Screening for breast cancer in transgender individuals undergoing gender-affirming hormone therapy: institutional protocol at a university hospital
DOI:
https://doi.org/10.29289/2594539420240022Palavras-chave:
transgender health, breast cancer screening, mammography, gender-affirming hormone therapy, transfeminine, transmasculineResumo
This study describes the development and implementation of an institutional breast cancer screening protocol for transgender individuals, based on a scoping review and clinical experience at a university hospital. Gender-affirming hormone therapy is widely used among transgender individuals to induce secondary sexual characteristics aligned with gender identity, and in transfeminine individuals, breast development typically occurs within the first months of estrogen exposure, reaching maximal maturation after approximately two years. Despite biological plausibility of oncologic risk associated with prolonged exogenous hormone exposure, evidence regarding breast cancer incidence in this population remains limited and heterogeneous. A scoping review was conducted in the LILACS, PubMed, SciELO, and MEDLINE databases, including publications from 2012 to 2022. In parallel, an institutional protocol was implemented at the Trans Mastology Outpatient Clinic of the Federal University of São Paulo, integrating available evidence with clinical practice. Screening strategies were defined according to risk stratification, duration of hormone exposure, presence of breast tissue, and international radiologic recommendations. All patients received structured counseling regarding current evidence and existing uncertainties. The resulting protocol recommends annual mammography for transfeminine individuals aged 40 years or older with at least five years of continuous estrogen exposure. Transmasculine individuals with preserved breast tissue follow the same screening strategy. For individuals who underwent mastectomy, clinical follow-up is recommended, with imaging reserved for symptomatic cases or those at increased risk. The protocol incorporates international radiologic guidance and Brazilian screening standards within a shared decision-making framework. In conclusion, this institutional protocol provides a structured and risk-adapted approach to breast cancer screening in transgender individuals, integrating biological plausibility, observational data, and clinical guidelines in the context of limited high-level evidence.
Downloads
Referências
1. Unger CA. Hormone therapy for transgender patients. Transl Androl Urol. 2016;5(6):877-84. https://doi.org/10.21037/tau.2016.09.04
2. Campos LML. Gênero e diversidade sexual na escola: a urgência da reconstrução de sentidos e práticas. Ciênc Educ (Bauru). 2015;21(4):1-4. https://doi.org/10.1590/1516-731320150040001
3. Corrêa S, Muntarbhorn V. Princípios de Yogyakarta: princípios sobre a aplicação da legislação internacional de direitos humanos em relação à orientação sexual e identidade de gênero [Internet]. Genebra: International Commission of Jurists; 2007 [cited on 2026 Jan 22]. Available from: https://www.clam.org.br/uploads/conteudo/principios_de_yogyakarta.pdf
4. Felipe J, Goellner SV. Corpo, gênero e sexualidade: um debate contemporâneo na educação. 9a ed. Petrópolis: Vozes; 2013.
5. Brasil. Ministério da Saúde. Secretaria de Gestão Estratégica e Participativa. Departamento de Apoio à Gestão Participativa. Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Brasília: Ministério da Saúde; 2013.
6. Spizzirri G, Eufrásio R, Lima MCP, Nunes HRC, Krekels BPC, Steensma TD, et al. Proportion of people identified as transgender and non-binary gender in Brazil. Sci Rep. 2021;11(1):2240. https://doi.org/10.1038/s41598-021-81411-4
7. Kiran T, Davie S, Singh D, Hranilovic S, Pinto AD, Abramovich A, et al. Cancer screening rates among transgender adults: cross-sectional analysis of primary care data. Can Fam Physician. 2019;65(1):e30-e37. PMID: 30674526.
8. Meriggiola MC, Gava G. Endocrine care of transpeople part II. A review of cross-sex hormonal treatments, outcomes and adverse effects in transwomen. Clin Endocrinol (Oxf). 2015;83(5):607-15. https://doi.org/10.1111/cen.12754
9. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Hassan Murad M, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869-903. https://doi.org/10.1210/jc.2017-01658
10. Blok CJM, Dijkman BAM, Wiepjes CM, Staphorsius AS, Timmermans FW, Smit JM, et al. Sustained breast development and breast anthropometric changes in 3 years of gender-affirming hormone treatment. J Clin Endocrinol Metab. 2021;106(2):e782-e790. https://doi.org/10.1210/clinem/dgaa841
11. Sonnenblick EB, Shah AD, Goldstein Z, Reisman T. Breast imaging of transgender individuals: a review. Curr Radiol Rep. 2018;6(1):1. https://doi.org/10.1007/s40134-018-0260-1
12. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women's Health Initiative randomized controlled trial. JAMA. 2002;288(3):321-33. https://doi.org/10.1001/jama.288.3.321
13. Gooren LJ, van Trotsenburg MAA, Giltay EJ, van Diest PJ. Breast cancer development in transsexual subjects receiving cross-sex hormone treatment. J Sex Med. 2013;10(12):3129-34. https://doi.org/10.1111/jsm.12319
14. Blok CJM, Wiepjes CM, Nota NM, van Engelen K, Adank MA, Dreijerink KMA, et al. Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands. BMJ. 2019;365:l1652. https://doi.org/10.1136/bmj.l1652
15. Grynberg M, Fanchin R, Dubost G, Colau JC, Brémont-Weil C, Frydman R, et al. Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population. Reprod Biomed Online. 2010;20(4):553-8. https://doi.org/10.1016/j.rbmo.2009.12.021
16. Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals. Clin Plast Surg. 2018;45(3):369-80. https://doi.org/10.1016/j.cps.2018.03.010
17. Oeffinger KC, Fontham ETH, Etzioni R, Herzig A, Michaelson JS, Shih YCT, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-614. https://doi.org/10.1001/jama.2015.12783
18. US Preventive Services Task Force, Nicholson WK, Silverstein M, Wong JB, Barry MJ, Chelmow D, et al. Screening for Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2024;331(22):1918-30. https://doi.org/10.1001/jama.2024.5534
19. National Comprehensive Cancer Network. Genetic/familial high-risk assessment: breast, ovarian, pancreatic, and prostate (Version 3.2024) [Internet]. Plymouth Meeting: NCCN; 2024 [cited on 2026 Jan. 22]. Available from: https://www.nccn.org/guidelines/guidelines-detail?category=2&id=1545
20. Sowinski JS, Gunderman RB. Transgender patients: what radiologists need to know. AJR Am J Roentgenol. 2018;210(5):1106-10. https://doi.org/10.2214/AJR.17.18904
21. Deutsch MB, Radix A, Wesp L. Breast cancer screening, management, and a review of case study literature in transgender populations. Semin Reprod Med. 2017;35(5):434-41. https://doi.org/10.1055/s-0037-1606103
22. Sterling J, Garcia MM. Cancer screening in the transgender population: a review of current guidelines, best practices, and a proposed care model. Transl Androl Urol. 2020;9(6):2771-85. https://doi.org/10.21037/tau-20-954
23. Hartley RL, Stone JP, Temple-Oberle C. Breast cancer in transgender patients: a systematic review. Part 1: male to female. Eur J Surg Oncol. 2018;44(10):1455-62. https://doi.org/10.1016/j.ejso.2018.06.035
24. Migowski A, Silva GA, Dias MBK, Diz MDPE, Sant'Ana DR, Nadanovsky P. Guidelines for early detection of breast cancer in Brazil. II – new national recommendations, main evidence, and controversies. Cad Saude Publica. 2018;34(6):e00074817. https://doi.org/10.1590/0102-311X00074817
25. Brasil. Ministério da Saúde. Instituto Nacional de Câncer José Alencar Gomes da Silva. Diretrizes para a detecção precoce do câncer de mama no Brasil. Rio de Janeiro: INCA; 2015.
26. Urban LABD, Chala LF, Bauab SDP, Schaefer MB, Oliveira ALK, Shimizu C, et al. Recomendações do Colégio Brasileiro de Radiologia e Diagnóstico por Imagem, da Sociedade Brasileira de Mastologia e da Federação Brasileira das Associações de Ginecologia e Obstetrícia para o rastreamento do câncer de mama no Brasil. Radiol Bras. 2023;56(4):207-14. https://doi.org/10.1590/0100-3984.2023-0064
27. Expert Panel on Breast Imaging; Brown A, Lourenco AP, Niell BL, Cronin B, Dibble EH, et al. ACR Appropriateness Criteria® Transgender Breast Cancer Screening. J Am Coll Radiol. 2021;18(11S):S502-S515. https://doi.org/10.1016/j.jacr.2021.09.005
28. National Comprehensive Cancer Network. Breast cancer screening and diagnosis (Version 1.2024) [Internet]. Plymouth Meeting: NCCN; 2024 [cited on 2026 Jan. 22]. Available from: https://www.nccn.org/guidelines/guidelines-detail?category=2&id=1421
Downloads
Publicado
Como Citar
Edição
Seção
Licença
Copyright (c) 2026 Marcos Paulo Ribeiro Sanches, Natália Monteiro Cordeiro, Morgana Domingues da Silva, Magnus Régios Dias da Silva, Simone Elias
Este trabalho está licenciado sob uma licença Creative Commons Attribution 4.0 International License.
