If gender-affirming chest surgery removes the breasts, why should someone be assessed for breast cancer risk beforehand?
The answer lies in a detail that many people do not know: gender-affirming chest surgery, often called “top surgery,” does not remove all breast tissue. Unlike preventive mastectomies performed in people with a high inherited risk of breast cancer, the procedure is designed to create a masculine chest contour while preserving enough tissue to achieve the desired surgical outcome. As a result, some breast tissue remains, and so does a degree of cancer risk.
A new study by researchers at Boston University argues that this is precisely why breast cancer risk assessment should become a routine part of pre-surgical planning for transgender and gender-diverse people. The goal is not to question or delay gender-affirming surgery, but to ensure that every patient can make fully informed decisions based on their individual cancer risk.
Interviews with 20 healthcare professionals involved in transgender care (including primary care physicians, genetic counsellors, oncologists and plastic surgeons) revealed that cancer risk assessment is often inconsistent. Unclear responsibilities, conflicting clinical guidelines and the absence of standardised care pathways mean that many patients do not receive coordinated cancer prevention before surgery. Many participants said the problem was not a lack of willingness, but the absence of clear responsibility for who should initiate cancer risk assessment before surgery.
These findings matter because the information obtained before surgery can sometimes influence the operation itself. Around 10–20% of breast cancers are linked to inherited genetic factors. For example, if genetic testing reveals a high inherited risk of breast cancer, patients and surgeons can discuss whether a different surgical approach—one that removes more breast tissue—would provide greater long-term protection against cancer.
The issue is particularly important because gender-affirming chest surgery is usually performed in early adulthood, often decades before people begin thinking about breast cancer or become eligible for routine screening programmes. According to the researchers, this timing makes conversations about future cancer risk more challenging, even though they may significantly affect lifelong prevention strategies.
The study also highlights that preventive care does not end after surgery. Because some breast tissue remains, healthcare professionals need clear recommendations on how to monitor patients over time according to their individual level of risk. However, participants described uncertainty about who should take responsibility for this follow-up and how it should be organised.
For Kim Zayhowski, genetic counsellor at Boston University Chobanian & Avedisian School of Medicine and the study’s corresponding author, the issue is fundamentally about equity in prevention. “Every person—transgender or cisgender—deserves clear information about their cancer risk and access to prevention. As it stands, trans people are diagnosed with cancer at later, more dangerous, stages than cisgender people.” The researchers argue that improving access to personalised cancer risk information could help reduce these disparities while supporting informed healthcare decisions.
Rather than creating new barriers to gender-affirming surgery, the researchers argue that cancer prevention should become a routine part of care. By integrating risk assessment, genetic counselling and personalised follow-up into the surgical pathway, patients can make informed decisions based on their individual cancer risk and receive gender-affirming care that is safer over the long term.
Associate Professor at University of Granada