Healthcare professional perspectives on hereditary breast cancer risk assessment prior to gender-affirming mastectomy

PURPOSE: Transgender and gender diverse (TGD) individuals undergoing gender-affirming mastectomy (GAM) face unique challenges related to breast cancer risk assessment and screening. This study aimed to identify factors that influence healthcare professionals' (HCPs) integration of cancer risk evaluation, including genetic assessment, within the context of GAM and pre-surgical planning. METHODS: We conducted semi-structured qualitative interviews with 20 healthcare professionals - including six primary care providers, five cancer genetic counselors, six oncologists, and three plastic surgeons - experienced in caring for TGD patients considering or undergoing GAM. Using a social constructivist framework, we applied reflexive thematic analysis to explore HCP perspectives and generate key themes. RESULTS: We conceptualized five key themes: (1) HCPs perceive no clear ownership for care integration of breast cancer risk assessment; (2) conflicting guidelines force HCPs to rely on their own judgment, resulting in inconsistent practice; (3) care pathways are driven by individual HCP champions rather than standardized protocols; (4) GAM frequently occurs at young ages prior to age of population cancer risk screening initiation, complicating risk discussions; and (5) structural failures in care delivery compromise patient safety. CONCLUSION: Improving cancer risk assessment for TGD patients undergoing GAM demands clear institutional accountability, harmonized evidence-based guidelines, standardized care pathways, and genetic counseling embedded into multidisciplinary gender-affirming care teams. These coordinated structural efforts are critical to integrate equitable, personalized, and patient-centered cancer prevention with gender-affirming surgical care.