Semi-structured qualitative interviews with 20 HCPs (6 primary care providers, 5 genetic counselors, 6 oncologists, 3 plastic surgeons) explored factors influencing breast cancer risk assessment and genetic counseling integration into gender-affirming mastectomy (GAM) pathways for transgender and gender diverse (TGD) patients.
Five themes emerged: (1) no clear ownership for breast cancer risk assessment in GAM pathways; (2) conflicting guidelines force HCPs to rely on personal judgment, causing inconsistent practice; (3) care pathways depend on individual 'champions' rather than standardized protocols; (4) GAM often occurs at ages younger than standard cancer screening initiation, complicating risk discussions; and (5) structural failures—including inadequate assessment of residual breast tissue—compromise patient safety, including at least one reported patient death from delayed diagnosis.
Small sample (n=20) with limited representation per specialty; geographic concentration in academic medical centers; snowball sampling likely overrepresented providers already familiar with genetics and TGD care.
Clinicians should proactively initiate hereditary breast cancer risk assessment and family history review before GAM, rather than deferring to other specialists, given the documented diffusion of responsibility. Embedding genetic counseling into multidisciplinary gender-affirming care teams—rather than relying on individual champions—is a critical step toward equitable, consistent care.
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