Every October, Breast Cancer Awareness Month brings a familiar wave of pink ribbons, fundraising campaigns and reminders to schedule mammograms. But behind the familiar messaging is a disease that’s more complicated than the public conversation often suggests.
Breast cancer is commonly framed as a women’s health issue. But while cisgender women account for the overwhelming majority of diagnoses, they aren’t the only people affected. Transgender women, transgender men, nonbinary people and cisgender men can also develop breast cancer, often with different risk factors and experiences navigating the healthcare system.
As advances in medicine change how breast cancer is detected and treated, questions remain. Who benefits from these developments? Who is represented in the research? And who gets overlooked when conversations about breast cancer are built around assumptions about gender?
Beyond the numbers
According to the American Cancer Society, an estimated 321,910 women will be diagnosed with breast cancer in 2026, and approximately 42,140 will die from the disease. But those numbers don’t tell the whole story.
White women are slightly more likely to develop breast cancer than Black women, yet Black women have the highest breast cancer mortality rate of any racial or ethnic group in the United States. Aggressive cancers, including triple-negative breast cancer, and disparities in screening, treatment and care contribute to this difference. These disparities also raise questions about outcomes among people whose experiences intersect across race, sexual orientation and gender identity.
Ericka Hart, a Black, queer, nonbinary breast cancer survivor and sexuality educator, has challenged the exclusion of LGBTQ+ people from traditional breast cancer awareness campaigns. Diagnosed with bilateral breast cancer at 28, Hart has publicly shared their mastectomy scars and advocated for greater visibility of Black LGBTQ+ survivors while speaking out about racism and barriers to healthcare.
Hormones add another layer of complexity. Some breast cancers are hormone receptor-positive, meaning estrogen or progesterone can help fuel their growth. But the relationship between hormone exposure and cancer risk varies depending on the type of treatment and individual circumstances.
The National Cancer Institute reports a modest increase in breast cancer risk among current or recent users of certain hormonal contraceptives, although the increase in diagnoses is small, particularly among younger people. Hormonal contraceptives also reduce risks of several other cancers.
Menopausal hormone therapy carries different considerations. Combined estrogen-progestin therapy has been linked to increased breast cancer risk, while estrogen-only therapy has a different risk profile.
Hormonal birth control, menopausal hormone therapy and gender-affirming hormone therapy serve different purposes, and findings about one cannot automatically apply to another. These distinctions matter when discussing transgender patients and gender-affirming care.
Breast cancer and transgender women
Toni Towasser is a trans woman living in New York. She is also a breast cancer survivor. In 2023, she shared her story publicly on “The Today Show.”
According to Towasser, she started taking “bootleg” hormones as part of her transition in 1984. In November 2022, she felt a lump in her breast. Her primary care physician downplayed it. In December, she could tell the lump was growing. Her doctor then ordered a mammogram, which resulted in her diagnosis: hormone-positive breast cancer.
Not many studies have been done regarding the incidence of breast cancer in trans women.
However, those that have been conducted indicate that there is an increased risk of breast cancer compared to cisgender men. One such study was conducted in the Netherlands and reported in the BMJ (formerly British Medical Journal) in 2019. According to the study, for trans women, “the risk of breast cancer increased during a relatively short duration of hormone treatment, and the characteristics of the breast cancer resembled a more female pattern.”
The Cleveland Clinic Journal of Medicine repeated the warning. “Current data suggest that transgender women on gender-affirming hormone therapy have a higher risk of breast cancer than cisgender men and a much lower risk than cisgender women.”
Towasser told Today that her surgeon told her to “stop taking hormones and then she was going to do this surgery.” Towasser’s surgical intervention was a lumpectomy.
Trans women are often prescribed treatment consisting of antiandrogens and estrogens to help in their physical transition (dealing with body hair and body shape/composition) and as an effort to reduce psychological stress. This includes mammary development and concomitant formation of ducts and lobules, and an increase in fat deposits.
It is well established that hormone replacement therapy (HRT) does increase breast cancer risk in cis women who have gone through menopause and could indicate a higher risk for trans women.
In the meantime, based on current data, efforts are being made to establish screening guidelines for trans women.
This effort is being conducted by the American College of Radiology (ACR), the U.S. Preventive Services Task Force, the World Professional Association for Transgender Health, the Endocrine Society, and the Center of Excellence for Transgender Health at the University of California, San Francisco (USCF).
A major factor in those guidelines is the length of time a patient has been taking estrogen. The ACR guidelines are time-use based.
- If less than 5 years of hormone use and average risk, no testing.
- If less than 5 years of hormone use, 25 to 30 years or older, and higher-than-average risk, annual digital breast tomosynthesis (DBT, aka 3-D mammogram) may be appropriate.’
- If 5 or more years of hormone use, 25 to 30 years or older, and higher-than-average risk, annual DBT or mammogram is ‘usually appropriate.’
- If 5 or more years of hormone use, 40 years or older, and average risk, annual DBT or mammogram ‘may be appropriate.’
USCF recommends mammograms every two years for trans women 50+ years of age and average risk who have been on hormones for at least five years.
Trans people face a myriad of obstacles in their journey to be true to their gender identity. There is still a lack of knowledge among many health practitioners. States are making gender-affirming care more difficult to obtain. And there is a lack of knowledge among the LGBTQ+ population when it comes to issues such as breast cancer among trans women in particular.
Dr. Joshua Safer, executive director of the Mount Sinai Center for Transgender Medicine and Surgery, told “Today” that, “It’s still the case that transgender people come to seek medical services less because they are less trusting of the medical system, and for something like breast cancer, it is a big deal.”
Who else gets overlooked?
For transgender men and nonbinary people, screening recommendations depend on factors including breast tissue, family history and previous chest surgery.
The American College of Radiology recommends mammographic screening for many transmasculine patients aged 40 and older who have not undergone chest surgery. Recommendations differ after bilateral mastectomy, or top surgery, although remaining tissue can still require attention.
Cisgender men also develop breast cancer, accounting for approximately 1% of U.S. diagnoses. Without routine screening, cancers are often discovered after symptoms appear, including lumps, nipple changes or discharge. Men may not recognize these symptoms as possible signs of breast cancer.
For transgender and nonbinary patients, screening recommendations also depend on medical history and anatomy, making individualized assessment particularly important.
Progress beyond awareness
Breast cancer treatment continues to evolve and researchers increasingly use tumor characteristics to identify targeted therapies. Antibody-drug conjugates, which deliver cancer-fighting medication to cells expressing specific targets, have expanded treatment options. Immunotherapy has also improved care for some patients with triple-negative breast cancer.
But breast cancer isn’t a single disease, and not every treatment works for every patient. Questions remain about access to new treatments, appropriate screening and representation in research.
Breast Cancer Awareness Month is an opportunity to recognize how differently the disease affects people and ensure those differences aren’t overlooked.
Because the goal shouldn’t simply be greater awareness. It should be better understanding, earlier detection and access to quality care for everyone affected.
This story is brought to you by Rosedale Health and Wellness and Dudley’s Place.
