What are the recommendations for breast cancer screening in transgender males?

Breast Cancer Screening Recommendations for Transgender Males

For transgender males (assigned female at birth) who have not undergone top surgery, breast cancer screening should follow the same guidelines as for cisgender women, while those who have undergone total mastectomy should receive yearly chest examinations but generally do not require routine imaging. 1

Screening Recommendations Based on Surgical Status

Transgender Males Without Top Surgery

• Follow the same screening recommendations as cisgender women 1

  • Begin mammography at age 40
  • Annual or biennial screening based on individual risk factors
  • Consider digital breast tomosynthesis (DBT) as an alternative to standard mammography

• Risk assessment should include:

  • Family history of breast or ovarian cancer
  • Personal history of chest radiation between ages 10-30
  • Genetic predisposition to breast cancer
  • Duration of testosterone use (though this doesn't appear to significantly reduce risk)

• Higher risk individuals should begin screening 10 years earlier than the affected relative's age at diagnosis, but not before age 30 1

Transgender Males With Top Surgery (Total Mastectomy)

• Routine imaging is usually not appropriate for breast cancer screening regardless of age or risk factors 1

• Consider yearly chest examinations to monitor for any changes in residual breast tissue 1

• Important caveat: The prevalence of residual breast tissue after top surgery varies, and multiple studies have noted the presence of some breast tissue post-procedure 1

• For patients with only breast reduction rather than complete mastectomy, a thorough surgical history is essential to determine appropriate screening 1

Special Considerations

1. Residual Breast Tissue Assessment:

   • Providers should conduct a thorough surgical history 1
   • Discuss with patients whether they have undergone complete mastectomy or breast reduction
   • Document the extent of residual breast tissue

2. Alternative Imaging for Post-Top Surgery Patients:

   • When mammography is not feasible post-top surgery, ultrasound or MRI may be appropriate after thorough discussion of risks and benefits 1
   • This is particularly relevant for patients with known residual breast tissue

3. Breast Cancer Risk in Transgender Males:

   • A Dutch study found breast cancer incidence of 5.9 per 100,000 person-years among transgender men 1
   • This is higher than cisgender men (1.28 per 100,000 person-years) but lower than cisgender women (155 per 100,000 person-years) 1
   • Those with top surgery appear to have lower risk than those without 2

Barriers to Screening

Transgender individuals face unique barriers to breast cancer screening:

• Limited access to medical care 3
• Experiences of discrimination in healthcare settings 1
• Lack of provider knowledge about transgender health 1
• Mental health concerns including depression and anxiety 1

Clinical Pitfalls to Avoid

1. Assuming all top surgeries are equivalent to complete mastectomies

   • Surgical techniques vary, and residual breast tissue is common 1
   • Always verify the extent of surgery performed

2. Neglecting screening in transgender males without top surgery

   • Despite testosterone use, these individuals maintain breast cancer risk similar to cisgender women 1
   • Regular screening remains essential

3. Failing to create a welcoming clinical environment

   • Use appropriate terminology and allow patients to designate their gender and personal history 4
   • This improves patient experience and increases likelihood of continued screening

4. Overlooking the psychological impact of breast imaging

   • Breast examinations and imaging may cause significant gender dysphoria
   • Approach with sensitivity and clear communication

The evidence supports a straightforward approach: screen transgender males without top surgery according to cisgender female guidelines, while those with complete mastectomy generally do not require routine imaging but should receive yearly clinical examinations.