Oncologic Considerations for Safe Gender-Affirming Mastectomy: Preoperative Imaging, Pathologic Evaluation, Counseling, and Long-Term Screening

Peri-surgical imaging of intersex and gender diverse youths

This publication provides an overview of current imaging indications and practices for patients undergoing gender-affirming surgery, with an emphasis on the importance of tailored, patient-specific care. Gender-affirming surgeries are performed with personalized approaches at various stages of life for those with intersex traits or differences in sex development (I/DSD) and transgender and gender diverse (TGD) individuals. For I/DSD patients, ultrasound, genitography, or MRI occurs during infancy and puberty to evaluate genital and gonadal anatomy. Facial harmonization involves bony and soft tissue modifications, guided by maxillofacial computerized tomography (CT) with three-dimensional reconstruction. Ultrasound is the main modality in assessing hormone-related and post-surgical changes in the chest. Imaging for genital reconstruction uses cross-sectional images and fluoroscopy to assess neoanatomy and complications.

Aspects to consider regarding breast cancer risk in trans men: A systematic review and risk management approach

BACKGROUND

The risk of breast cancer in trans men is currently a poorly understood subject and trans men likely carries a different level of risk from that of cis women.

AIM

This review aims to review several aspects that affects breast cancer risk in trans men and to apply the Swiss cheese model to highlight these risks. The study takes its cue from a systematic review of all described breast cancer cases in trans men following medical or surgical intervention because of gender dysphoria.

METHODS

PubMed was systematically searched on the 14th of March 2023 to find all published cases of breast cancer following chest contouring surgery in trans men. Included articles had to involve trans men, the diagnosis of breast cancer had to be preceded by either a medical or surgical intervention related to gender dysphoria, and cases needed to involve invasive breast cancer or ductal carcinoma in situ. Articles were excluded if gender identity in the case subject was unclear and/or a full English version of the report was unavailable. Quality and risk of bias was evaluated using the GRADE protocol. A literature review of specific risk altering aspects in this population followed. The Swiss cheese model was employed to present a risk analysis and to propose ways of managing this risk.

RESULTS

28 cases of breast cancer in trans men have been published. The Swiss cheese model identified several weaknesses associated with methods of preventing breast cancer in trans men.

CLINICAL IMPLICATIONS

This study may highlight the difficulties with managing risk factors concerning breast cancer in trans men to clinicians not encountering this patient group frequently.

CONCLUSION

This review finds that evidence for most aspects concerning breast cancer in trans men are inadequate, which supports the establishment of a risk-management approach to breast cancer in trans men.

Cancer Screening for Transgender Individuals: Guidelines, Best Practices, and a Proposed Care Model

Few transgender-specific cancer screening recommendations exist. This review aims to cover current guidelines and practice patterns of cancer screening in transgender patients and, where evidence-based data are lacking, to draw from cisgender screening guidelines to suggest best practices for transgender patients based on anatomic inventory. Sufficient evidence does not exist to determine the long-term effects of gender-affirming hormone therapy on cancer risk. In the future, cancer screening and prevention should be focused on anatomic inventory and high-risk behaviors.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

The Effect of Preoperative Health Education, Delivered as Animation Videos, on Postoperative Anxiety and Pain in Femoral Fractures

OBJECTIVE

This article explores the effect of preoperative health education, in the form of animation videos, on postoperative self-reported pain levels and anxiety in femoral fractures.

METHODS

Ninety cases of femoral fracture were divided at random into the oral instruction group, the recorded video group, and the animation video group, with 30 cases in each group. Sociodemographic data were collected the day before surgery. Health education was then offered in one of three ways: orally, using a recorded video, or using an animation video. On days 2, 4, and 7 after surgery, the state-trait anxiety inventory (STAI) and the visual analog scale (VAS) were used to assess postoperative anxiety and pain levels, respectively, in the participants.

RESULTS

At different time points during the evaluation, total anxiety scores in the animation and recorded video groups were significantly lower than in the oral instruction group (P < 0.01), and the pairwise comparisons indicated statistically significant differences (F = 11.04, 10.06, 10.37, P < 0.01). However, the levels of postoperative pain in the animation and recorded video groups were not significantly different (P > 0.05). STAI scores in the three groups were found to have significant interactions with the measurement time (F = 6.74, P < 0.01). However, there were no apparent interactions between the VAS score and the measurement time (F = 1.31, P > 0.05) in the three groups.

CONCLUSION

Preoperative health education with the aid of multimedia is more effective than oral instruction in lowering patients' postoperative anxiety and pain levels. In addition, animation videos are superior to recorded videos in mitigating postoperative anxiety. Whether the two approaches differ in reducing postoperative pain in bone fractures remains to be further tested.

Transgender Mastectomy: Incidence of High-Risk Pathologic Findings and the Need for Postoperative Cancer Surveillance

BACKGROUND

Chest masculinization surgeries are one of the most common gender-affirming procedures performed. There is a need for better understanding of the risk of breast cancer and postsurgical screening in female to male (FtM) individuals. This study aimed to evaluate the incidence of high-risk pathologic findings in FtM transgender patients undergoing gender-affirming chest reconstructive surgery.

METHODS

Medical records were reviewed from all FtM patients undergoing gender-affirming chest reconstructive surgery from January 2010 to February 2021 by 3 plastic surgeons at the University of Pittsburgh Medical Center. Relative risk of malignant progression was used to stratify pathologic data. Subsequent management of atypical, in situ, and invasive pathology were recorded.

RESULTS

A total of 318 patients were included in this study; the average age at surgery was 24.6 ± 8.1 years. Eighty-six patients (27%) had a family history of breast and/or ovarian cancer. Overall, 21 patients (6.6%) had some increased risk of breast cancer: 17 (5.3%) had proliferative lesions, mean age 38.2 ± 12.4 years; 2 had atypical ductal hyperplasia, ages 33.4 and 38.3 years; and 2 had invasive ductal carcinoma, ages 35.4 and 40.6 years.

CONCLUSIONS

In this study, we found that 6.6% of FtM transgender patients undergoing top surgery had an elevated risk of breast cancer, with 1.2% of patients having a greater than 2 times risk of breast cancer. These results highlight the importance of appropriate preoperative screening as well as pathological analysis of surgical specimens to help guide clinical care. The authors advocate for a thorough breast cancer risk assessment before surgery for all patients, as well as using pathologic findings to guide postoperative cancer screening and follow-up.

Surgical Implications of LGBTQ+ Health Disparities: A Review

Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) patients face challenging health care disparities. However, due to restrictions in reporting and collection of sexual orientation and gender identity (SOGI) demographic data, comprehensive studies of surgical disparities in the LGBTQ+ population are limited. This review aims to summarize the existing literature describing surgical disparities in LGBTQ+ patients and to identify areas of surgical care in which further studies are warranted. This review addresses the literature in infectious diseases, substance use disorders, bariatrics, cardiovascular medicine, oncology, and laryngology as relevant to surgical practice. Understanding the current landscape of knowledge in LGBTQ+ surgical disparities and the areas where gaps in research exist will help the surgeon to create a framework of practice to provide more equitable care to LGBTQ+ patients.

A Single-Center Study of Adherence to Breast Cancer Screening Mammography Guidelines by Transgender and Non-Binary Patients

BACKGROUND

Adherence to screening guidelines among transgender and non-binary (TGNB) populations is not well studied. This study examines breast cancer screening patterns among TGNB patients at an urban academic medical center.

METHODS

Demographic information, risk factors, and screening mammography were collected. Mammography rates were calculated in populations of interest according to national guidelines, and mammogram person-years were also calculated. Univariate and multivariate logistic regression was performed.

RESULTS

Overall, 253 patients were analyzed: 193 transgender women and non-binary people designated male at birth (TGNB DMAB) and 60 transgender men and non-binary people designated female at birth (TGNB DFAB). The median (interquartile range) age was 53.2 years (42.3-62.6). Most patients had no family history of breast cancer (n = 163, 64.4%) and were on hormone therapy (n = 191, 75.5%). Most patients where White (n = 164, 64.8%), employed (n = 113, 44.7%), and had public insurance (n = 128, 50.6%). TGNB DFAB breast screening rates were low, ranging from 2.0 to 50.0%, as were TGNB DMAB screening rates, ranging from 7.1 to 47.6%. The screening rates among the TGNB DFAB and TGNB DMAB groups did not significantly differ from one another. Among TGNB DFAB patients, univariate analyses showed no significant predictors for mammography. Among TGNB DMAB patients, not being on hormone therapy resulted in fewer odds of undergoing mammography. There were no significant findings on multivariate analyses.

CONCLUSION

Mammography rates in the TGNB population are lower than institutional and national rates for cisgender patients, which are 77.3% and 66.7-78.4%, respectively. Stage of transition, organs present, hormone therapy, and risk factors should be considered to guide screening.