Breast Cancer Diagnosis, Treatment, and Outcomes of Patients From Sex and Gender Minority Groups

Abstract

ImportanceSexual orientation and gender identity data are not collected by most hospitals or cancer registries; thus, little is known about the quality of breast cancer treatment for patients from sex and gender minority (SGM) groups.ObjectiveTo evaluate the quality of breast cancer treatment and recurrence outcomes for patients from SGM groups compared with cisgender heterosexual patients.Design, Setting, and ParticipantsExposure-matched retrospective case-control study of 92 patients from SGM groups treated at an academic medical center from January 1, 2008, to January 1, 2022, matched to cisgender heterosexual patients with breast cancer by year of diagnosis, age, tumor stage, estrogen receptor status, and ERBB2 (HER2) status.Main Outcomes and MeasuresPatient demographic and clinical characteristics, as well as treatment quality, as measured by missed guideline-based breast cancer screening, appropriate referral for genetic counseling and testing, mastectomy vs lumpectomy, receipt of chest reconstruction, adjuvant radiation therapy after lumpectomy, neoadjuvant chemotherapy for stage III disease, antiestrogen therapy for at least 5 years for estrogen receptor–positive disease, ERBB2-directed therapy for ERBB2-positive disease, patient refusal of an oncologist-recommended treatment, time from symptom onset to tissue diagnosis, time from diagnosis to first treatment, and time from breast cancer diagnosis to first recurrence. Results were adjusted for multiple hypothesis testing. Compared with cisgender heterosexual patients, those from SGM groups were hypothesized to have disparities in 1 or more of these quality metrics.ResultsNinety-two patients from SGM groups were matched to 92 cisgender heterosexual patients (n = 184). The median age at diagnosis for all patients was 49 years (IQR, 43-56 years); 74 were lesbian (80%), 12 were bisexual (13%), and 6 were transgender (6%). Compared with cisgender heterosexual patients, those from SGM groups experienced a delay in time from symptom onset to diagnosis (median time to diagnosis, 34 vs 64 days; multivariable adjusted hazard ratio, 0.65; 95% CI, 0.42-0.99; P = .04), were more likely to decline an oncologist-recommended treatment modality (35 [38%] vs 18 [20%]; multivariable adjusted odds ratio, 2.27; 95% CI, 1.09-4.74; P = .03), and were more likely to experience a breast cancer recurrence (multivariable adjusted hazard ratio, 3.07; 95% CI, 1.56-6.03; P = .001).Conclusions and RelevanceThis study found that among patients with breast cancer, those from SGM groups experienced delayed diagnosis, with faster recurrence at a 3-fold higher rate compared with cisgender heterosexual patients. These results suggest disparities in the care of patients from SGM groups and warrant further study to inform interventions.

Risk and incidence of breast cancer in transgender individuals: a systematic review and meta-analysis

“…a delay in BC diagnosis, with higher rates of cancer reappearance in comparison to cisgender patients (Eckhert et al, 2023). Our results demonstrated that the risk for BC development is appreciable in transgender patients.…”

“…The literature reports contrasting indications, suggesting a mammography every 2 years, the same as cisgender women (Brown and Jones, 2015; de Blok et al ., 2019), or after 5 years of hormonal treatment (T’Sjoen et al ., 2019); other authors contraindicated breast screening (Gooren, 2011; Hartley et al ., 2018). However, current evidences demonstrate clearly a disparity among transgender patients that experienced a delay in BC diagnosis, with higher rates of cancer reappearance in comparison to cisgender patients (Eckhert et al ., 2023). Our results demonstrated that the risk for BC development is appreciable in transgender patients.…”

“…The risk of developing breast tumors in FtM individuals could be partly explained by a possible genetic predisposition, such as BRCA1/2 (Cortina, 2023), although literature about a genetic test is very scarce. Other explanation about higher BC risk in FtM (or in women who have sex with women) is the incidence of some risk factors, such as nulliparity, alcohol and tobacco use, and higher BMI (Eckhert et al ., 2023).…”

Barriers, facilitators, and recommendations for sexual orientation and gender identity data collection in community oncology practices

“…Thus, we must acknowledge the importance of SOGI data collection in oncology care. Studies show SGM individuals experience lower satisfaction with their cancer care, more distress during survivorship, delays in care, and unmet needs in patient‐provider communication 6–10 . Not only does SOGI data inform equitable, patient‐centered care, tailored resources, and reduced minority stress, SOGI disclosure itself may help reduce delays in care seeking 38 .…”

Cancer care in transgender and gender-diverse persons: results from two national surveys among providers and health service users by the Italian Association of Medical Oncology

“… 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 Low awareness, lack of specific medical training and socioeconomic variables may be the drivers of delays in cancer diagnosis and treatments, resulting in worse survival outcomes compared to cisgender patients. 14 , 15 , 16 …”