October is Breast Cancer Awareness Month
Breast cancer is the uncontrolled growth of abnormal breast cells. There are two types of breast cancer: non-invasive, which does not spread to surrounding tissues, and invasive, which is more serious and can spread to other parts of the body.
The American Cancer Society estimates that 230,000 new cases of invasive breast cancer will be detected in U.S. women this year, and nearly 40,000 people will die from the disease. Breast cancer is the most common cancer among women in the United States, other than skin cancer, and the second leading cause of cancer death in women, after lung cancer. It is the most common cancer in African American women. Fortunately, breast cancer death rates have been going down in recent years, which is probably the result of early detection (through mammograms and self exams) and improved treatment.
Any person with breast tissue – that means all of us – may be susceptible to breast cancer. However, it is important to know that people in lesbian and transgender communities may have unique risk factors and health needs that are different from other communities.
If you are a lesbian or bisexual woman, research shows that you may have an increased risk of developing breast cancer over your lifetime. This is not due to your sexual orientation, but rather, to a higher concentration of other risk factors present in the community. For instance, higher rates of alcohol and tobacco use, obesity, and not having children biologically are some of the biggest known risk factors for breast cancer. Lesbian and bisexual women are also more likely to neglect breast examinations and mammograms, in part due to fear of discrimination they may face from their health care providers, and/or lack of adequate health insurance. While not applicable to all lesbian and bisexual women, statistically, these factors are higher in our communities.
Little is known about prevalence of breast/chest cancer among trans-women. This is partly due to low rates of screening and detection due to fear of discrimination or lack of awareness among both the community and medical providers. However, what we do know is that estrogen and progestin play a big role in breast/chest cancer. Trans-women on hormones may have an increased risk of breast/chest after five years. This relationship is assumed based on the increased risk of cancer for non-trans women who have been on hormone replacement therapy for five or more years. Trans-women whose hormone levels are not monitored and regulated by a medical provider may be at particularly high risk. Also, if you have implants, it is especially important that you become familiar with how they feel so that you can detect an abnormality if one should exist.
As is the case with trans-women, there is a dearth of information available on the prevalence of breast/chest cancer among trans-men. Again, this is partly due to low rates of screening and detection, and may also be due to individuals’ gender identity not being recorded in many health databases. We do know that estrogen is a prime culprit when it comes to breast/chest cancer. We also know that when the body receives too much testosterone that it cannot use, it turns that testosterone into estrogen. This means that trans-men on hormones need to be monitored by their medical provider to ensure their testosterone levels are appropriate. It is important to note that, even if you have had top surgery, some breast tissue may still remain and there is still some risk for developing cancer.
The Susan G. Komen for the Cure organization has developed a series of recommendations that they call “Breast Self-Awareness,” based on four key elements:
1) Know your risk: talk to your family to learn about your family health history; and talk to your provider about your personal risk of breast cancer
2) Get screened: talk with your provider about which screening tests are right for you if you are at a higher risk; have a clinical breast exam at least every three years starting at age 20, and every year starting at age 40; have a mammogram every year starting at age 40 if you are at average risk
3) Know what is normal for you, and see your health care provider if you notice any of these breast changes: lump, hard knot or thickening inside the breast or underarm area; swelling, warmth, redness or darkening of the breast; change in the size or shape of the breast; dimpling or puckering of the skin; itchy, scaly sore or rash on the nipple; pulling in of your nipple or other parts of the breast; nipple discharge that starts suddenly; new pain in one spot that doesn’t go away
4) Make healthy lifestyle choices. Maintain a healthy weight; add exercise into your routine; limit alcohol intake; limit postmenopausal hormone use.
Here in Philadelphia, Mazzoni Center’s outreach program for the lesbian, bisexual and transgender communities provides education, direct services, and referrals for these populations. The agency actively collaborates with the Jefferson Health System, the Drexel University College of Medicine Women’s Health Project, and individual specialty providers to complete the continuum of care. Mazzoni Center’s breast health services are housed in two departments: the Prevention Services Department, which delivers community outreach and one-on-one education interventions; and the Medical Practice, located at 809 Locust Street, which maintains a patient reminder system, conducts clinical breast exams, and facilitates mammogram referrals.
The Affordable Care Act, which was signed into law in March 2010, and is being rolled out in phases through 2015, brings some critical improvements with regard to women’s preventive health, and mammograms in particular. The new law requires any health plans starting after August 1, 2012, to cover certain prevention-related health care services – including mammograms, as well as annual ‘well-woman’ visits, pap smears, and more – free of charge. That means no deductibles or co pays. We know this is important because according to a June 2012 Kaiser Opinion Poll, more than 60% of U.S. women reported they had delayed or avoided accessing health care in the past year because of costs. And when it comes to breast cancer, early detection improves the chances that breast cancer can be diagnosed at an early stage and treated successfully.
Treatment options for those diagnosed with breast cancer have grown more sophisticated in recent years, and include targeted therapy, which is aimed at certain aspects of cancer cells; hormone therapy, which is aimed at reducing or stopping estrogen; radiation and/or chemotherapy, which works to weaken and destroy cancel cells in the body. Other treatment options include lymph node removal, lumpectomy, and mastectomy.
If diagnosed at an early stage, breast cancer has an encouraging survival rate – up to 97% of women diagnosed with localized breast cancer survive. Right now, there are more than 2½ million breast cancer survivors in the U.S. The best chance of surviving breast cancer is early detection. Not everyone recommends breast self-exam as a screening tool, however Susan G. Komen for the Cure recommends that you become familiar with the way your breasts normally look and feel. Knowing what is normal for you may help you see or feel changes in your breast, so that you can alert your provider.
The best thing for anyone to do is have a discussion with your medical provider about your unique risk factors, including any family history of the disease. This will help to determine an appropriate schedule for clinical breast examinations and annual mammograms, according to your age and individual risk profile. Being familiar with how your own breasts feel, and talking openly with your health care provider, will help you notice any unusual changes - and stay on top of this important aspect of your health.
Additional resources: Mazzoni Center Family and Community Medicine (www.mazzonicenter.org); Susan G. Komen for the Cure Philadelphia (http://ww5.komen.org); Mautner Project, The National Lesbian Health Organization (www.mautnerproject.org); Gilda’s Club of the Delaware Valley (gildasclubdelval.org)
Author: Nancy Brisbon, MD, is a Physician at Mazzoni Center Family and Community Medicine and Assistant Professor in the Department of Family & Community Medicine at Thomas Jefferson University