Creating Breast and Gynecologic Cancer Guidelines for Transgender Patients With BRCA Mutations

Abstract

More than 1.5 million individuals in the United States identify as transgender. Transgender individuals have lower rates of health care utilization and higher rates of health care discrimination than cisgender patients. With a growing interest in providing comprehensive and compassionate care to the transgender community, there has been a concurrent increase in research on transgender health. However, lack of long-term data limits understanding the effects of hormone therapy on cancer risk factors in this population. This is particularly relevant for patients with hormonally mediated cancers and those at elevated risk from hereditary breast and ovarian cancer syndromes. Few cancer-screening and management guidelines currently exist for this population. Specific practices guided by the nuances of gender identity and gender-affirming care are essential to improve clinical management and to avoid further alienating a population that is already marginalized from the health care system. This commentary summarizes screening, management, and surveillance strategies devised for cisgender patients to offer corresponding recommendations tailored for transgender BRCA mutation carriers. In doing so, it highlights critical unanswered questions pertaining to the care of these patients. To address these questions, we must prioritize this population and adopt more inclusive frameworks in medicine and research.

Genetic Testing for All: Overcoming Disparities in Ovarian Cancer Genetic Testing

“…[36][37][38][39] In addition to ongoing racial and ethnic disparities, as more individuals openly identify as transgender and nonbinary, there is a need to increase awareness of the unique medical needs of this community, including in the setting of gynecologic oncology care. 40,41 Existing literature suggests that transgender individuals have higher rates of mortality associated with cancer diagnoses, in part because of avoidance of gender-assigned cancer screenings, resulting in later stage at diagnosis. 42 Studies suggest that there are large gaps in clinicians' ability to accurately and appropriately estimate cancer risks for this population.…”

Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults

“…Cancer screening recommendations for TGD individuals who are BRCA1 or BRCA2 mutation carriers follow cisgender guidelines, as do recommendations for testing for BRCA mutations, although longer-term prospective studies are needed to inform the impact of exogenous GAHT and duration of GAHT on cancer risk independent of mutation status. As noted by Bedrick et al, 63 having a BRCA mutation may reduce insurance barriers to receiving gender-affirming care (including surgery) that aligns with a person's gender affirmation.…”

Gynecologic Care of Black Breast Cancer Survivors

“…One study of transgender veterans in the U.S. showed an incidence rate of 20.0/100,000 person-years (regardless of hormonal therapy use) [ 113 ]. To date, the impact of exogenous estrogen taken for gender affirmation on breast cancer risk for transgender women is unclear [ 114 ]. However, increased concentrations of prediagnostic endogenous estradiol have been found to be associated with breast cancer in AMAB people [ 115 ]; furthermore, a retrospective study from the Netherlands demonstrated a 46-fold increased breast cancer risk among transgender women (95% CI 27.2 to 75.4) compared to cisgender men [ 116 ].…”

“…However, increased concentrations of prediagnostic endogenous estradiol have been found to be associated with breast cancer in AMAB people [ 115 ]; furthermore, a retrospective study from the Netherlands demonstrated a 46-fold increased breast cancer risk among transgender women (95% CI 27.2 to 75.4) compared to cisgender men [ 116 ]. While screening recommendations for those with enhanced breast tissue following exogenous hormone administration have not been established, some organizations have proposed biennial screening mammography starting at age 50 for transgender women who have had at least 5–10 years of feminizing hormone therapy [ 114 , 117 ]. There are no established guidelines for transgender females taking estrogen for gender affirmation with concurrent breast cancer diagnosis.…”