Transgender and Gender-Diverse Patient Perspectives on Hereditary Breast Cancer Risk Assessment in Gender-Affirming...

Transgender and gender-diverse (TGD) people have increased cancer morbidity and mortality relative to cisgender individuals. Existing breast cancer prevention guidelines fail to adequately address gender-affirming care implications, especially in the context of gender-affirming mastectomies (top surgery). Evaluation of familial and germline genetic risk before top surgery is recommended by some transgender health guidelines. This evaluation can facilitate shared surgical decision making regarding breast tissue resection extent. In this study, we use in-depth interviews with TGD people planning or having recently undergone top surgery. We aimed to understand barriers and facilitators to pre- and post-top surgery breast cancer risk assessment and screening, and the perceived utility and acceptability of presurgical genetic evaluation.

We conducted qualitative community-engaged research through interviews with 16 TGD adults who had or were considering top surgery. Through a social constructivist lens, we used reflexive thematic analysis to generate themes.

We conceptualized six key themes: (1) post-top surgery cancer screening uncertainty, (2) lack of provider knowledge hindering appropriate care, (3) the experience of breast health spaces as heavily feminized, (4) the balance of aesthetic goals with cancer risk reduction, (5) increased comfort with postsurgical screening because of reduced dysphoria and greater body confidence, and (6) the desire for cancer genetics integration with top surgery care navigation.

From these themes, we derived actionable guidance to address breast cancer health equity in this population. Enhancing patient education, increasing provider awareness, and developing inclusive clinical practice guidelines are crucial steps in effectively addressing breast cancer risk in individuals receiving surgery. It is vital to degender health spaces to promote inclusion and accessibility of breast cancer prevention. Integrating genetics professionals and cancer risk assessment into transgender health clinics and the top surgery process is paramount for delivering personalized care and facilitating informed surgical decision making.