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Breast/Chest Screening Guidelines for Trans People

This past spring was tough for Tyson Crenshaw. The 51-year-old transgender sexual-health prevention specialist at Columbus, Ohio’s Equitas Health was worried about his wife―who was in the hospital with respiratory distress due to COVID-19.

Amid that stress, Crenshaw still proceeded with a mammogram screening he needed before finally embarking on his long-anticipated plan to have top surgery (removal of breast tissue), as part of a transition that had begun with hormone therapy about 12 years prior.

Then things got even tougher. He was informed that something strange had turned up on the mammogram and that he would have to report first thing the next morning to Ohio State University’s cancer center for an ultrasound. Not wanting to scare his sick wife or his daughter, he held back the news from everyone except for his mom.

“I was scared to death,” he recalls, while also worrying about, “What was it going to be like for me walking into a breast cancer appointment with a beard? I was preparing for negativity.”

Spoiler alert: Happy endings follow! Not only was Crenshaw addressed respectfully as his proper gender at OSU (the staff has had training on how to respectfully treat and care for transgender patients), but—after inspecting his mammogram from 12 years prior—his radiologist determined that what had emerged since then was merely the result of being on hormones, not cancerous.

“They told me I was cleared for my top surgery,” says Crenshaw. “I felt like a giant elephant had been pulled off my chest.” Moreover, his wife has since recovered from her scary bout with COVID-19 and is doing well.

But Crenshaw emerged from his experience with such strong feelings about the importance of trans folks (particularly trans men) having regularly scheduled breast/chest screenings that he agreed to tell his story on a special May 13 90-minute webinar (watchable here), sponsored by Equitas and WOSU Public Media, on breast and chest screening recommendations for transgender patients.

The webinar was hosted by Cindy Gaillard, content director for WOSU TV, and featured Crenshaw; Equitas Health Institute director Julia Applegate, M.P.H.; Annie Brown, M.D., assistant professor of radiology at the University of Cincinnati College of Medicine; and Melissa Davis, M.D., clinical assistant professor of family medicine at OSU.

Gaillard began the webinar by pointing out research showing that, due to discrimination and past negative experiences with health care, trans folks are less likely to adhere to mammography screening guidelines than their cis peers—but that delayed screening can cause late diagnosis of and/or increased severity of cancerous breast and chest tissue. The webinar also highlighted that the American College of Radiology had, in April, released new guidelines for breast/chest cancer screening in trans folks.

Some general takeaways from the guidelines are:

  • Breast cancer screening recommendations are based on four factors: age, sex assigned at birth, personal risk (for instance, family history), and history of gender-affirming therapies such as hormone therapy or surgeries.

  • Mammograms may be appropriate every year or every other year for transgender women age 40 or older who have had five or more years of hormone therapy.

  • Trans women with significant risk factors may also be considered for screening, even in the absence of long-term hormone use. But no screening is indicated in the total absence of hormone use.

  • Imaging is not usually indicated for screening trans men of any age who’ve undergone top surgery, but self-exams are still important. Also, trans men who’ve had breast/chest reduction or no top surgery should have mammograms when age-appropriate and depending on personal risk level. (The webinar pointed out, for those who may not know this, that “breast/chest” is used because many trans men find the use of the term “breast(s)” alienating.)

  • Generally speaking, being transgender does not seem to confer an increased risk of breast/chest cancer, but the true incidence of such cancer in the trans population is largely still unknown due to insufficient data.

  • Even if all breast tissue is removed in top surgery, there is still some risk of cancer, even though there is a nearly 90% risk reduction.

  • There is some evidence that lifelong exposure to estrogen in trans women may increase their overall risk compared to others assigned male at birth.

After sharing his experience during the webinar, Crenshaw noted that he is “excited to see these guidelines implemented” and that he advocates strongly that trans men, if possible, get a mammogram done before beginning hormone therapy, so they can have a baseline comparison for future mammograms.

“For me,” he said on the webinar, “having that older mammogram to compare the new one to made all the difference.”

Of equal importance was being seen at a place that had training in treating trans patients. “If someone had said to me,” based on his beard, “that I was in the wrong spot, that would’ve sent me right home.” Several studies have affirmed the importance of gender-affirming health care when it comes to the mental health of trans and gender-nonconforming folks.

On the webinar, Davis urged patients: “Schedule a visit with your provider when you aren’t sick, so you can sit down and come up with a screening plan based on your risk factors and family history—such as having a colonoscopy starting at 45.”

Davis also urged patients to “go ahead and touch themselves in the mirror to assess what’s normal. Is there a particular spot that’s begun to change or grow?” If so, said Davis, get seen.

Via TheBody, Crenshaw offered this additional advice to fellow trans patients: “Be your own advocate! Know enough to ask the right questions. There’s resources out there to keep you from falling into that lab-rat category. Because we’re not lab rats. We’re people, and we deserve answers and professionalism just like anyone else.”

Crenshaw’s top surgery took place on July 8. “I’m feeling excited,” he told TheBody before going in. “I’ve raised my kid and now have a grandson. I’ve got everyone stabilized enough that I can take some time to enjoy the rest of my life”—and, pointing to his breasts/chest—“without those two little problems!” And sure enough, after the surgery, he reported, “It went phenomenally—my doctor was amazing.”

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