New Insights on Breast Cancer Outcomes Among Sexual, Gender Minorities

There is poor representation of individuals who identify as a sexual and gender minority in cancer research, despite there being a great demand for data collection on sexual orientation and gender identity.^1,2 In the breast cancer setting, in particular, previous research shows potentially higher rates of breast cancer recurrence among this patient population vs cisgender heterosexual individuals.²

Researchers presenting at this year’s San Antonio Breast Cancer Symposium are hoping to fill this information void, with 2 posters delivering preliminary findings on breast cancer risk prior to gender-affirming chest masculinization surgery (GACMS) and data on breast cancer care disparities in sexual minority women (SMW).

Chandler Cortina, MD, MS, FSSO, FACS

In the first poster, of an ongoing pilot study,³ investigators are examining the impact of “top surgery,” or chest masculinization surgery—removing most of the breast tissue—on future breast cancer risk among transgender and gender-diverse individuals assigned female or intersex at birth. Patients are being actively recruited from Medical College of Wisconsin’s Comprehensive LGBTQIA+ Inclusion Health Clinic and Plastic Surgery Clinics, and each undergoes a personalized breast cancer risk assessment.

“We want to see if we could identify those patients who have an elevated lifetime breast cancer risk based on the Gail or IBIS models or their family history and who might have a genetic mutation,” explained Chandler Cortina, MD, MS, breast surgical oncologist and assistant professor of surgery at Froedtert & the Medical College of Wisconsin, “in order to ensure that people who are high risk or have a genetic mutation get the option to have a true oncologic risk-reducing mastectomy.”

The 3 categories of risk for this analysis, per international consensus guidelines, are less than 17% lifetime risk and no genetic mutation (average risk), 17% to 30% lifetime risk and no genetic mutation (moderate risk), and above 30% lifetime risk and/or mutation (high risk). For these risks, the recommendations are to continue with GACMS as planned, to consider a risk-reducing mastectomy (RRM) as part of their GACMS, and to consider RRM plus GACMS, respectively. Genetic testing is also offered to those who have a family history of a potential hereditary cancer.

Final results expected in 2024, with hopes for a multisite prospective observational study in 2025/2026 that will observe what surgeries high-risk patients have and their 5- and 10-year outcomes.

“The majority of people who are getting these operations are usually in their 20s. Most 25-year-olds are not thinking about breast cancer or future breast cancer risk,” Cortina stated. “The goal is to find those who may benefit from a true oncologic risk-reducing mastectomy now and not have to be worried about developing breast cancer in their 60s or 70s.”

Lucas Hauser, MSBS

In the second poster,⁴ the researchers, led by second-year medical student Lucas Hauser, MSBS, University of Nebraska Medical Center, used the National Institutes of Health All of Us Database to compare lifestyle risk factors and care access for breast cancer risk among cisgender women who identify as bisexual or lesbian (SMW) vs heterosexual/straight-identifying women. Of the total study population of 229,917, just 11.9% identified as SMW, and among the overall 3.0% who reported a breast cancer diagnosis, 6.1% were SMW.

“There aren't any national databases that collect sexual orientation and gender identity information, based on several lifestyle risk factors, including some discriminatory practices,” Hauser noted. “Sexual minority women are less likely to receive routine care, as well as partake in higher-risk activities, such as drinking, smoking, and delaying health care.” He noted the limitations from previous research in the space on smaller patient samples.

Among the lifestyle risk factors examined in this analysis, SMW were more likely than straight women to report the following:

• 6 or more drinks daily, weekly, monthly, and less than monthly
• 10 or more, 7 to 9, 5 or 6, and 3 or 4 drinks daily
• Smoking on some days or every day and 100 cigarettes over their lifetime
• An inability to afford health, specialist, and follow-up care, and prescription medicine
• They had never spoken to a general doctor or had done so from 1 to 2 years to more than 5 years ago
• They delayed care because they were nervous of the high cost
• Emergency department or urgent care use
• Never having had an annual history taken, an annual physical, mammography, breast biopsy, mastectomy, or lumpectomy

Most of the data on discrimination experiences were deemed significant findings. SMW were more likely than straight women to report they are treated with less respect and courtesy and that doctors or nurses do not listen to them, provide worse service, act afraid, act superior, and treat them as if they are stupid during visits.

“We show that this is a highly disparaged community, and we’re assuming that outcomes are probably worse,” Hauser noted. “I think some of the next directions would be to look at different ages of diagnosis, different characteristics, and outcomes in general, as well as to expand to look at what other disparities might exist among other cancer types as well.”

References

1. Warwar S, Beach LB, Jordan SW. Breast cancer disparities among sexual and gender minority populations. Transl Cancer Res. 2023;12(8):2219-2223. doi:10.21037/tcr-23-623

2. Eckhert E, Lansinger O, Ritter V, et al. Breast cancer diagnosis, treatment, and outcomes of patients from sex and gender minority groups. JAMA Oncol. 2023;9(4):473-480. doi:10.1001/jamaoncol.2022.7146

3. Cortina CS, Purdy, A, Stachowiak, et al. A prospective single-arm pilot interventional trial to assess individual breast cancer risk prior to gender-affirming chest masculinization surgery. Poster presented at: San Antonio Breast Cancer Symposium; December 5-9, 2023; San Antonio, TX. Poster PO1-20-01.

4. Houser L, Doughtery C, Figy S, Maxwell J, Santamaria-Barria J. Breast cancer care disparities in sexual minority women: an analysis of the National Institutes of Health All of Us Research Program. Poster presented at: San Antonio Breast Cancer Symposium; December 5-9, 2023; San Antonio, TX. Poster PO2-09-11.