Cancer Screening in the Transgender Population

A Review of Current Guidelines, Best Practices, and a Proposed Care Model

Joshua Sterling; Maurice M. Garcia

Disclosures

Transl Androl Urol. 2020;9(6):2771-2785. 

In This Article

Abstract and Introduction

Abstract

Over the last 50 years cancer mortality has decreased, the biggest contributor to this decrease has been the widespread adoption of cancer screening protocols. These guidelines are based on large population studies, which often do not capture the non-gender conforming portion of the population. The aim of this review is to cover current guidelines and practice patterns of cancer screening in transgender patients, and, where evidence-based data is lacking, to draw from cis-gender screening guidelines to suggest best-practice screening approaches for transgender patients. We performed a systematic search of PubMed, Google Scholar and Medline, using all iterations of the follow search terms: transgender, gender non-conforming, gender non-binary, cancer screening, breast cancer, ovarian cancer, uterine cancer, cervical cancer, prostate cancer, colorectal cancer, anal cancer, and all acceptable abbreviations. Given the limited amount of existing literature inclusion was broad. After eliminating duplicates and abstract, all queries yielded 85 unique publications. There are currently very few transgender specific cancer screening recommendations. All the guidelines discussed in this manuscript were designed for cis-gender patients and applied to the transgender community based on small case series. Currently, there is not sufficient to evidence to determine the long-term effects of gender-affirming hormone therapy on an individual's cancer risk. Established guidelines for cisgender individuals and can reasonably followed for transgender patients based on what organs remain in situ. In the future comprehensive cancer screening and prevention initiatives centered on relevant anatomy and high-risk behaviors specific for transgender men and women are needed.

Introduction

Widespread cancer screening has resulted in decreased cancer mortality over the past fifty years. Screening has resulted in a 13% reduction in mortality from colorectal cancer and a 14% cancer specific mortality in lung cancer.[1,2] Mortality rates of breast and cervical cancer have both decreased following widespread adoption of screening mammograms and pap smears.[3,4] PSA screening does reduce prostate cancer mortality but is also associated with false-positive and overtreatment.[5,6] The American Cancer Society (ACS) and US Preventative Services Task Force (USPSTF) and numerous professional organizations (ACS, AMA, AUA, ACOG) have clear recommendations for the early detection of cancer in average-risk and high-risk cis-gender patients.

These guidelines become less straight forward when applied to the transgender community and currently World Profession Association of Transgender Health (WPATH) has no guidelines on cancer screening. It is important to consider that transgender patients' cancer screening needs will vary by "what stage of their transition" they are in as initiation of gender-affirming hormone therapy (GAHT), non-genital gender affirming surgery (GAS), genital GAS, and surgical removal of some or all of their reproductive organs may affect cancer risk. WPATH Standards of care version 7 states, "In the absence of large-scale prospective studies, providers are unlikely to have enough evidence to determine the appropriate type and frequency of screening…Patients may find cancer screening gender affirming, or both physically and emotionally painful".[7] Large databases in the United States, like the Surveillance, Epidemiology and End Result (SEER) and the National Cancer Database (NCDB), do not capture non-binary genders, thus it is difficult to postulate if the cancer risk of transgender individuals is different from the general population. A UK study found gay and bisexual men had increased odds of a cancer diagnosis compared to heterosexual males; although main driver of this difference was the higher rates of viral-related cancers: Kaposi's sarcoma, anal cancer, and penile cancer.[8] Studies in the US have tried to look at cancer rates in areas with a high population of LGBT individuals to extrapolate any associated cancer risk;[9,10] the results of these studies were varied and no firm conclusions can be drawn from them. The differences in cancer rates seen in the LGBT community is often attributed to high risk behaviors: smoking, alcohol and drug use, obesity, and significantly higher HIV rates.[11–13] The CDC reported that in 2013, 1.9% of HIV tests done by transgender individuals were positive, compared to 0.9% for cis-gender males and 0.2% for cis-gender females.[14] The estimated prevalence of HIV among transgender women of reproductive age (range, 15–49) is 21.7% (95% CI: 18.4–25.1%), which is 34 times higher than cis-gender adults in the same age range.[15]

Transgender patients often face discrimination and are stigmatized in ways that decrease healthcare screening encounters. Transgender individuals have reported difficulties when interfacing with the US healthcare system: 19% have reported refusal of care, 28% reported harassment, and 50% were turned off of the healthcare system due to a lack of gender nonconforming providers.[16,17] Clinicians also may fail to provide the appropriate screening and counseling based on the patient's anatomy. This includes PSA checks and prostate exams for anyone that still has a prostate and Pap smears for patients that still have a cervix, regardless of what gender they identify with.

Additionally, many transgender patients only seek medical care as a part of gender affirmation and may avoid primary health care concerns. Patients that do seek routine healthcare checkups are reluctant to bring up gender incongruous organs. Hence, transgender patients may be more reliant on their health care providers to initiate cancer screening discussions than cis-gender patients.

The aim of this review is to cover current guidelines and practice patterns of cancer screening in transgender patients, and, where evidence-based data is lacking, to draw from cis-gender screening guidelines to suggest best-practice screening approaches for transgender patients.

We performed a systematic search of PubMed, Google Scholar and Medline, using all iterations of the follow search terms: transgender, gender non-conforming, gender non-binary, cancer screening, breast cancer, ovarian cancer, uterine cancer, cervical cancer, prostate cancer, colorectal cancer, anal cancer, and all acceptable abbreviations. Given the limited amount of existing literature inclusion was broad. After eliminating duplicates and abstract, all queries yielded 85 unique publications. We present the following article in accordance with the PRISMA-ScR reporting checklist (available at http://dx.doi.org/10.21037/tau-20-954).

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