversation requires an additional 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 drafted changes to its guidelines for screening mammography, and now proposes that women ages 40 to 74 at average risk of breast cancer get screened biannually.

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

In reality, trans people’s breast cancer risk is a bit more nuanced.

“There are populations within the LGBTQ+ community that are at higher risk for developing breast cancer—specifically, male-to-female transgender individuals who have undergone five years of hormone replacement, and also female-to-male individuals who have not had top surgery,” Robyn Roth, MD, a board-certified radiologist specializing in breast imaging and podcast host, told Health.

Here’s what experts had to say about transgender people and breast cancer, why this population often doesn’t receive adequate care, and what people of all gender identities should be doing to stay on top of their personal breast cancer risk.

Hormone Therapy, Gender-Affirming Surgery Dictate Breast Cancer Risk

Being transgender doesn’t necessarily influence a person’s physical health, but certain therapies can lower or elevate a person’s risk of breast cancer.

In particular, people who have undergone gender-affirming care—whether that be hormone therapy or surgery—may experience a different level of breast cancer risk than what is considered typical for the gender they were assigned at birth.

For trans women, taking hormones such as estrogen or progesterone can up their cancer risk.

“If you have a breast cancer, usually these occur because there’s a mutation in the cells,” Edward Ray, MD, associate professor of surgery and a plastic surgeon specializing in gender affirmation surgery at Cedars-Sinai, told Health.

“Estrogen is linked to that process as well in many cases,” he said. “So a lot of breast cancers grow faster and more aggressively if they’re exposed to estrogen.”

Though there’s more research that needs to be done on the topic, the inverse is true for trans men who’ve undergone gender-affirming care, Dr. Ray said. Androgen therapy, such as testosterone, may lower the risk of developing estrogen receptor-positive breast cancer.

Breast cancer risk is also “significantly decreased” if a person gets top surgery, or most of their breast tissue removed, Tami Rowen, MD, associate professor of obstetrics, gynecology, and reproductive sciences at the Center of Excellence for Transgender Health at the University of California, San Francisco, told Health.

However, it’s important to remember that not all trans people fall under this category.

“If somebody is transgender but has not used hormones or undergone surgery, they’re going to have the same breast cancer risk as the cis [...] population,” Dr. Rowen said. “You wouldn’t screen them or treat them any differently.”

There are also a host of social factors that could also be impacting trans people’s breast cancer risk, Dr. Roth added.

Past discomfort with doctors could cause trans people to avoid necessary medical treatment, as could being in spaces made specifically for cisgender men or women, she said.

Lifestyle factors may also play a role. Transgender people are more likely to have alcohol and nicotine use disorders, both of which raise breast cancer risk. And trans men may be less likely to become pregnant or to breastfeed, Dr. Roth said, both of which would otherwise lower a person’s risk for breast cancer long term.

“They have a higher unemployment rate and lack of insurance, making it even harder to get routine screening,” said Dr. Roth. “Also, it may just be harder for them to find a doctor that’s familiar with the needs of the LGBTQ+ individual.”

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

“Our healthcare system is predominantly designed by and for cisgender heterosexual people,” Dr. Roth said. “So we know that the LGBTQ+ community—especially with regards to breast cancer—are more likely to have their symptoms dismissed or ignored.”

Creating Guidelines for Breast Cancer Screening Isn’t So Simple

The lack of clear guidelines for trans people and breast cancer risk is certainly a concern, Dr. Roth said. Though trans men are included in the USPSTF’s draft guidelines for screening mammography, 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.

Taking Charge of Your Own Health

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.”