When treatment for breast cancer triggers an identity crisis and web of unprecedented decisions

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When he was diagnosed with an aggressive form of breast cancer, Ottawa’s Spencer Hayward faced a complex web of decisions about his medical risk and personal identity.

Hayward, then 49, had been living as a trans man for two years when he discovered a lump in his breast in April 2021.

He was sent for a biopsy and doctors discovered his cancerous tumour expressed receptors – proteins – that could be fuelled by hormones. Unusually, Hayward’s hormone-sensitive tumour could be affected not only by the female hormones, estrogen and progesterone, but also by testosterone.

Hayward was taking testosterone as part of masculinizing hormone therapy, also called gender affirming therapy. The therapy produces physical changes in the body, such as a deeper voice, heavier musculature and the growth of facial hair, common during the onset of male puberty.

After undergoing a double mastectomy and four rounds of chemotherapy, Hayward was told by doctors he might have to stop taking testosterone permanently since the hormone could promote a recurrence of his breast cancer.

“I had to take testosterone off my list of meds – so I was gutted,” Hayward remembers. “I was a couple of years into my journey with the testosterone and I didn’t want to just stop.”

Although the testosterone had some unhappy side-effects, including male-pattern hair loss and acne, it consistently lifted Hayward’s mood and gave him peace of mind. Its effects were also important to his identity as a trans man.

To help him navigate the situation, Hayward was referred to the newly formed Gender Diversity Specialty Clinic at The Ottawa Hospital.

Launched in January 2022 by endocrinologists Dr. Irena Druce and Dr. Heidi Dutton, the clinic cares for medically complex cases involving trans and non-binary patients. It’s one of the only such hospital-based programs in the country.

Druce met with Hayward, who told her he wanted to continue with testosterone if at all possible. “The problem was we had no precedent for this kind of thing whatsoever,” Druce remembers.

Medical data in the transgender patient population is thin, Druce said, and there’s even less when it comes to complex cases like Hayward’s. Druce’s literature search turned up a few case reports of other trans men with hormone-sensitive breast cancers, but those cases all involved estrogen receptors. None of them involved testosterone.

“There was nothing like Spencer’s case,” said Druce.

It meant, Druce said, that the risk-benefit analysis in Hayward’s case had to be based on probability rather than precedent.

She offered Hayward the option of using testosterone microdoses – less than one-tenth of what he was receiving before his cancer diagnosis – as a means to continue hormone therapy.

“But even if we give you these tiny doses of testosterone,” Druce warned him, “it may increase your risk of this cancer coming back.”

It’s a bit of a compromise, but as far as I’m concerned, I’d rather live ten years and be myself and happy in those ten years than live 20 and be miserable

Spencer Hayward

Such a small amount of testosterone might not help his musculature, Druce told Hayward, but it would promote his mental well-being, energy and libido. Meanwhile, his deeper voice, facial and body hair would remain unchanged.

Hayward had to decide if he would accept a small cancer risk in order to continue his hormone therapy and maintain his identity.

“It was a really tough decision to do any of this,” he said. “I really had to sit down and weigh the pros and cons.”

He ultimately opted to take the small doses of testosterone.

“It’s a bit of a compromise, but as far as I’m concerned, I’d rather live ten years and be myself and happy in those ten years than live 20 and be miserable,” said Hayward.

He has not suffered any ill-effects since restarting testosterone therapy last year.

Dr. Druce said she may publish a case study on Hayward’s treatment.

“He’s the poster child of the kind of patient this clinic aims to help because his case is so unique and so complex,” Druce said.

In addition to providing highly specialized care, the Gender Diversity Specialty Clinic also offers training in the field of transgender medicine to other endocrinologists. The clinic’s patient population includes people with heart disease, cancer, and those whose hormone therapy could interact with anti-seizure drugs, immune suppressants or HIV medication.

The clinic operates one-half day every month.

Druce said transgender medicine often relies on careful experimentation since the field is relatively new, and long-term treatment data is only now starting to become available.

“None of the medications we use are actually indicated for transgender medicine,” she noted. “If you read the product monograph of testosterone, for instance, it doesn’t say, ‘For gender affirming hormone therapy.’ Everything is completely off-label.”

It means, she said, that doctors have to listen carefully to what patients want and try to find safe options for their treatment.

“My goal is to try to get for the patient the end result they’re after – it is going to be extremely individual – but to do so in as safe a way as possible. I want them to be happy and healthy.”

Druce opened her endocrinology practice in October 2018 and she became known as someone willing to help transgender patients in Ottawa. Word spread quickly in the community.

“These patients need hormonal help; I am a hormonal doctor. It just seemed obvious that I would provide this service. I didn’t realize that other endocrinologists were refusing to see transgender patients.”

Hayward said he’s thankful for Druce’s empathetic care and for the clinic’s personalized approach. “They deal with the whole person not just the breast cancer,” he said.