A 40-year-old trans woman (anatomically born as a man) presents to the office to find out about her risk of developing cancer and the preventive measures she can take. Her mother died at the age of 65 from ovarian cancer due to a mutation in the BRCA2 gene, which carries a 68% risk of breast cancer. The patient has been on hormone therapy for ten years and has developed breasts without the need for implants. What should I do, she asks. Stop hormone therapy? Have a mastectomy? Start getting mammograms?
The case has been presented by Megha Ranganathan, from New York's Memorial Sloan Kettering Hospital, at the American Society of Clinical Oncology (ASCO) congress that closes today in Chicago. She has presented it in the first session in the history of the congress dedicated to the care of trans people, a group hitherto ignored in the area of oncology.
It is a group that "avoids receiving medical attention because of the treatment it receives," Ranganathan has declared. "More than 50% of trans men [born anatomically as women] avoid going to gynecological consultations because of the language used when speaking with them." But he has recalled that 1.6% of the US population identifies as transgender, according to a Pew Research Center survey published in 2022.
"The fact that we do not see them in the consultations does not mean that they do not need medical attention," says Judith Balmaña, from the Vall d'Hebron hospital in Barcelona, who has participated in the session as a specialist in genetic counseling.
To make it easier for trans people to seek care when they need it, Ranganathan recommends avoiding language that presupposes patients' gender identity or sexual orientation and asking them what names and pronouns they prefer to be addressed by. “My name is Megha and my pronoun is she, what are yours?” she says when she introduces herself to the patients.
It also recommends not asking questions or comments about gender identity unless they are relevant to the query and apologizing if a mistake is made. “We are here to help the patients, not for the patients to help us,” she said.
In a survey carried out via mobile phone during the session, which was attended by a hundred specialists, 90% acknowledged having made mistakes when addressing trans people.
The counseling offered to the woman whose mother had died of ovarian cancer was based on assessing her own risk of developing cancer in the future. A genetic analysis confirmed that she had inherited the BRCA2 gene mutation. Their risk of breast cancer was considered less than 68% of cis women (whose anatomical sex at birth matches their gender identity) but greater than 2-7% of cis men who have this mutation, although there are no data to establish your breast cancer risk more accurately. She was also told that she has a higher-than-average risk of pancreatic cancer for the population and for a higher-than-average risk of prostate cancer for cis men.
Based on these data, she was recommended to continue the gender-affirming hormonal treatment, because "it is very important for trans women" (as Judith Balmaña has argued) and because "mental health is not secondary to physical health" ( added Lola Fayanju, from the University of Pennsylvania).
But she was also advised to consider a mastectomy and subsequent breast reconstruction surgery to eliminate the risk of breast cancer; the removal of testicles to reduce the dose of estrogens necessary for hormone treatment; preservation of the scrotum to facilitate a subsequent vaginoplasty; and annual controls for early detection of prostate cancer and pancreatic cancer.
In a second case presented by Lola Fayanju, a trans man (anatomically born as a woman) came to the clinic to start a gender affirmation treatment. His mother had died at the age of 39 from breast cancer due to a mutation in the BRCA1 gene. He wanted to find out about her own risk and whether he could have children after treatment.
“Trans people show a willingness to have children similar to that of cis people,” Fayanju said.
In this case, after it was confirmed that she had inherited the BRCA1 mutation, her breast reshaping surgery was recommended to consist of a bilateral mastectomy and subsequent reconstruction - rather than keeping part of the original breast as would have been recommended if she had I would not have had the mutation.
She was informed that she could conceive children with her own eggs and gestate them in her own womb. But a consultation with fertility specialists was recommended to assess the advisability of preserving eggs before starting gender-affirming testosterone treatment. Informed of her high risk of ovarian cancer due to the BRCA1 gene mutation, she was recommended for ovarian and fallopian tube removal surgery between the ages of 35 and 40.
"We hope that more cases will come to the consultations as we learn to better serve trans people," says Balmaña, who warns that "it is a group about which we still have little data to guide us in decision-making."
Declaration of transparency: La Vanguardia has attended the congress of the American Society of Clinical Oncology in Chicago invited by Novartis
