Incidence of breast cancer in a cohort of 5,135 transgender veterans

Abstract

Transgender (TG) persons often receive, or self-treat, with cross-sex hormone (CSH) treatments as part of their treatment plans, with little known about their incidence of breast cancer. This information gap can lead to disparities in the provision of transgender health care. The purpose of the study was to examine the incidence of breast cancer in the largest North American sample of TG patients studied to date to determine their exposure to CSH, incidence of breast cancer, and to compare results with European studies in transsexual populations. We used Veterans Health Administration (VHA) data from 5,135 TG veterans in the United States from 1996 to 2013 to determine the incidence of breast cancer in this population. Chart reviews were completed on all patients who developed breast cancer. Age-standardized incidences of breast cancer from the general population were used for comparison. Person-years of exposure to known CSH treatment were calculated. Ten breast cancer cases were confirmed. Seven were in female-to-male patients, two in male-to-female patients, and one in a natal male with transvestic fetishism. Average age at diagnosis was 63.8 (SD = 8.2). 52 % received >1 dose of CSH treatment from VHA clinicians. All three males presented with late-stage disease were proved fatal. The overall incidence rate was 20.0/100,000 patient-years of VHA treatment (95 % CI 9.6-36.8), irrespective of VA CSH treatment. This rate did not differ from the expected rate in an age-standardized national sample, but exceeded that reported for smaller European studies of transsexual patients that were longer in duration. Although definitive conclusions cannot be made regarding breast cancer incidence in TG veterans who did or did not receive VA CSH due to the sample size and duration of observation, it appears that TG veterans do not display an increase in breast cancer incidence. This is consistent with European studies of longer duration that conclude that CSH treatment in gender dysphoric patients of either birth sex does not result in a greater incidence than the general population.

Cancer in Transgender People: Evidence and Methodological Considerations

“…Two articles were published using clinical data from the Ghent University Hospital in Belgium (115,116). In the United States, 3 studies assessed cancer-related morbidity and mortality among transgender people identified in the US Department of Veterans Affairs (VA) national health system (117)(118)(119). The next sections of this review describe cancerrelated findings for each of these study populations.…”

“…Three studies examined the morbidity and mortality of transgender US veterans (117)(118)(119). Eligibility was determined by International Classification of Diseases, Ninth Revision, codes for transvestic fetishism (code 302.3), transsexualism (code 302.5), gender identity disorder not otherwise specified (code 302.6), and gender identity disorder in adolescents or adults (code 302.85).…”

“…The 2 proportions were similar, 21% versus 23.6%, respectively. A more recent study assessed breast cancer incidence among 5,135 transgender veterans (118). The cohort members were categorized as "female" or "male" on the basis of the demographic variable in the Vital Status Files, but this variable may reflect either natal sex or gender identity.…”

Clinical Nursing Care for Transgender Patients With Cancer

“…With prolonged estrogen exposure, prostate-specific antigen levels may be falsely low (Epstein, 1993). Brown and Jones (2015) examined the incidence of breast cancer among 5,135 transgender veterans on hormones. Ten cases of breast cancer were confirmed, including seven in FtM patients and two in MtF patients.…”

“…The authors concluded that enough evidence did not exist to support a connection between crossgender hormones and breast cancer. However, Brown and Jones (2015) recommended that healthcare providers demonstrate more sensitivity and increase their knowledge about transgender care. For example, this population has many risk factors for breast cancer, including a transwoman's long-term exposure to estrogen, testosterone converting to estradiol, and remaining breast tissue after a transman's chest surgery (Unger, 2014).…”