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California Society of Plastic Surgeons

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Breast cancer in transmen after gender-affirming mastectomy
Nisha Parmeshwar MD1, Andre Alcon MD1, Esther Kim MD1 1 University of California San Francisco, Division of Plastic Surgery, San Francisco, CA

Background: As the field of transgender medicine continues to grow, new guidelines for management of breast cancer and preventive care for these patients are necessary. Past studies have shown a link with increased androgen levels and breast cancer. As most transmale patients are taking exogenous hormone in order to achieve secondary masculine characteristics, these patients may be at increased risk for cancer at younger ages. Plastic surgeons who perform gender affirming mastectomy (GAM) are often one of the few medical professionals sought out by this population, placing them in a unique position to not only deliver surgical care but also improve access to preventative cancer care.

Methods: We reviewed the senior author's experience with gender affirming mastectomies over the past 5 years for any incidence of breast cancer noted after the time of surgery. We subsequently performed a thorough review of the literature for cases of breast cancer in transmen, to provide a comprehensive overview of screening, therapy, and post-operative surveillance practices.

Results: We identified two cases of breast cancer (ages 49 and 54) found on routine examination of pathology specimens after gender affirming mastectomy at our institution. Both patients had been taking hormone therapy for the past 1 year. No masses were palpable on pre-operative exam. Mammograms were negative. After gender affirming mastectomy, pathology specimen revealed low grade ER/PR+ ductal carcinoma in situ in one patient, and ER/PR+ invasive ductal carcinoma in the other. Both patients were referred to oncology, and elected to continue their exogenous hormone therapy for personal reasons. Review of the literature demonstrated twenty-four other cases of documented breast cancer in transmen. 67% (19) were found after GAM, and 25% (6) were incidentally found on pathology specimen. 80% (19) were found to be either ER, PR, or AR hormone receptor positive cancers. At least 30% (17) of cases documented continued use of masculinizing hormone therapy after cancer diagnosis.

Conclusion: The majority of transmen diagnosed with cancer elected to continue their testosterone therapy despite potential added risks. Over two-thirds of the documented cases of breast cancer in a transmale were diagnosed after gender-affirming surgery, which would suggest the residual breast tissue left behind does pose increased risk. We use these cases along with review of the current literature to highlight the need for agreement in current screening practices, surgical recommendations, continuation of masculinizing hormone therapy, and post-operative surveillance guidelines. Ultimately as plastic surgeons are more informed of these topics, they can improve access to cancer-related care for this population.

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