[2010=07-28 Diagnostic Imaging]
http://www.diagnosticimaging.com/controversies-in-breast-screening/content/article/113619/1622961
Controversies in Breast Screening
Diagnostic Imaging.
Study recommends normal breast screening for transsexual women; sex expert disagrees
By Rebekah Moan
28 July 2010
Breast screening habits for transsexual women shouldn’t differ from those of biological women, according to a recent European study. However, a human sexuality expert disagrees, saying screening for transsexual women should depend on when the patient started estrogen therapy and not age alone.
Reports of transsexual women developing cancer are scarce; however there may be some degree of under reporting. The study sought to remedy this problem and examined 50 women post–sex-reassignment surgery (EJR 2010;74:508-513).
The researchers found mammography and breast sonography were technically feasible in the women. No gross anomalies were detected. In addition, 98% of the patients intended to come back for screening.
“It is not unlikely that in transsexual women, who receive life-long estrogen therapy, the risk of developing breast cancer will prove to be higher than for their male counterparts,” said study author Dr. Steven Weyers from the gynecology department at Ghent University Hospital in Ghent, Belgium.
The study recommended a normal screening regimen for transsexual women. The mean age of study subjects was 43 ± 10.5 years.
Other studies have found women with breast implants are not at a higher risk of developing breast cancer. Women with breast implants are not diagnosed at a later stage, nor do they have more recurrences or shorter survival, Weyers said.
Not everyone agrees with the study’s conclusions, however.
The pathophysiology of breast cancer suggests that risk is largely related to years of estrogen exposure, according to Dr. Jamie Feldman, an associate professor in the human sexuality program at the University of Minnesota.
“It really makes no sense to screen a 40- or even 50-year-old transwoman who just started estrogen therapy two weeks ago,” she said.
Given the estrogen exposure factor, using the screening schedule developed for biological women is not cost-effective and exposes transsexual women with a low risk of cancer to unnecessary x-rays, false positives, anxiety, and possible biopsies, she said.
Instead, Feldman suggests screening mammography for transsexual women start at age 50 provided they have had five years of hormone therapy. High-risk patients should begin sooner, Feldman said.
–
© 1996 – 2010 UBM Medica LLC
A couple of flaws and omissions.
Not all transsexuals come out and transition in middle age. Some of us start hormones as young teens or young adults. We definitely need to follow the same sort of breast cancer screening patterns as natal females. Plus the other screenings related to hormone usage i.e. liver function, blood clots etc.
Further this is one place where it would be good to use the dyad transsexual and transgender as not only transsexual to female people use hormones or get implants but non-op transgender women do as well.
08/06/2010 at 6:31 pm
This article was based on the paper in a radiography journal: Weyers, S. et al. Mammography and breast sonography in transsexual women (2010). URL http://linkinghub.elsevier.com/retrieve/pii/S0720048X09001314?showall=true
The risks for breast cancer, regardless of birth sex, are determined by (1) inherited genetics, (2) Carcinogen exposure, (3) hormone action. Unfortunately everyone above misunderstands and underestimates the complexity of the hormone action, principally in the different pattern of exposure that exogenous hormones create compared to endogenous (that’s taken products versus ovarian hormones to you and me).
Endogenous hormones grow the mammary tissue and continue to support it until menopause (when it largely disappears) by a constant daily and monthly cycle of changes of levels and proportions of estrogen, progestogen and growth hormone. This causes mammary cells to grow and die, time after time, thousands of times in each woman’s life. And every time a new cell is created there is a chance it will be a mutant that is the start of a cancer. Many of them probably are, but the normal body’s systems then work smoothly to clean them up.
With exogenous hormones there is at most a cycle between doses, of at most estrogen and progestogen. It may not even be much of a cycle – depending on how efficiently the body eliminates the hormones and how much is held, buffered in the blood and tissues. So the cell deaths and re-growths are much more limited, perhaps almost at the level of cells areas of the body far less susceptible to cancer. Certainly less than the lungs which are constantly exposed to pollutants, or skin exposed to UV.
And this is probably why cases of primary breast cancer in TG women, or women with a transsexual history are so few. And that should really be reflected in the advice on risk and screening. Not what is suggested above.
However, there are two big factors to also remember. The first is that high genetic risk is not much dependent upon hormone action – men are subject to it too. Everyone should suspect the cancer history of their blood relatives and consider their own risk, but most are in denial, especially those who cling to potent carcinogens, like smoke. The second is that T->F treatment, and perhaps even transsexuality itself, has its own cancer-related risks.
Foremost of those is that estrogens without progesterone (or selected other progestogens) causes fibrotic growth of mammary tissue (that’s “lumpy” in plain language) which is harmless but can easily be mistaken for something suspect, leading to cancer scares and even unnecessary surgery. The paper cited above doesn’t disclose how many of these false positives they found, but the standard hormone regimen in that country would maximise the risk of such lumps and minimise mammary development – they talk of most subjects having implants and report most found the procedures not at all painful.
It is highly likely that many, if not all cases of transsexuality arise from genomic variations, and these may carry cancer risks, but not necessarily for breast cancer. There are, for example, many reports of tumours (cancerous or “benign”, ranging from skin and lung cancer, through leukemia’s, to schwannomas) linked to a genetic reduction in the body’s Tumor Necrosis Factor (TNF) – a protein that kills cancer cells – in women of transsexual history. TNF also increases the effect of estrogen at a cellular level, and with estrogen responsible for masculinising the brain, that might be a link.
Genetic research on transgender (such as using the DSM GID criteria) produces no viable results, probably because the “umbrella” sweeps in subjects that are too diverse.
Incidentally, the paper refers to both mammograms (X-rays) and sonograms (ultrasound) although most screening programmes only use X-rays, which are useless where mammary tissue is normally dense and consistent – it is the same density as most cancer cells might be so it all shows up as white. The same goes for some breast implants. And X-rays increase cancer risk by promoting mutation, so shouldn’t be used inappropriately.
TG women or women with a history of transsexuality attending for unnecessary mammograms out of misplaced desire to be an womanly as possible would increase their cancer risk generally, by X-ray exposure.
Sonograms have poor definition, which is again likely to lead to false positives. The ideal screening for breast abnormalities in women with normal breast tissue is MRI, but it is rarely offered, and still expensive. Neither involve the pain most women complain of from their mammary tissue being sandwiched between plates during mammography.