Breast imaging, a medical specialty extensively developed around the health risks and anatomy of cisgender women, now faces a critical examination of its significant blind spots. Recent discussions among experts at the European Society of Breast Imaging (EUSOBI) annual scientific meeting have cast a harsh light on profound deficiencies in research, clinical guidelines, and provider education for male and transgender patients. These two distinct populations share a common and concerning reality: they are navigating a healthcare system that is inadequately equipped to address their specific needs. This systemic failure has created dangerous knowledge gaps and fostered healthcare inequities, resulting in a consensus that immediate and targeted action is required to ensure accurate diagnostics and improve patient outcomes for everyone, regardless of their gender identity or sex assigned at birth.
A Blind Spot in Breast Imaging The Male Patient
One of the most significant deficiencies identified is the complete absence of dedicated European guidelines for male breast imaging, a gap that compels practitioners across the continent to rely on standards developed by external bodies like the American College of Radiology (ACR) and the United Kingdom’s Royal College of Radiologists. While men may constitute a relatively small fraction of referrals to breast units, at just 5%, they generate a disproportionately significant workload, with an estimated 75% requiring some form of imaging. This discrepancy highlights a fundamental oversight in a field that has largely failed to plan for or prioritize this patient demographic. Although the vast majority of male breast conditions are benign—encompassing pathologies such as lipoma, fat necrosis, and gynecomastia—the rarity of male breast cancer creates a perilous paradox that leads to severe consequences and highlights the urgent need for a more nuanced and informed clinical strategy.
The lack of dedicated scientific inquiry into male breast cancer, which accounts for only 1% of all breast cancers, has led to a clinical environment where treatment strategies are almost entirely extrapolated from the extensive data available for female breast cancer. This approach is inherently problematic, as the disease can present and progress differently in male patients. The most alarming consequence of this knowledge deficit is the tendency for late-stage diagnosis. A startling report indicated that approximately 40% of male breast cancers are already at stage 3 or 4 at the time of discovery. This advanced presentation directly contributes to significantly worse patient outcomes when compared to their female counterparts. Key risk factors for male breast cancer are well-established and include advanced age, hormonal imbalances, and genetic predispositions, with the BRCA2 gene mutation being more commonly associated with male than female breast cancer. Despite awareness of these factors, the healthcare system is failing to translate this knowledge into effective early detection protocols.
Inconsistent Practices and Alarming Gaps in Care
To better map the current clinical landscape, EUSOBI conducted a pan-European survey that revealed considerable and concerning variability in imaging approaches. With 825 responses from breast imagers across 34 countries, the survey showed a clear lack of standardization, even with the existing ACR and UK guidelines in place. A distinct trend emerged based on patient age and the nature of the presenting mass. For benign or indeterminate palpable masses, ultrasound is the preferred initial imaging modality for men under the age of 25, while mammography or digital breast tomosynthesis (DBT) is favored for men over 50. This age-based protocol, while seemingly logical, is not rooted in robust, male-specific evidence and instead reflects the absence of a unified, evidence-based approach. This variability in practice underscores an urgent need for the development of specific European guidelines to ensure all male patients receive consistent and optimal care, regardless of their location.
Perhaps the most troubling findings from the survey were the identified gaps in care for high-risk and post-cancer male patients, exposing a critical failure in both preventative care and long-term monitoring. The survey found that a substantial 41% of responding radiologists do not perform routine screening or imaging for male patients who are considered to be at high risk for developing breast cancer. This oversight leaves a vulnerable population without the proactive surveillance that could lead to earlier detection and better outcomes. Furthermore, 13% of practitioners do not conduct regular follow-up imaging for male patients with a prior history of breast cancer, abandoning a crucial component of post-treatment care aimed at detecting recurrence. These statistics paint a stark picture of a system that is not only inconsistent but also dangerously neglectful of a patient group that deserves a clear and reliable standard of care.
Overcoming Barriers in Transgender Breast Imaging
The challenges in providing competent and affirming breast imaging for transgender patients are multifaceted, beginning with the foundational importance of using precise and respectful terminology to build trust and ensure clear communication. A central scientific challenge in this field is the severe lack of evidence regarding breast cancer risk for individuals undergoing gender-affirming care, particularly feminizing or masculinizing gender-affirming hormone therapy (GAHT). This critical knowledge gap is attributed to a confluence of factors, including a lack of long-term follow-up studies, inadequate and inconsistent documentation of patients’ lifetime hormone exposure, and a complete absence of prospective research studies specifically designed to assess cancer risk in this population. Without this foundational data, clinicians are left to navigate complex care decisions without evidence-based guidance, potentially compromising patient safety and well-being.
Beyond the scientific limitations, transgender individuals face a host of systemic barriers and healthcare inequities that impede their access to and participation in breast cancer screening. These challenges include low awareness of available screening programs, a pervasive lack of trust in healthcare professionals and the healthcare system at large, and poor knowledge of screening guidelines among both the transgender population and their providers. This situation is compounded by a widespread lack of specific training on transgender health issues among clinicians. To address these deep-seated issues, experts have proposed a multi-pronged call to action. This includes educating radiologists and other providers on correct terminology and gender-affirming processes, collaborating with scientific societies to close research gaps, and actively involving LGBTQIA+ advocacy groups in the design of research and educational initiatives to ensure they are community-informed and effective.
Forging a Path Toward Inclusive Breast Health
The discussions ultimately revealed that both male and transgender patients have been profoundly underserved by the field of breast imaging due to a shared root cause: a systemic lack of dedicated research. This deficiency created a ripple effect, leading to the absence of standardized guidelines, highly variable clinical practices, and insufficient provider education. The initiatives highlighted at the EUSOBI meeting represented a crucial acknowledgment of these long-standing disparities. The commitment from the professional community signaled a turning point, marking the beginning of the vital work required to bridge these knowledge gaps. This effort was not merely academic; it was aimed directly at reducing healthcare inequities and improving tangible outcomes for all patients, ensuring that the future of breast imaging is one of inclusivity, evidence, and comprehensive care.
