PROJECT SUMMARY/ABSTRACT Transgender and gender diverse (TGD) individuals comprise a growing population of over 1.3 million people in the United States. TGD individuals experience cancer care-related disparities with comparatively more frequent late-stage cancer diagnoses and more premature cancer deaths. Although cancer screening mammography saves lives, previous, relatively small studies suggest TGD individuals who are eligible for screening are not screened. Further, TGD people generally remain inaccessible to research because of fear of discrimination. This K23 career development application seeks to learn how many of these screening-eligible individuals are not screened for breast cancer and why. In aim 1, we propose to acquire the necessary – but unknown -- benchmark data on the actual rates of cancer screening mammography in TGD individuals who should be screened and to identify factors associated with screening or lack thereof. We propose to interrogate and analyze data from a 200 million-patient insurance claims database (the national Optum Labs Data Warehouse). To identify TGD patients, we will use surgical, pharmacy, and outpatient visit coding information (our preliminary data demonstrate access to 13,561 eligible TGD individuals). We will report cancer screening mammography rates in these TGD individuals and compare these rates to those in cisgender women. This first aim promises to provide the most robust data to date on cancer screening mammography in TGD individuals and will be crucial in planning future studies to improve screening rates in this population. In aim 2, the principal investigator (PI) will undertake qualitative interviews of TGD individuals who are 40+ years of age (40 years is the age when screening mammography typically starts) to understand these individuals’ thoughts on screening mammography (and on other cancer screening). These in-depth interviews will allow us to learn directly from these underserved individuals how life-saving cancer screening procedures can be made more accessible and will enable the PI to forge trust among TGD individuals. These 2 aims – in conjunction with the completion of relevant coursework and ongoing interactions with a multidisciplinary team of senior mentors (an endocrinologist, who directs the Mayo Clinic Transgender and Intersex Specialty Care Clinic; a medical oncologist, who is interested in healthcare disparities among older sexual and gender minority patients; a statistician; a qualitative researcher; a primary care physician with expertise in the effects of hormones on disease outcomes; and an epidemiologist who focuses on screening mammography) -- will enable the PI, a medical oncologist, to develop the necessary skills to emerge as a national leader in cancer care of TGD individuals. The ultimate goal of this research is to help underserved TGD individuals receive the same lifesaving benefits of cancer screening as the general population.

PROJECT NARRATIVE Transgender and gender diverse (TGD) individuals are often diagnosed with late-stage cancer and often die from cancer prematurely. These individuals appear to be underscreened for breast cancer at rates and for reasons that are unknown. This K23 application will enable the principal investigator to investigate these rates and reasons; to learn from her 6 senior mentors; to take necessary coursework; and ultimately to emerge as a national leader with the goal of helping TGD individuals acquire equity in cancer screening and cancer care.