Breast cancer has no gender.
Wherever someone falls on the gender spectrum, there's a finite breast cancer risk they need to understand. Many different factors feed into breast cancer risk, including the organs you're born with, the organs you have now, age, lifestyle and personal health history. Now more than ever, there's no one-size-fits-all—or even one-size-fits-most—approach to breast cancer screening and risk evaluation.
"We're in a time of transition with our words and our concepts about gender," says BJ Rimel, MD , a surgeon who works with Cedars-Sinai's Samuel Oschin Cancer Center and the Transgender Surgery and Health Program. "It's a great opportunity to think about breasts and how they span the gender spectrum. When it comes to screening, we screen what you've got."
When it comes to cancer risk, an open dialogue between patients of all genders and their healthcare providers is essential.
"Everyone has breast tissue," says Edward Ray, MD, a surgeon in the Breast Cancer Program and Transgender Surgery and Health Program at Cedars-Sinai. "We shouldn't be afraid to talk about breast health with any patient."
"Cancer risk is personal and complex. It's not just about which chromosomes you have. Medications you're taking, family history and many other factors are at play in cancer risk. Everyone's at some risk of breast cancer. Everyone."
Understanding Risk The breast cancer factoid that is repeated thousands of times during Breast Cancer Awareness Month—often framed in pink ribbons—is that women in the U.S. have a 1 in 8 lifetime risk of getting breast cancer. The statistic is useful for thinking broadly about how common breast cancer is, but it's often misunderstood. The 1 in 8 risk is much higher than an average woman faces in a single year, for example. What it does mean is that in a group of women of different ages, 1 in 8 of them would be expected to get breast cancer in her lifetime. "Cancer risk is personal and complex," says Ray. "It's not just about which chromosomes you have. Medications you're taking, family history and many other factors are at play in cancer risk. Everyone's at some risk of breast cancer. Everyone." Breast cancer is not an issue faced solely by people assigned female sex at birth. With 1.4 million transgender adults and 1.2 million nonbinary adults living in the U.S., breast cancer risk is a concern that should be broadly considered. People who have taken hormone therapy as part of their gender affirmation face a lack of research into their risk assessment. Few studies have been conducted, with limited numbers of participants. "Any time you take medications that affect your body's hormones, you have to stay aware of cancer risk," Ray says. A study published in the British Medical Journal found that transgender women—those assigned male sex at birth, with female gender identity—who took hormone therapy have a higher risk of breast cancer than cisgender men, but less risk than cisgender women. (Cisgender people's gender identity align with their assigned sex at birth.) Their absolute risk is low, according to the study. Other studies indicate that transgender men who have had gender-affirming surgery to remove breasts have significantly lower risk of breast cancer than cisgender women, but higher risk than cisgender men. Ray and his colleagues are studying breast tissue in the laboratory and assessing how hormone therapies affect it to try to better understand how they influence cancer risk. "The impact of hormone therapies is a growing area in research—not just in breast health, but everywhere in the body," he says.
Reframing Screening Guidelines For decades, screening guidelines were split between men and women—a model that's increasingly ineffective. Cedars-Sinai worked with an LGBTQ+ community advisory group who were quick to point out that many people have difficulty relating to these gendered guidelines. A more inclusive approach is to organize information about screenings as an organ inventory, says Zul Surani, director of community outreach and engagement and associate director of the Research Center for Health Equity. "We're saying, 'What organs do you have? What organs were you born with? What has been removed?' And based on that, these are the conversations you need to be having with your doctor," Surani says. A team led by Surani and Robert Haile, DrPH, MPH, director of the Research Center for Health Equity, and Boostershot Media, developed an online toolkit designed to improve cancer screening in the transgender community. Sexual and gender minorities tend to have more barriers to accessing healthcare that affects cancer prevention, early detection, diagnosis, treatment and survival. People of color who also fall into those minorities are even more challenged. The website crafted by Boostershot Media in collaboration with Surani and Haile, createyourguide.com, prompts users to watch a five-minute video tailored to LGBTQ+ individuals. The primer explains cancer basics, screening and how the tool can help them assess their personal risk. An organ inventory tool then asks for a person's pronouns and age, then takes them through a series of questions about which reproductive organs they have. "We want to determine if this kind of tool empowers community members to have discussions about proactively protecting their health with their providers," Surani says. The team is collaborating with investigators at the University of California, San Francisco, to test the organ inventory and incorporate community-based navigation
A More Inclusive Future
As research continues to improve understanding of risk factors and to develop better tools to expand access to cancer screening and treatment, some actions can be taken immediately. Patients can initiate conversations with their physicians about which cancer screenings are appropriate and comfortable for them. Healthcare providers can shift their thinking to take a more inclusive approach. Surani emphasizes that the education efforts around organ inventories are not just for patients. "Doctors are often not starting the right conversations with their patients," he says. "Education efforts in the medical community to help doctors understand how to use organ inventories and frame cancer screening differently are as important as those among patients."