Category: Other - Transgender Medicine
The most recent Endocrine Society guidelines for the Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons suggest that for transgender (TG) females with “no known increased risk of breast cancer, providers follow breast-screening guidelines recommended for those designated female at birth.” There is a consensus among national guidelines that cisgender women age 50-74 should have at least biennial (if not annual) screening with mammography; for women age 40-49, most guidelines suggest an individualized approach regarding initiation of screening. The objective of this study is to characterize the use of screening mammography for TG female patients receiving care at Emory University.
A retrospective chart review of 157 TG females identified clinically by an endocrinologist and had at least one visit from 1/2000-8/2018. After local IRB approval, medical records were accessed and pre-specified data was extracted in a de-identified manner.
At the time of the analysis, 25 patients were age 40-49 (15.9%) and 44 were age 50-73 (28%). Fifteen of 69 (21.7%) patients at an eligible age for screening mammogram were found to have at least one mammogram completed; 9 of the 15 patients had more than one. Of the 15 patients with screening mammograms, 4 were age 40-45 and 11 were age 50-73 (none were age 46-49). An additional 2 patients had a diagnostic mammogram without a preceding screening mammogram. Two of the 15 patients who had a screening mammogram went on to have breast biopsy, both of which were negative for cancer.
Only a minority of patients seen (21.7%) had screening mammograms completed. It is important to point out that these percentages do not include imaging studies done outside the study institution, which may underestimate actual screening uptake. The present analysis also does not take into account the length of time each patient had been on hormone therapy (HT), or any interruptions in HT, and this could have impacted the decision to order screening mammogram. Prior procedures (i.e. mammoplasty), family history of breast cancer, and insurance status need to be considered in future analyses.
Breast cancer risk and routine screening in TG females on hormone therapy remains an area of ambiguity. Despite the most recent professional society guidelines, we suspect that providers are under-screening their TG female patients with respect to breast cancer. Further research regarding time on HT and its relation to breast cancer risk may be helpful in guiding screening recommendations. With the use of electronic medical records, implementing preventative health maintenance reminders based on gender identity may also be helpful.
Mary Stevenson– Clinical Fellow, Emory University, Atlanta, Georgia
Robert Sineath– Medical Student, Emory University School of Medicine, Brookhaven, Georgia
Michael Goodman– Professor of Epidemiology, Emory University Rollins School of Public Health
Vin Tangpricha– Professor of Medicine, Emory University
Second year clinical endocrinology fellow at Emory University in Atlanta, GA.
Emory University School of Medicine
R. Craig Sineath received his bachelors degree in Biological Sciences from Clemson University in 2008 and his Master of Public Health Degree from Emory University's Rollins School of Public Health in 2011 in Global Epidemiology. He is currently a fourth year medical student applying into urology. As a graduate student, he coordinated an internet-based research project aimed to determine boundaries of recruiting men who have sex with men (MSM) in rural areas. He also spent 11 weeks in Namibia coordinating focus groups and in-depth interviews to evaluate the feasibilty of implementing couples-based HIV counseling and testing for same-sex partners. He has led numerous projects from start to finish including a 10-country pilot study to collect behavioral data on MSM; an online peer-referral project through Facebook; an online respondent driven sampling project through Facebook; an online cross-sectional study of MSM in three countries to inform a prevention packaging project; a pilot study to develop prevention messaging; and numerous online focus groups to support other projects. He has worked on numerous other projects including Keep It Up! (a randomized controlled trial of an online HIV prevention intervention for young MSM), a national web-based behavioral survey, an exploratory project to develop alternate methods of consent and retention in online surveys, a medical records abstraction study supplemented with an online survey to determine care-seeking behaviors and the effects of long-term exposure of hormonal therapies among transgender individuals, and a pilot study to collect rectal biopsy and blood samples from highly-exposed sero-negative MSM. As a future urologist, he hopes to continue working with the transgender population and become a surgeon providing gender-affirming care.
Professor of Epidemiology
Emory University Rollins School of Public Health
Michael Goodman, MD MPH is a Professor of Epidemiology, at the Emory University Rollins School of Public Health. He is a licensed physician with board-certification in Pediatrics and Preventive Medicine. The specific focus of Dr. Goodman’s current research is on health status of transgender people. In addition to his research activities, Dr. Goodman teaches epidemiology both at Emory and at the Centers for Disease Control and Prevention (CDC).