ACR Appropriateness Criteria® Transgender Breast Cancer Screening

Evaluation of the Current Knowledge Base of Breast Cancer Screening Recommendations in the Transgender Population at an Academic Medical Center

Health care disparities within the LGBTQIA+ community are readily apparent. Guidelines have been published regarding breast cancer screening for transgender individuals. Uptake of these recommendations is widely unknown. The purpose of this study is to determine the current knowledge base of providers regarding these recommendations within our academic hospital system. A voluntary, anonymous survey was e-mailed to 303 recipients via RedCap to physicians within our academic hospital system. This assessed the respondents' current knowledge and comfort regarding breast cancer screening recommendations in the transgender population. 85 responses were received for a response rate of 28.1%. Descriptive statistics for all survey questions was conducted. 82.4% of respondents report caring for transgender patients. 62.4% report that they are not familiar with the current screening recommendations, and few (10.6%) have received formal education regarding the topic. The majority of respondents reported that they would be interested in receiving formal training. The results suggest that there is no difference in how individuals rate their current comfort level discussing breast cancer screening recommendations for the transgender population despite their current level of education. Our findings suggest that, while the majority of providers within our academic hospital system care for transgender patients, they are unfamiliar with current breast cancer screening recommendations and have received no formal training. The results also suggest that providers are interested in receiving formal education.

Clinical characteristics of transgender patients with breast cancer: a single institution experience

Breast cancer presents unique complexities for transgender individuals. This retrospective study characterized breast cancers in 14 transgender and nonbinary patients treated at a specialized transgender health center from 2016 to 2023. Patients with a median age of 53 (31-65 years) were identified using international classification of disease-10 codes. Most (86%) were aged 40 or older and eligible for screening mammography. The cohort included 6 trans men, 7 trans women, and one genderqueer individual. Diagnoses included ductal carcinoma in situ (36%), lobular carcinoma in situ (7%), stage 1 (29%), stage 2 (21%), and breast implant-associated anaplastic large cell lymphoma (7%). Screening mammography diagnosed 29%, 43% presented with a mass, and 29% were detected during pre-surgical imaging. Half had estrogen-based gender-affirming hormone therapy (GAHT) and half testosterone-based, with mean GAHT durations of 16.6 years. Biomarker profiles revealed 67% estrogen receptor (ER)-positive and 33% ER-negative cancers. This study highlights underutilized screening mammography and diverse cancer subtypes in this underserved population.

Expert Panel on Breast Imaging, Paulis LV, Lewin AA, Weinstein SP, Baron P, Dayaratna S, Dodelzon K, Dogan BE, Gulati A, Kantor O, Kasales C, Kunjummen JM, Kuzmiak CM, Newell MS, Salkowski LR, Sharpe RE, Small W, Ulaner GA, Slanetz PJ. ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density: 2024 Update

Screening mammography has been proven to reduce the mortality from breast cancer by approximately 30%, however, it is less sensitive in women with dense breast tissue and certain risk groups. Supplemental screening may be considered based on the patient's risk level and breast density. In all women, digital breast tomosynthesis improves screening sensitivity. Average-risk women with heterogeneously dense tissue may also benefit from breast MRI, abbreviated breast MRI (AB-MRI) or breast ultrasound (US). In intermediate-risk women with nondense tissue, breast MRI and ABMRI may be appropriate. In intermediate-risk women with heterogeneously dense and extremely dense tissue, breast MRI and AB-MRI are usually appropriate, whereas US and contrast-enhanced mammography (CEM) may be appropriate. Breast MRI or ABMRI is usually appropriate in all high-risk women, regardless of density. Screening breast US or CEM could be considered in this population. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Oncological needs in transgender patients

Transgender people encounter unique health disparities in oncology. They face substantial barriers in accessing healthcare that are exaggerated by bias/discrimination from healthcare professionals and systems, and socio-economic marginalisation. This review explores the current landscape of cancer risk, screening and management in transgender individuals from a Spanish perspective. Nationwide data are lacking, but estimates from Madrid suggest that 22 per 100,000 individuals are transgender. The needs of the transgender individual for gender-affirming surgeries and gender-affirming hormone therapy may alter the individual's oncological risk profile and likelihood of receiving appropriate screening, and when diagnosed with cancer may have to be balanced against treatment requirements (e.g., endocrine therapy for breast cancer). There remain unmet needs in the oncological care of the transgender patient. Concerted effort is required to address clinical research gaps, and reform healthcare education and policy, in order to develop inclusive clinical practices that enhance patient care and outcomes.

A review of menopause in transgender and gender diverse individuals

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of the specific challenges, health considerations, and healthcare needs of transgender and gender diverse (TGD) people navigating menopause, highlighting the intersection of gender identity, hormone treatment, and age-related changes.

RECENT FINDINGS

Research on menopause in TGD individuals is lacking, without guidelines to support clinical management. This is the first review of its type to summarize the described impact of the menopausal transition on TGD individuals, the potential long-term risks associated with both gender-affirming hormone therapy and the intersectionality with aging, and how these risks may impact hormone management and overall comprehensive care.

SUMMARY

By drawing on the shared principles of cisgender menopausal hormone therapy and gender-affirming hormone therapy, providers are well positioned to apply their expertise to support the TGD population during menopause. We recommend using shared decision-making, culturally competent care, and a strong understanding of the biological, personal, and social experiences of TGD people that do not necessarily conform to stereotypically ciswoman experiences.

Breast imaging characteristics in Thai transgender women: mammography and ultrasound outcomes in a pilot study

Background

Breast cancer screening in transgender women, particularly those undergoing hormone therapy, remains understudied. Limited screening guidelines exist for transgender individuals, creating a need for tailored recommendations. This study addresses breast cancer screening outcomes in Thai transgender women using mammography and ultrasound.

Objectives

To assess breast imaging characteristics and screening outcomes in transgender women in Thailand and identify factors associated with breast density.

Design

A descriptive correlation study with a cross-sectional design.

Methods

Sixty-six transgender women over 40 years of age, who had been on hormone replacement therapy for at least 5 years, were recruited from three clinics. Participants underwent mammography and breast ultrasound, with imaging analyzed using the Breast Imaging-Reporting and Data System (BI-RADS) system. Data were analyzed with descriptive statistics and Spearman's correlation.

Results

The average age of participants was 49.2 years, with an average of 16.3 years of hormone use. Of the participants, 80.3% had undergone breast augmentation. Most participants (86.4%) were classified as BI-RADS 2 and dense breast tissue. Screening findings were mostly negative or benign (94%), with the remaining 6% demonstrating probably benign findings. No signs of malignancy were detected. There was no significant correlation between age, BMI, hormone use duration, BI-RADS, and breast density.

Conclusion

Breast cancer screening among transgender women in Thailand showed high rates of dense breast tissue and low abnormality detection. Moreover, most of them have previously undergone breast augmentation. Therefore, screening guidelines should use both mammography and ultrasound for early detection.

Body Image and Self-Identity in Transgender Patients: A Comprehensive Review from a Psycho-Oncological Perspective

As the number of transgender and gender-diverse (TGD) individuals seeking gender-affirming care continues to increase, it is crucial for healthcare providers to acknowledge the distinct challenges that this community faces and to offer personalized care. This article proposes a comprehensive review aimed at synthesizing current knowledge on the psycho-oncological challenges faced by TGD individuals. By exploring existing literature, it seeks to identify research gaps and provide a framework for addressing the intersection of gender identity, body image, and cancer-related healthcare needs. We aim to explore the complex relationship between being transgender and an oncologic patient, focusing primarily on the effects of gender-affirming hormone therapy (GAHT) and the implications of anatomical structures that remain after gender-affirming surgeries. The complex interplay between GAHT and cancer risks is highlighted, emphasizing the need for ongoing monitoring and tailored healthcare strategies. Psychological aspects of body image and self-identity among transgender individuals, particularly in the context of cancer treatment, are explored, as these treatments may involve significant bodily changes. For TGD individuals, these changes are intricately linked to their sense of identity and self-worth, leading to heightened distress and impaired quality of life. The disruption of sexual function due to cancer treatments can profoundly impact sexual identity and relationships, areas already vulnerable in the TGD population due to societal stigma. The role of social factors in shaping the experiences of TGD individuals in healthcare settings is also discussed, noting how these stressors can influence both the accessibility and quality of care. Research and clinical practice currently face gaps, and more comprehensive studies and guidelines that address the specific healthcare needs of TGD patients are warranted. The importance of an interdisciplinary approach, combining oncological care with gender-affirming practices, is underscored as essential for improving the overall health outcomes and quality of life for TGD individuals facing cancer.

Cancer care for transgender and gender-diverse people: Practical, literature-driven recommendations from the Multinational Association of Supportive Care in Cancer

In the United States, over 2 million individuals openly identify with a gender that differs from their sex assigned at birth. A cancer diagnosis is physically and psychologically taxing-and, in some, traumatic. However, for transgender and gender-diverse (TGD) people, many of whom have experienced discrimination in myriad health care settings, the challenges may be even greater. These recommendations focus on how best to deliver quality cancer care to transgender men (individuals who identify as men but were assigned female sex at birth), transgender women (individuals who identify as women but were assigned male sex at birth), and people who identify somewhere beyond this gender spectrum as nonbinary or using other terms, based on the available, albeit sparse, literature. This review broaches: (1) the epidemiology of cancer in TGD individuals, including the incidence of cancer and cancer-related mortality; (2) cancer center practices that are welcoming and affirming to TGD patients; (3) the need for awareness and intentionality in the spaces of diagnosis and treatment for cancer; (4) the inevitable conclusion that gender differences exist but much more needs to be learned about the impact of gender-affirming therapy, consisting of gender-affirming surgeries and gender-affirming hormone therapy, on cancer therapy; and (5) the efficacy and perceived safety of antineoplastic therapy and gender-affirming hormone therapy.

Breast/chest imaging findings and clinical considerations in transgender patients

The transgender population, a historically marginalized group, is growing in size, visibility, and cultural acceptance. However, lack of provider knowledge contributes to the disparities and discrimination that this group continues to face in the healthcare setting. Special considerations for transgender individuals undergoing imaging for breast/chest care can improve health equity, including appropriate evidence-based screening, tailored protocols, and inclusive radiology facilities. This article will focus on the imaging findings that can be seen in transgender patients during the course of gender-affirming care, which may involve hormone therapy and/or surgery. Relevant examples of benign and malignant pathologies that can be seen in transgender patients will be highlighted, and their imaging on mammogram, ultrasound, and magnetic resonance imaging (MRI) will be reviewed.

Disparities in Study Inclusion and Breast Cancer Screening Rates Among Transgender People: A Systematic Review

BACKGROUND

Breast cancer screening trends of transgender and gender diverse (TGD) people remain largely unknown. This is concerning, as data are necessary to inform recommendations made by clinicians to their patients and by national guidelines to clinicians. The aim of this review is to explore the state of existing research literature and provide a summary report of current breast cancer screening rates in TGD adults.

METHODS

All articles were identified using Medical Subject Headings terms. Inclusion criteria were all the following: (1) documents inclusion of at least one participant who identifies as a TGD person; (2) at least one TGD participant with top surgery or currently receiving estrogen-based gender-affirming hormone therapy; (3) results that report rates of breast cancer screening or mammogram referral.

RESULTS

Twelve articles met inclusion criteria, six cross-sectional studies and six retrospective chart reviews. Three studies conducted secondary analysis of the Behavioral Risk Factor Surveillance System national dataset, and nine articles recruited their own sample with number of TGD participants ranging from 30 to 1,822 and number of cisgender women ranging from 242 to 18,275. Three studies found lower rates of screening in transfeminine persons receiving gender-affirming care compared with cisgender women; two studies found lower rates among TGD people compared with cisgender women; and three studies found no differences between the breast cancer screening rates of TGD and cisgender participants.

CONCLUSION

Limited studies recruit and report trends in breast cancer screening of TGD people. Those that do include TGD participants have mixed results, but overall TGD people had lower rates of breast cancer screening. More research is needed regarding breast cancer screening of TGD people to inform the development of protocols that ensure equitable access to preventative care.

Assessing sex and gender equity in submission guidelines of radiology journals: A cross-sectional study

PURPOSE

Our study aimed to determine the current percentage of gender and sex equity promoting (GSEP) radiology journals, defined as satisfying at least one criterion of the Sex and Gender Equity in Research (SAGER) checklist, published by the European Association of Science Editors (EASE). A secondary objective was to compare characteristics of GSEP and non-GSEP journals.

METHODS

A cross-sectional analysis between June 24 and July 3, 2023, was conducted. The author submission guidelines of radiology journals with a 2021 Journal Impact Factor (JIF) were assessed according to the SAGER checklist. GSEP journals were defined as satisfying one or more SAGER checklist criteria in their research instructions. Bibliometric data and journal information were collected from the Journal Citation Reports and National Library of Medicine catalogue.

RESULTS

Only 39.7 % (52) of 132 journals satisfied at least one SAGER checklist criterion. Median 2021 JIFs were higher in GSEP journals (4.62, IQR: 3.73 - 5.21) than non-GSEP journals (2.70, IQR: 2.32) (p = 0.00). Median 2021 Journal Citation Index (JCI) scores were higher in GSEP (0.64, 0.56 - 0.73) than non-GSEP journals (0.97, 0.83 - 1.10) (p = 0.00). Cited half-life was shorter for GSEP (5.40, 4.80 - 6.50) than non-GSEP journals (6.70, 5.70 - 7.40) (p = 0.05). Elsevier published 33 of 52 of GSEP journals.

CONCLUSION

60.3% of radiology journals with a 2021 JIF do not meet a single SAGER checklist criterion in their author submission guidelines. GSEP journals had higher impact and source metrics and a shorter cited half-life. Publishers may play a significant role in promoting endorsement of the SAGER checklist in the author submission guidelines of radiology journals.

Tumors, Treatments, and Trust: Cancer Characteristics, Outcomes, and Screening Uptake in Transgender and Gender-Diverse Patients

BACKGROUND

More than 2.5 million adults in the United States identify as transgender or gender-diverse (TGD), but little data exist on cancer screening and care for this population. We examined cancer characteristics, screening adherence, genetic testing, and provider inclusive language for TGD patients with cancer.

METHODS

This single institution retrospective cohort study identified TGD patients with cancer between 2000 and 2022. Demographic, clinicopathological, treatment, and screening data were collected, as well as data on gender-affirming care (GAC) and use of patients' personal pronouns in medical records. Descriptive statistics and regression analyses were used to report outcomes.

RESULTS

Sixty unique patients with 69 cancer diagnoses were included: 63.3% were transgender women, 21.7% transgender men, 6.7% nonbinary, and 8.3% were genderqueer. Sixty-five percent had a family history of cancer. Only 46.2% of those who met genetic testing criteria were referred. On review of recommended cancer screening, colorectal screening had the greatest uptake (62%), followed by breast (48.3%), lung (35.7%), cervical (33.3%), and prostate (32%); 8.5% of cancers were diagnosed on screening. Individuals with Medicare had reduced odds of screening uptake (OR 0.07, 95% CI 0.01-0.58) versus private insurance. With respect to GAC, 73.3% used gender-affirming hormone therapy and 41% had gender-affirming surgery. After initiating GAC and asserting personal pronouns, 75% were referred to by incorrect name/pronouns in provider documentation.

CONCLUSIONS

Our TGD cancer patient cohort had low rates of disease-specific cancer screening and inadequate genetic referrals. Many providers did not use appropriate patient names/pronouns. Provider and patient interventions are needed to ensure inclusive preventative and oncologic care for this marginalized population.

Transgender preventative health-chest/breast cancer screening

Cancer mortality rates have decreased over the last 48 years attributable to standardized cancer screenings. These screenings were developed without deliberate inclusion of transgender and non-binary populations. While specialists are familiar regarding cancer screening in this distinct population, those in primary care might be more limited. As such, we aimed to develop a screening risk tool that combines the Breast Cancer Risk Assessment Tool (Gail model) with the updated American College of Radiology Appropriateness Criteria-Transgender Breast Cancer Screening, into an online questionnaire designed to accommodate primary care physicians performing routine health screenings to advise appropriate imaging and referral for this population. This new tool can be used for transgender chest/breast risk assessment whereas the Gail model alone was developed without transgender populations in mind, with the aim of early detection and cancer prevention in this historically underserved healthcare population.

Breast and cervical cancer in transgender men: literature review and a case report

Transgender individuals exhibit a higher prevalence of cancer-related risk factors, such as substance abuse and sexually transmitted infections. These factors, coupled with suboptimal adherence to cancer screening recommendations, may lead to a higher incidence of cancers, such as breast and cervical cancer, and contribute to delayed diagnoses in transgender patients. Herein, we report a unique case of a transgender man with a history of alcohol and drug abuse, undergoing gender-affirming exogenous testosterone therapy, who developed synchronous locally advanced breast cancer and human papilloma virus (HPV)-related cervical cancer. He underwent concurrent chemoradiation for cervical cancer and surgery followed by endocrine therapy for breast cancer. The treatments were suboptimals due to patient's comorbidities, among them liver cirrhosis leading to an early death. Additionally, we have conducted a review of existing literature, including case reports, clinical studies, and review articles investigating the role of potential risk factors specifically related to breast and cervical tumors in transgender men. Gender-affirming testosterone therapy is common among transgender men to induce gender affirmation, but its link to breast cancer risk remains ambiguous, with studies being limited and sometimes contradictory. Conversely, HPV is a well-established cause of up to 99% of cervical cancers. Despite persistent risk for cervical cancer in transgender men who retain their cervix, several studies indicate notable disparities in screening adherence, due to personal and structural barriers. Moreover, alcohol and drug use disorders, commonly encountered in transgender population, may negatively influence the adherence to screening programs. Current cancer screening guidelines for this population are somewhat unclear, and specific programs based on more robust data are urgently required along with further tailored studies.

Gender affirming care for the minimally invasive gynecologic surgeon

PURPOSE OF REVIEW

Given the current political climate and the release of an updated version of the World Professional Association for Transgender Health's guidelines, this review assesses recent updates in the care of transgender and gender diverse (TGD) patients, specifically related to care provided by gynecologists.

RECENT FINDINGS

The number of people identifying as TGD and pursuing gender affirming care is increasing. Contraception for these patients is underdiscussed and high rates of pelvic pain and irregular bleeding were identified. Rates of regret are low following gender affirming surgeries, and studies have repeatedly shown their benefits for gender dysphoria. A minimally invasive approach is recommended for gender affirming hysterectomy, and the decision to proceed with bilateral salpingo-oophorectomy should be based on shared decision making. Surgical techniques include ensuring an adequate margin when taking the infundibulopelvic ligament, and consideration for two-layer vaginal cuff closure.

SUMMARY

Gynecologists play a key role in the care of TGD patients. Recent reviews have found extensive gaps in our knowledge, including a lack of guidelines for cancer prevention, effects of testosterone on benign conditions, and the long-term effects of bilateral salpingo-oophorectomy on health outcomes for patients on testosterone.

Congressional Expansion of Enhancing Breast Cancer Screening and Care at the Veterans Health Administration

Despite high screening rates, breast cancer disparities persist among women veterans because of occupational risks and barriers to access. Three essential bills recently passed in Congress seek to expand access to breast cancer screenings and cancer care within the Veterans Health Administration. The Making Advances in Mammography and Medical Options for Veterans Act expands screening via partnerships with the National Cancer Institute, integrating telescreening and upgrading imaging technology. The Dr. Kate Hendricks Thomas Supporting Expanded Review for Veterans In Combat Environments Act broadens eligibility for those exposed to toxins and personalized risk assessments. The bipartisan Sergeant First Class Health Robinson Honoring our Promise to Address Comprehensive Toxics Act extends benefits for toxin-exposed veterans with presumptive conditions, including breast cancer. Further programs such as National TeleOncology, the Breast & Gynecologic Oncology System of Excellence, and research collaborations between the Veterans Health Administration, National Cancer Institute, and Surveillance, Epidemiology and End Results Program seek to improve access, enhance understanding and care for women veterans with cancer, and mark significant progress in comprehensive care.

Overview of gender-affirming surgery

This publication will discuss the diversity of procedures that are common to those with intersex traits,/differences of sex development (I/DSD), and transgender and gender diverse (TGD) patients. It will address how these procedures are performed, and common after care and long-term considerations which are relevant to the pediatric radiologist. Some surgeries offered to these patient populations have shared surgical approaches and radiographic considerations. With the growth of TGD procedures as a field, more pediatric subspecialties are performing these procedures, and the approaches are informing the surgical care of the growing number of I/DSD individuals who are seeking surgery in adolescence and young adulthood. Surgeries discussed will include procedures to masculinize or feminize breast/chest tissue, facial bony contours, as well as internal and external genital structures. Patients are diverse and this includes their embodiment goals. As such, not all TGD and I/DSD patients will desire to undergo these procedures. It is important for radiologists to have a foundational understanding of this heterogenous set of procedures so they can provide optimal care for these patient populations.

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.

ACR Appropriateness Criteria® Female Breast Cancer Screening: 2023 Update

Early detection of breast cancer from regular screening substantially reduces breast cancer mortality and morbidity. Multiple different imaging modalities may be used to screen for breast cancer. Screening recommendations differ based on an individual's risk of developing breast cancer. Numerous factors contribute to breast cancer risk, which is frequently divided into three major categories: average, intermediate, and high risk. For patients assigned female at birth with native breast tissue, mammography and digital breast tomosynthesis are the recommended method for breast cancer screening in all risk categories. In addition to the recommendation of mammography and digital breast tomosynthesis in high-risk patients, screening with breast MRI is recommended. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Imaging the Male Breast: Gynecomastia, Male Breast Cancer, and Beyond

The number of men undergoing breast imaging has increased in recent years, according to some reports. Most male breast concerns are related to benign causes, most commonly gynecomastia. The range of abnormalities typically encountered in the male breast is less broad than that encountered in women, given that lobule formation rarely occurs in men. Other benign causes of male breast palpable abnormalities with characteristic imaging findings include lipomas, sebaceous or epidermal inclusion cysts, and intramammary lymph nodes. Male breast cancer (MBC) is rare, representing up to 1% of breast cancer cases, but some data indicate that its incidence is increasing. MBC demonstrates some clinical features that overlap with those of gynecomastia, including a propensity for the subareolar breast. Men with breast cancer tend to present at a later stage than do women. MBC typically has similar imaging features to those of female breast cancer, often characterized by an irregular mass that may have associated calcifications. Occasionally, however, MBC has a benign-appearing imaging phenotype, with an oval shape and circumscribed margins, and therefore most solid breast masses in men require tissue diagnosis. Histopathologic evaluation may alternatively reveal other benign breast masses found in men, including papillomas, myofibroblastomas, and hemangiomas. Radiologists must be familiar with the breadth of male breast abnormalities to meet the rising challenge of caring for these patients. ©RSNA, 2024 Supplemental material is available for this article.

Review of Breast Imaging in Transgender and Gender-Diverse Patients: Gender-Affirming Care, Histopathologic Findings, Breast Cancer Risk, and Screening Recommendations

Gender diversity, especially pertaining to transgender and gender-diverse (TGD) populations, is often stigmatized. A small but not insignificant number of adults in the United States identify as TGD, including transgender, nonbinary, and other gender identities than cisgender. Accessing health care remains a significant challenge for TGD individuals because many health care systems adhere to a gender binary model and many TGD individuals experience negative interactions when interfacing with health care. There is also a scarcity of literature addressing their unique health care needs, limiting our current understanding of breast cancer risks and screening recommendations for TGD patients. This article reviews important considerations when providing care to TGD patients. It covers background information on gender identity and sexuality, explores gender-affirming care, discusses histopathologic findings of breast biopsy specimens, examines breast cancer risks, and presents current breast cancer screening recommendations for TGD patients. Education on TGD breast cancer risks and screening and creating a standardized screening protocol for TGD patients who may receive gender-affirming care through hormonal and surgical therapies could help improve their health care equity and access.

Canadian Association of Radiologists Breast Disease Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Breast Disease Expert Panel consists of breast imaging radiologists, a high-risk breast clinician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 30 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 69 recommendation statements across the 20 scenarios. This guideline presents the methods of development and the recommendations for referring asymptomatic individuals, symptomatic patients, and other scenarios requiring imaging of the breast.

Breast Cancer Screening Recommendations for Transgender Patients: A Review

Shifting societal attitudes trending toward increased acceptance of transgender people has contributed to a growth in the population of individuals who openly identify as transgender as well as an increase in utilization of gender-affirming surgeries. Therefore, health care providers should work toward increasing their knowledge with respect to the health care needs of the transgender population, particularly given that these individuals often face discrimination in the health care system. Moreover, transgender breast cancer screening rates lag behind breast cancer screening rates for cisgender individuals. We attempt to clarify important terminology about the transgender population and introduce the concept of equity-centered language. We review current transgender breast cancer screening guidelines by using PubMed, Google Scholar, and Google with search terms that included transgender breast cancer guidelines, transgender breast cancer screening guidelines, and transgender cancer screening guidelines. Searches were not filtered based on year of publication, language of publication, or geographic location. We compare the various guidelines as they pertain to both transgender men and transgender women and offer special considerations for upholding inclusivity in the health care field. An easy-to-reference summary of the current transgender breast cancer screening guidelines and the major points of this article were compiled into an original infographic that health care providers can reference to ensure that appropriate care is being offered.

Benign phyllodes tumour in a transgender woman receiving hormonal therapy

We present a case of a transwoman taking hormonal feminisation therapy for over 20 years, who underwent surgical excision of a benign phyllodes tumour of the breast. Hormones progesterone and oestrogen act on breast epithelium to increase proliferation. For ciswomen, endogenous and exogenous oestrogen exposure over a lifetime is associated with increased risk for certain benign and malignant breast pathologies. Transwomen taking hormonal therapy may also be at an increased risk of breast disease.

Considerations for Gender-Affirming Hormonal and Surgical Care Among Transgender and Gender Diverse Adolescents and Adults With Congenital Heart Disease

BACKGROUND

Transgender and gender diverse (TGD) individuals and long-term survivors with adult congenital heart disease (ACHD) are both growing populations with specialized needs. No studies assess temporal trends or evaluate the care of TGD individuals with ACHD.

METHODS AND RESULTS

Meetings between congenital cardiology and gender-affirming care specialists identified unique considerations in TGD individuals with ACHD. A retrospective chart review was then performed to describe patient factors and outpatient trends in those with an ACHD diagnosis undergoing gender-affirming hormonal or surgical care (GAHT/S) at 1 adult and 1 pediatric tertiary care center. Thirty-three TGD individuals with ACHD were identified, 21 with a history of GAHT/S. Fourteen (66%) had moderate or complex ACHD, 8 (38%) identified as transgender male, 9 (43%) transgender female, and 4 (19%) other gender identities. Three had undergone gender-affirming surgery. There were zero occurrences of the composite end point of unplanned hospitalization or thrombotic event over 71.1 person-years of gender-affirming care. Median age at first gender-affirming appointment was 16.8 years [interquartile range 14.8-21.5]. The most common treatment modification was changing estradiol administration from oral to transdermal to reduce thrombotic risk (n=3). An increasing trend was observed from zero TGD patients with ACHD attending a gender diversity appointment in 2012 to 14 patients in 2022.

CONCLUSIONS

There is a growing population of TGD patients with ACHD and unique medical and psychosocial needs. Future studies must fully evaluate the reassuring safety profile observed in this small cohort. We share 10 actionable care considerations for providers with a goal of overseeing a safe and fulfilling gender transition across all TGD patients with ACHD.

Breast Cancer Disparity and Outcomes in Underserved Women

Women in the United States who continue to face obstacles accessing health care are frequently termed an underserved population. Safety-net health care systems play a crucial role in mitigating health disparities and reducing burdens of disease, such as breast cancer, for underserved women. Disparities in health care are driven by various factors, including race and ethnicity, as well as socioeconomic factors that affect education, employment, housing, insurance status, and access to health care. Underserved women are more likely to be uninsured or underinsured throughout their lifetimes. Hence they have greater difficulty gaining access to breast cancer screening and are less likely to undergo supplemental imaging when needed. Therefore, underserved women often experience significant delays in the diagnosis and treatment of breast cancer, leading to higher mortality rates. Addressing disparities requires a multifaceted approach, with formal care coordination to help at-risk women navigate through screening, diagnosis, and treatment. Mobile mammography units and community outreach programs can be leveraged to increase community access and engagement, as well as improve health literacy with educational initiatives. Radiology-community partnerships, comprised of imaging practices partnered with local businesses, faith-based organizations, homeless shelters, and public service departments, are essential to establish culturally competent breast imaging care, with the goal of equitable access to early diagnosis and contemporary treatment. Published under a CC BY 4.0 license. Test Your Knowledge questions are available in the Online Learning Center. See the invited commentary by Leung in this issue.

Strategies enhancing the patient experience in mammography: A scoping review

INTRODUCTION

A positive experience in mammography is essential for increasing patient attendance and reattendance at these examinations, whether conducted for diagnostic or screening purposes. Mammograms indeed facilitate early disease detection, enhance the potential for cure, and consequently reduce breast cancer mortality. The main objective of this review was to identify and map the strategies aiming to improve the patient experience in diagnostic and screening mammography.

METHODS

This scoping review was performed following the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Searches were performed through databases of MEDLINE, Embase.com, CINAHL, APA PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, ProQuest Dissertation and Theses, and three clinical trial registries. This review considered studies evaluating the effect of interventions, occurring within the mammography department, on the patient experience.

RESULTS

The literature search yielded 8113 citations of which 60, matching the inclusion criteria, were included. The strategies were classified into eight categories. The most represented one was breast compression and positioning, followed by relaxation techniques and analgesic care, communication and information, screening equipment, examination procedures, patient-related factors, physical environment, and finally staff characteristics. The studied outcomes related to patient experience were mainly pain, anxiety, comfort, and satisfaction. Other types of outcomes were also considered in the studies such as image quality, technical parameters, or radiation dose. Most studies were conducted by radiographers, on female patients, and none mentioned the inclusion of male or transgender patients.

CONCLUSION

This review outlined a diversity of strategies to improve patient experience, although technique-based interventions were predominant. Further research is warranted, notably on psychological strategies, and on men and transgender people.

IMPLICATIONS FOR PRACTICE

This scoping review provides guidance to healthcare providers and services for better patient/client-centered care.

Male Breast: A Review of the Literature and Current State of the Art of Diagnostic Imaging Work-Up

Pathological conditions affecting the male breast (MB) share some similarities with those found in women, while others are specific to men. The first part of this review provides an overview of MB disorders, exploring the most common types of MB diseases. The second part then emphasizes the state-of-the-art approaches proposed in the literature for screening and follow-up with MB cancer patients, which highlights the importance of tailored strategies for diagnosis, follow-up, and identifying high-risk populations. Considering the increasing attention in recent years on the topic, transgender individuals are also included in this review. Together with the MB, it is an understudied category thus far. This review aims to raise awareness among radiologists that MBs should be approached differently from female breasts, contributing to the advancement of medical knowledge, improving patient outcomes, and promoting early detection of MB disorders. The review also provides an update on breast cancer and screening in the transgender population.

ACR Appropriateness Criteria® Breast Implant Evaluation: 2023 Update

This document discusses the appropriate initial imaging in both asymptomatic and symptomatic patients with breast implants. For asymptomatic patients with saline implants, no imaging is recommended. If concern for rupture exists, ultrasound is usually appropriate though saline rupture is often clinically evident. The FDA recently recommended patients have an initial ultrasound or MRI examination 5 to 6 years after initial silicone implant surgery and then every 2 to 3 years thereafter. In a patient with unexplained axillary adenopathy with current or prior silicone breast implants, ultrasound and/or mammography are usually appropriate, depending on age. In a patient with concern for silicone implant rupture, ultrasound or MRI without contrast is usually appropriate. In the setting of a patient with breast implants and possible implant-associated anaplastic large cell lymphoma, ultrasound is usually appropriate as the initial imaging. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Position paper of the Italian association of medical oncology on health disparities among transgender and gender-diverse people: the Assisi recommendations

Transgender and gender-diverse individuals experience substantial health disparities across the cancer care continuum. Despite well recognized unique healthcare needs, there are barriers in accessing cancer prevention and treatment services, influenced by disadvantages in key social-economic determinants of health which result in worse clinical outcomes, as compared to the general population. The Italian Association of Medical Oncology (AIOM) acknowledges the critical relevance of this issue. The "Assisi Recommendations" here summarize the outcomes of the "AIOM Oncology Ethics Day" dedicated to gender differences in oncology and cancer care of transgender and gender-diverse people. The recommendations generated during a 2-day multidisciplinary discussion address the various aspects of cancer care experience of transgender and gender-diverse people. The promotion of research in this field, through the generation of new evidence and the collection of prospective data, has been identified as a priority action to mitigate these disparities. By acknowledging the challenges of cancer care in transgender and gender-diverse people and recognizing the need for dedicated policy and clinical recommendations, AIOM demonstrates its commitment to improving the health and well-being of all patients with cancer, regardless of their gender identity or any other personal or social circumstances, as part of health-for-all societal vision.

Cancer surveillance for transgender and gender diverse patients with Lynch syndrome: a practice resource of the Collaborative Group of the Americas on Inherited Gastrointestinal Cancer

Transgender and gender diverse (TGD) populations with hereditary cancer syndromes face unique obstacles to identifying and obtaining appropriate cancer surveillance and risk-reducing procedures. There is a lack of care provider knowledge about TGD health management. Lynch syndrome (LS) is one of the most common hereditary cancer syndromes, affecting an estimated 1 in 279 individuals. There are no clinical guidelines specific for TGD individuals with LS, highlighting a need to improve the quality of care for this population. There is an urgent need for cancer surveillance recommendations for TGD patients. This commentary provides recommendations for cancer surveillance, risk-reducing strategies, and genetic counseling considerations for TGD patients with LS.

Educating Radiology Stakeholders on Relevant Health Issues and Terminology Regarding LGBTQIA+ Patients in 2023

RATIONALE AND OBJECTIVES

Over 20% of the Lesbian, Gay, Bisexual, Queer or Questioning, Intersex, Asexual or Ally, and more (LGBTQIA+) community reports experiencing discrimination upon accessing health care, causing many to defer access to care and resulting in poorer outcomes. While members of this community routinely undergo imaging studies, little formal education exists within the field of radiology to review the unique health care needs of this population and the specific relevance to imaging, in addition to actionable methods to promote inclusion.

MATERIALS AND METHODS

A 1-hour educational conference was held for a cohort of radiology resident physicians at our institution, in which topics including LGBTQIA+ health care disparities, clinical nuances relevant to the field of radiology, and actionable suggestions that both academic and private-practice centers can adopt to foster inclusion were presented. All attendees were required to complete a 12-question, multiple-choice preconference and postconference examination.

RESULTS

Median prelecture and postlecture quiz scores for four first-year radiology residents were 29% and 75%, for two second-year radiology residents were 29% and 63%, for two third-year radiology residents were 17% and 71%, and for three fourth-year radiology residents were 42% and 80%.

CONCLUSION

Multiple areas of opportunity to foster LGBTQIA+ inclusion at the provider and administration levels currently exist throughout the field of radiology. A radiology-focused education module regarding clinical nuances, health care inequities, and ways to foster an inclusive environment with the LGBTQIA+ community is an effective way to promote learner knowledge.

Breast Cancer Screening Recommendations for Transgender and Gender Diverse Patients: A Knowledge and Familiarity Assessment of Primary Care Practitioners

Breast cancer screening recommendations for transgender and gender diverse (TGD) patients have only been recently developed and many primary care practitioners (PCPs) are unaware of these specific recommendations. The aim of this study is to assess the level of familiarity and knowledge PCPs have with breast cancer screening recommendations for TGD patients. An anonymous survey was distributed to primary care physicians, primary care advanced practice practitioners, and internal medicine and family medicine residents at three academic medical systems in the United States (Mayo Clinic, University of Michigan, University of Texas - Medical Branch). Survey questions assessed the familiarity and knowledge base of TGD breast cancer screening recommendations, training and experience with TGD patients, and basic demographics of the practitioners. Of the 95 survey respondents, only 35% of respondents were aware that breast cancer screening recommendations for TGD patients existed. PCPs who had increased transgender specific health care training and direct clinical exposure to TGD patients demonstrated significantly higher levels of screening recommendation awareness. Two-thirds of respondents received TGD specific medical education during training or medical career and those who had increased transgender specific medical education or direct clinical exposure to TGD patients demonstrated significantly higher levels of screening recommendation awareness. Awareness of breast cancer screening recommendations for TGD patients is low among PCPs and varied based on the practitioner's prior TGD education and experience. Up-to-date breast cancer screening recommendations for TGD patients should be readily available across multiple platforms, target key audiences, and integrated into transgender health educational curriculums to maximize awareness of these important recommendations.

Beyond the Binary: Moving the Radiology Workforce Toward Gender Inclusion, From the AJR Special Series on DEI

Gender representation in radiology has traditionally been evaluated and reported through binary models, accompanied by advocacy efforts focused on increasing the number of women in radiology. A paucity of data exists to understand the entire gender composition of the radiology workforce, including representation of people who are transgender and gender diverse. Further, little information exists on how to provide a supportive work environment for radiologists and support staff who identify as belonging to an underrepresented gender minority group. Intentional efforts to comprehensively understand the gender representation of the radiology workforce can help to establish a diverse workforce that is more representative of the patient populations that we serve, while promoting high-quality inclusive health care. Moving beyond gender binary thought and practices can help foster a culture of inclusion and belonging in radiology. This article provides practical steps that radiology practices can take to understand and support gender diversity beyond the binary in the radiology workforce, including providing definitions and inclusive language, understanding limitations of historical methods of gender data collection in radiology and relevant published literature, establishing best practices for future data collection, and developing a strategic vision with action items to create a more inclusive work environment.

Clinical outcomes of radiation therapy for transgender and gender-expansive people with cancer

Introduction

Approximately 1.6 million people in the US identify as transgender, many of whom undergo gender-affirming medical or surgical therapies. While transgender individuals are diagnosed with cancer at similar rates as those who are cisgender, the impacts of radiation therapy on outcomes of gender-affirming care in transgender, nonbinary, and gender-expansive people with cancer are understudied. We report on the experiences and outcomes of transgender and gender-expansive patients receiving radiation therapy for cancer treatment.

Methods

This study is a multi-institutional retrospective review of patients evaluated from 2005-2019 identified as transgender or gender-expansive in the medical record and treated with radiation therapy.

Results

We identified 23 patients who received radiation to 32 sites, including 12 (38%) to the brain, head, or neck, 8 (25%) to the thorax, and 7 (22%) to the pelvis. Seventeen patients (74%) received gender-affirming hormone therapy and 13 patients (57%) underwent gender-affirming surgery. Four patients had pelvic radiation before or after gender-affirming pelvic surgery, including two trans women who had pelvic radiation after vaginoplasty. Four patients had radiation to the chest or thorax and gender-affirming chest or breast surgery, including two trans men with breast cancer. Two pediatric patients developed hypopituitarism and hypogonadism secondary to radiation therapy and, as adults, changed their hormone replacement therapy to affirm their transgender identities.

Discussion

Transgender people with cancer undergo radiation therapy for a wide range of cancers. Understanding their prior gender-affirming medical or surgical treatments and future gender affirmation goals may identify important considerations for their oncologic care.

Cultural Competence in the Care of LGBTQ+ Patients: A Primer for Breast/Chest Centers

The number of individuals identifying as lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) has doubled over the past 10 years, and this figure continues to rise. The LGBTQ+ community is diverse, encompassing a vast array of differences in gender identity and sexual orientation. Additionally, it is inclusive of people from all races, ethnicities, religions, and socioeconomic backgrounds. This intersectionality of identities and experiences impacts both access to health care and its delivery. Barriers to care for this population are multifactorial and include stigma, discrimination, bias, limited role models, issues with insurance coverage, lack of education and training for health care providers, and lack of research on LGBTQ+ health-related issues. Specific to breast cancer, the screening recommendations for this group are influenced not only by risk but also by gender-affirming hormonal and surgical therapies. This article will provide an overview of the LGBTQ+ population, review breast cancer screening compliance and recommendations, summarize the multitude of health disparities, and offer potential interventions to improve care delivery at the individual, facility, organizational, and health policy levels.

Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery

BACKGROUND

Literature focused on cancer screening and management is lacking in the transgender population.

AIM

To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming (TGNC) patients.

METHODS

We performed a systematic search of PubMed on January 5th, 2022, with the following terms: "TGNC", OR "transgender", OR "gender non-conforming", OR "gender nonbinary" AND "cancer screening", AND "breast cancer", AND "cervical cancer", AND "uterine cancer", AND "ovarian cancer", AND "prostate cancer", AND "testicular cancer", AND "surveillance", AND "follow-up", AND "management". 70 unique publications were used. The findings are discussed under "Screening" and "Management" categories.

RESULTS

Screening: Current cancer screening recommendations default to cis-gender protocols. However, long-term gender-affirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection. The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer. Management: Prior to undergoing Gender Affirmation Surgery (GAS), discussion should address cancer screening and management in the organs remaining in situ. Cancer treatment in this population requires consideration for chemotherapy, radiation, surgery and/or reconstruction. Modification of hormone therapy is decided on a case-by-case basis. The use of prophylactic vs aesthetic techniques in surgery is still debated.

CONCLUSION

When assessing transgender individuals for GAS, a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential. Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social, medical, surgical and gender affirming surgery related specifications. Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes. A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS. Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address. We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature. Further research is required to ensure more comprehensive and individualized care for this population.

Breast cancer in a transgender woman undergoing gender-affirming exogenous hormone therapy

Gender-affirming hormone therapy may be utilized by transgender women hoping to induce feminizing changes and suppress the effects of endogenous testosterone. It is well established that exogenous hormone use increases risk of breast cancer in cisgender women; however, a link in the transgender population is less clear. Our case presents a transgender woman undergoing gender-affirming exogenous hormone therapy who subsequently developed breast cancer. We review the available literature regarding risks of exogenous hormone therapy with regards to breast cancer development. Additionally, we present current societal guidelines and recommendations for screening in this population.

Radiology and radiation oncology considerations for transgender and intersex patients: A qualitative study

INTRODUCTION

In this qualitative study, we explored experiences of radiologists and radiation oncologists in providing clinical care to transgender, gender diverse (TGD), and intersex patients by asking about comfort level, relevant past training and training gaps, and clinical recommendations for TGD and intersex patient care.

METHODS

A purposive sample of radiology and radiation oncology professionals (n = 16) from diverse practice settings were interviewed on a videoconferencing platform. Transcripts were auto-populated and checked manually for accuracy. Two coders used a mix of deductive and inductive coding to identify key themes. Member checking was conducted with interviewees.

RESULTS

Participants reported major gaps in training, knowledge, and confidence related to all aspects of TGD and intersex patient care. Recommendations for improvements included training that encompassed key terminology, how to conduct a physical exam on TGD and intersex patients, radiology and radiation oncology adaptations for TGD and intersex patients, and care coordination among multi-disciplinary oncology team members and gender affirming care providers. Exposure to diverse TGD and intersex persons in personal and professional life contributed to higher levels of comfort among providers in caring for TGD and intersex patients.

CONCLUSION

Gaps in knowledge and limited confidence characterized the sample. Training at all levels is needed to improve radiology and radiation oncology care for TGD and intersex patients.

Health inequities in mammography: A scoping review

OBJECTIVE

The objective of this scoping review is to chart the existing evidence on health inequities related to mammography and identify existing knowledge gaps to guide future research.

METHODS

This scoping review followed guidelines from the Joanna Briggs Institute and the PRISMA extension for scoping reviews. In July 2022, we searched PubMed and Ovid Embase for published articles on mammography screening, published between 2011 and 2021, written in English, and examining at least one health inequity as defined by the NIH. Screening and charting were both performed in a masked, duplicate manner. Frequencies of each health inequity examined were analyzed and main findings from each included study were summarized.

RESULTS

Following screening, our sample consisted of 128 studies. Our findings indicate that mammography screening was less likely in historically marginalized groups, patients who live in rural areas, and in women with low income status and education level. Significant research gaps were observed regarding the LGBTQ + community and sex and gender. No trends between inequities investigated over time were identified.

DISCUSSION

This scoping review highlights the gaps in inequities research regarding mammography, as well as the limited consensus across findings. To bridge existing research gaps, we recommend research into the following: 1) assessments of physician knowledge on the LGBTQ + community guidelines, 2) tools for health literacy, and 3) culturally competent screening models.

Breast Cancer Among Transgender and Nonbinary Patients: Paradigms for Improving Data Collection and Inclusion in Breast Imaging Settings

Breast cancer incidence among transgender and nonbinary (TGNB) individuals is not well characterized owing to the absence of robust data collection among this patient population. Consequently, breast cancer risks are largely unknown, and screening guidelines are not based on robust evidence. Additionally, TGNB patients experience barriers to access health care. A first step in improving data collection, research, and ultimately care of TGNB individuals is the identification of group members and demonstration to patients that our breast imaging centers are champions of LGBTQ+ health. At our institution, patients who present for breast imaging complete an iPad-administered breast imaging history and breast cancer risk assessment survey. Using the modified Tyrer-Cuzick model, the lifetime risk of developing breast cancer is estimated, and additional key history that may impact breast care and future breast imaging is collected. Under the previous clinic workflow, patients are identified as either "male" or "female" and complete a corresponding gender-specific survey. To improve care, we revised the survey using gender-inclusive language and developed four versions to allow patients to separately self-report their sex assigned at birth and gender identity. Relevant queries relating to hormone use and gender-affirming chest/breast surgery that are concordant with six gender-identity groups were added. Long-term collection of these inclusive data by imaging centers has the potential to enhance the data set available to improve breast care and better understand breast cancer risk and outcomes among TGNB populations.

Updates in Transgender Breast Imaging

Transgender patients are seen in breast imaging centers for routine screening mammography and diagnostic imaging of the symptomatic breast. This comprehensive review of transgender breast imaging aims to update the radiologist on appropriate terminology, breast cancer risk in different patient populations, screening guidelines, and diagnostic scenarios. The chapter concludes with practical tips on how to optimize the patient experience.

Imaging Care for Transgender and Gender Diverse Patients: Best Practices and Recommendations

Transgender and gender diverse (TGD) people experience health disparities, and many avoid necessary medical care because of fears of discrimination or mistreatment. Disparate care is further compounded by limited understanding of gender-affirming hormone therapy (GAHT) and gender-affirming surgery among the medical community. Specific to radiology, TGD patients report more negative imaging experiences than negative general health encounters, highlighting the need for guidance and best practices for inclusive imaging care. A patient's imaging journey provides numerous opportunities for improvement. Inclusive practice in a radiology department starts with ordering and scheduling the examination, facilitated by staff education on appropriate use of a patient's chosen name, gender identity, and pronouns. Contemporary electronic health record systems have the capacity for recording detailed sexual orientation and gender identity data, but staff must be trained to solicit and use this information. A welcoming environment can help TGD patients to feel safe during the imaging experience and may include institutional nondiscrimination policies, gender-neutral signage, and all-gender single-user dressing rooms and bathrooms. Image acquisition should be performed using trauma-informed and patient-centered care. Finally, radiologists should be aware of reporting considerations for TGD patients, such as avoiding the use of gender in reports when it is not medically relevant and using precise, respectful language for findings related to GAHT and gender-affirming surgical procedures. As a field, radiology has a range of opportunities for improving care delivery for TGD patients, and the authors summarize recommended best practices. See the invited commentary by Stowell in this issue. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Gender Medicine in Clinical Radiology Practice

Gender Medicine is rapidly emerging as a branch of medicine that studies how many diseases common to men and women differ in terms of prevention, clinical manifestations, diagnostic-therapeutic approach, prognosis, and psychological and social impact. Nowadays, the presentation and identification of many pathological conditions pose unique diagnostic challenges. However, women have always been paradoxically underestimated in epidemiological studies, drug trials, as well as clinical trials, so many clinical conditions affecting the female population are often underestimated and/or delayed and may result in inadequate clinical management. Knowing and valuing these differences in healthcare, thus taking into account individual variability, will make it possible to ensure that each individual receives the best care through the personalization of therapies, the guarantee of diagnostic-therapeutic pathways declined according to gender, as well as through the promotion of gender-specific prevention initiatives. This article aims to assess potential gender differences in clinical-radiological practice extracted from the literature and their impact on health and healthcare. Indeed, in this context, radiomics and radiogenomics are rapidly emerging as new frontiers of imaging in precision medicine. The development of clinical practice support tools supported by artificial intelligence allows through quantitative analysis to characterize tissues noninvasively with the ultimate goal of extracting directly from images indications of disease aggressiveness, prognosis, and therapeutic response. The integration of quantitative data with gene expression and patient clinical data, with the help of structured reporting as well, will in the near future give rise to decision support models for clinical practice that will hopefully improve diagnostic accuracy and prognostic power as well as ensure a more advanced level of precision medicine.

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.