"o the Editor,

We read with interest the article recently published by Vyas et al.¹ in Annals of Surgery Open. It is an important contribution to the management of patients after gender-affirming chest masculinization surgery (GACMS), and we applaud their efforts. In the article, the authors call for standardized operative documentation that clearly communicates the surgeon’s assessment of retained fibroglandular tissue (RFGT), and postoperative screening that may include imaging (ultrasound or breast magnetic resonance imaging [MRI]) if there is residual tissue. While we agree that the performing surgeon’s assessment of RFGT is crucial, in our opinion the role for mammography has been underestimated in the author’s proposed algorithm.

Mammography remains the mainstay of breast cancer (BC) screening, with the highest level of evidence compared to other modalities.² It is accessible, low-cost, and forms the backbone of organized population-based screening programs. Importantly, mammography is more sensitive than ultrasound for ductal carcinoma in situ, particularly when presenting as microcalcifications. Literature suggests that mammography has a sensitivity of 87% to 95% for ductal carcinoma in situ as compared to 47% to 71% for ultrasound.³ Ultrasound is used more commonly as an adjunct when patients present with palpable lesions^3–5 and has not been validated as a sole modality for BC screening. MRI with contrast offers the best soft tissue contrast with high spatial resolution and is the optimal supplemental screening tool in high-risk populations and individuals with extremely dense breast tissue.

RFGT is an important factor to consider; and the ability to accurately identify RFGT at the time of surgery. In a prior study on individuals undergoing mastectomy for risk reduction (eg, BRCA+) or BC, RFGT was identified in 50% of nipple-sparing procedures and 13% of skin-sparing procedures; and a lead contributor to recurrence.⁶ Recommending against the use of mammography in post-GACMS patients, especially if they are high-risk, may result in suboptimal screening strategies with less robust evidence, which raises concerns about equitable access to care. Further, limited tissue volume alone is not a strong argument to forgo mammography. In BC screening algorithms, breast size is not used to determine eligibility for mammography, and those with very small breasts are routinely imaged successfully. The American College of Radiology guidelines recommend mammography as the initial diagnostic modality for cisgender men who present with breast symptoms (eg, palpable lesions or nipple changes).⁷ Since post-GACMS patients with residual breast tissue may be anatomically similar to cisgender men in terms of breast tissue volume, there is no reason to withhold mammography considering the comparable anatomy. Screening mammography may still be feasible for many average-risk individuals post-GACMS, especially after an appropriate healing interval, and GACMS should not pose a barrier to accessing mammography for diagnostic purposes. Average-risk individuals who have undergone GACMS with documented RFGT should undergo annual mammography. High-risk individuals who have undergone GACMS with documented RFGT should undergo annual high-risk screening with mammography and MRI.⁸

Overall, we would like to reinforce Vyas et al.’s¹ call for individualized screening strategies that integrate risk-assessment and residual breast parenchyma, while emphasizing the role mammography continues to play in screening and diagnosis."