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Raising Awareness for Breast Cancer Risks in Transgender Patients With Valerie Brutus, MD, FACS

In honor of Breast Cancer Awareness Month, Dr. Valerie Brutus, a Breast Surgical Oncologist at St. Vincent's Medical Center of Hartford HealthCare, spoke with Oncology Data Advisor about the risks for breast cancer in transgender individuals. Dr. Brutus shares the importance of starting the conversation about individualized risk assessment to provide the most appropriate screening recommendations and personalized care for every patient.  

Oncology Data Advisor: Welcome to Oncology Data Advisor, I'm Keira Smith. Today I'm here with Dr. Valerie Brutus, who is a Breast Surgical Oncologist at St. Vincent's Medical Center of Hartford HealthCare in Connecticut.

Since October is Breast Cancer Awareness Month, I know that one of the areas that you're passionate about is breast cancer in transgender patients. Would you like to talk to us a little bit about the risk factors and the screening recommendations for this population?

Valerie Brutus, MD, FACS: When we talk about gender and risk factors, the risk factors are for sex assigned at birth. Breast cancer is much more common in women versus men in terms of sex assigned at birth. For those patients, we have several risk factors. One is family history, and one is a person's own risk. If someone had prior breast biopsies in the past and they were found to have some abnormal or atypical cells or some precancerous cells, this is also an increased risk factor.

We know that the length of exposure, specifically extra exposure to the tissue, can also be a certain risk factor. For example, if you have your period earlier in life, if you get to menopause later in life, if you have a child at past the age of 30, these are considered to have a slight increased risk. Another risk factor is dense breast tissue. Dense breast tissue just means that you have more gland in your tissue versus the amount of fat. It has no relationship with the shape or size of the breast; it's just a composition of the breast from the inside. Patients who have dense breast tissue are going to have an increased risk of cancer. These are some key factors that we just want patients to be aware of.

What's important is that all patients should have a breast cancer risk assessment by their mid-thirties. This goes for all individuals who were sex-assigned at birth as females. That's what we recommend. For screening, if one is at average-risk, the recommendation is to start to have a yearly mammogram at the age of 40. For those who are at a higher risk, based on the different types of risk factors, we come to a more personalized recommendation for breast cancer screening.

The recommendations also vary. For those who have had gender-affirming surgeries, specifically if the patient has undergone mastectomy, in which the breasts are removed, the risk factors are also going to depend on that person's family history or if there's a genetic mutation. The majority of the time, if one had a mastectomy and there's no family history or they are not at higher risk, then they could just get their exam once a year and it's fine. If the risk is higher, specifically for patients who are a carrier of genetic abnormalities, this also should be defined on a case-to-case basis.

It's just important to have that conversation so that each individual can know, "What is my risk?" They may have a family history. They may have been on hormone suppression therapy; they may have had gender-affirming surgery. This allows us to have a really personalized screening recommendation to say, "For you, this is who you are, and these are your risk factors. Therefore, we recommend you get a mammogram at 40." Or if the risk is higher and if the breast tissue is still in place, they can get a mammogram and a magnetic resonance imaging (MRI) or an ultrasound. There are definitely different ways that we can screen, but I think it's important for us to individualize those risk recommendation strategies, in order to know who to screen and when to screen that specific person.

For those who have taken hormones and the breast tissue was grown with hormones—this would apply to a patient whose sex assigned at birth was male and then they transitioned to female and have been taking hormone supplementation—the current recommendation now is just to have a discussion, because the length of hormone therapy and when the hormone therapy was started can affect the recommendation too. This can affect whether that person needs to be screened or not. Again, it's just about having a discussion to try to find the best recommendation for each person. Not everybody fits in a box. It's important for us to know, for each particular person, what's the most appropriate breast cancer screening recommendation and to have those discussions.

Oncology Data Advisor: Is there anything else you would like to share about ways to help increase awareness about breast cancer among transgender patients, particularly with it being Breast Cancer Awareness Month? 

Dr.Brutus: I have male patients, I have transgender patients, and I have patients who are non-binary, and I always tell all my patients the same, "Listen, when you're here and you are a patient, we treat you as a person. This is where we do individualized risk assessment to know, in your case, what the best treatment option is for you. If you need to be screened, if you're at high-risk because of different conditions, what's appropriate for you? Do you just get a mammogram and ultrasound every year, or do you need to be screened more aggressively with a breast MRI? Do you have genetic mutation, or are you interested in discussing risk-reducing surgeries?"

It's really important for patients to understand that we are a time now where everything is individualized, and we're here to try to make the recommendation that's most appropriate for the person and the patient. It's about just each person's own risk assessment. You can have different treatment options, but it's important just to start the conversation to know, "This is something I have to ask, this is something that can affect me, and where do I stand? Am I high-risk, am I medium-risk, or am I low-risk?" Then based on that, we can say, "This is what's more appropriate for you." I think that's the key point.

Oncology Data Advisor: This is all really fantastic advice, so thank you so much for sharing it and helping us to raise awareness.

About Dr. Brutus

Valerie Brutus, MD, FACS, is a Breast Surgical Oncologist at St. Vincent's Medical Center of Hartford HealthCare, Connecticut. She specializes in the treatment of patients with all stages of breast cancer, with particular interests in genetic testing, oncoplastic surgery, breast reconstruction, neoadjuvant chemotherapy, and sentinel node procedures. Dr. Brutus is a member of the American Association of Breast Surgeons, a member of the Society of Surgical Oncology, and a Fellow of the American College of Surgeons.

Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.


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