Disparities in breast cancer risk and research for transgender people

In 2013, the American Cancer Society stated that 232,340 new cases of invasive breast cancer are reported each year. This number includes transgender people, the “T” in the well-known acronym “LGBTQ+,” though we don’t know how many. Early research suggests that the rate of breast cancer in transgender people is very low.

The Centers for Disease Control and Prevention, CDC, states that: "Breast cancer is the second leading cause of cancer deaths among women in the United States.” But where do transgender women fall within that statistic, and what exactly do we know and not know about breast cancer in transgender people?

Much of what is known about breast cancer, its treatments, care and outcomes deals with the general, non-transgender community.

Transgender people have special considerations and issues that often differ from those of the average man or woman. Many times transgender people are under-represented in breast cancer research, which leads to disparities.

How disparities, known and unknown, affect transgender people with breast cancer

We do not have breast cancer data from CDC about transgender people as we do for other non-trans people. This may be due to a lack of adequate data collection on transgender people and that many transgender individuals may avoid seeking healthcare due to discrimination, or may not disclose their transgender status to their provider.

Financial hardships, social biases against them, internal self-rejection and other mental struggles may also make joining research studies or taking part in surveys challenging. Without many participants, data on transgender people with breast cancer is hard to gather.

There is no data to show how disparities have reduced breast cancer care, how many trans people have breast cancer, or worse: How many transgender people are dying from it.

Gender identity, anatomy, and breast cancer

There is a saying in the trans community: “It’s about the heart and not about the parts.” But when it comes to breast cancer risk factors, prevention and treatment of the disease, parts do indeed matter. Respecting a person’s gender expression and identity is very important, but anatomy cannot be ignored.

Talking with your doctor

Many factors may impact whether you’re fully comfortable talking with your doctors about your gender identity. Whether to talk openly with them is a personal choice.

Know that being open and honest about your breasts and your body can help your doctors provide more comprehensive care for you, because the more a doctor knows about you, the more they can help you with decisions.

Be clear about your gender identity and the pronouns you use to describe yourself. It’s OK to ask your providers to acknowledge you the way you want to be acknowledged. If your provider speaks to you in a way that makes you uncomfortable, consider reaching out to an LGBTQ+ liaison or social worker for help.

Hormone Replacement Therapy and breast cancer

If you are taking hormone replacement therapy, HRT, because you are transitioning, you should make sure your doctor knows about it. HRT could be another risk factor for developing breast cancer, regardless of the type of hormone you are taking.

In particular, estrogen taken by mouth, by injection or produced in the body itself may add complications that promote cancer cell growth if you have estrogen receptor-positive, ER-positive, disease.

Everyone diagnosed with breast cancer will be given a test to show whether the cancer is growing because of estrogen or other hormones in the body. Cancer that does grow because of estrogen is called estrogen receptor-positive, or ER-positive. When a trans person has ER-positive breast cancer, taking hormone replacement therapies may be stopped. In some cases, testosterone may also be a risk.

If you’re taking HRT, the thought of stopping it because of breast cancer may cause stress and worry. However, be aware that the very hormone that assists in your breast growth and female development in a positive way may also be dangerous and affect your breast cancer treatment.

Realities of HRT and breast cancer

Your doctor may recommend that HRT and other supplemental estrogen be stopped altogether. This news may be very difficult and it might feel unfair to have to choose between cancer treatment and hormones for transition. Talking to your doctor or a therapist may help you make the right decision for you, but know that treating the cancer is very important.

You may need to take anti-estrogen therapies to treat estrogen receptor-positive cancer growth. In most people, anti-estrogen therapies cause menopausal symptoms and other side effects related to hormones in the body. It is not clear whether these would be different if you are transitioning.

One or both breasts may eventually be removed in mastectomy. Most people who are diagnosed need to have surgery to remove part of all of the affected breast, and sometimes the unaffected breast, to remove breast cancer cells from the body.

Another treatment for ER-positive breast cancer is a selective estrogen modulator or SERM. SERMs are medicines that target particular estrogen receptors in the body. This type of treatment may allow a carefully monitored use of HRT.

If you’re transgender, talk to your doctor about all treatment options if HRT and estrogen present complications to treatment.

Some anti-estrogen treatments are dependent on the presence of ovaries. While a transgender male with breast cancer and who has ovaries may be a candidate for such medicines and surgery to remove the ovaries, a transgender female who does not have ovaries may be asked to stop all estrogen pills and injections.

The trauma and fears associated with stopping HRT and halting the transition process may become too much to handle, in addition to being diagnosed with breast cancer. A counselor who is familiar with transgender issues and HRT can guide you and address any mental health concerns you may have.

When choosing a therapist, consider if the therapist has experience with:

• LGBTQ+ issues, specifically in the transgender community
• cancer or other life-threatening diseases and the trauma they can cause a transgender person
• hormone therapy as it relates to a person diagnosed with cancer

The lack of awareness about transgender health issues may make breast cancer an even more challenging diagnosis for you. Seeking care from a team that respects you and your needs can help through treatment and beyond.