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

General Transgender Screening Recommendations and Considerations

There are currently no established cancer screening guidelines, recommendations, or protocols for transgender patients at any point in their transition. The recommendations presented in this manuscript are based on accepted guidelines for cis-gender patients and applied to the transgender community based on small case series. The screening protocols that will be discussed in this manuscript should not just be applied to any patient without a full discussion with the patient about where they are in their transition, what natal organs are still present, and what other lifestyle factors would make the patient high risk. These recommendations are intended to foster open dialogue between patients and physicians about what cancer screening they may benefit from given the overall lack of large-scale prospective data to guide these decisions.

Colon Cancer

Patients over 50 should be screened for colorectal cancer with either guaiac-based fecal occult blood test, fecal immunochemical test, multitarget stool DNA test, double-contrast barium enema or CT colonography.[6] The frequency of screening depends on the screening method and any positive test needs to be followed up with a colonoscopy. Patient's considered to be high risk, due to personal history of disease, family history or history of inflammatory bowel disease are recommended to undergo more intensive surveillance regimens.[6] No publications were found that examined if rates of colorectal cancer in transgender patients differed from the general population. These guidelines should also be followed for all transgender individuals at any point in their transition.

Lung Cancer

Current or former smokers of either sex with 30 pack year history, or former smokers who quit less than 15 years ago should discuss annual lung cancer screening with their health care provider.[6] No publications were found that examined if rates of lung cancer in transgender patients differed from the general population. These guidelines should also be followed for all transgender individuals at any point in their transition.

Anal Cancer

There is not a specific guideline about screening for anal cancer, but the American Society of Clinical Oncology recommends that routine testing for high risk patients, defined as HIV-infected individuals that engage in anal receptive intercourse. The prevalence of HPV and rate of HPV vaccination in the transgender community is poorly reported. What data is available groups all LGBT individuals into a single category which does not provide any granularity or useful specificity. HPV is known risk factor for developing anal cancer especially in persons that engage in anal receptive intercourse. Many younger patients are unaware of this risk and not being accustomed to needing medical screening do not ask physicians to be checked; additionally, physicians are often reluctant to bring up HPV or perform routine inspection of the anus.[32]

The most common screening method is cytology from an anal pap smear and confirmatory testing is done with anoscopic biopsy. Similar to Pap smear, cytological screening aims to detect anal high-grade squamous intraepithelial lesions (HSIL), and as with cervical washings these are considered pre-malignant with the potential to progress to anal cancer.[33] A 2017 study of HIV positive transfeminine patients found that 91% of patients biopsied had some degree of dysplasia, although none of the patients screened were found to have cancer.[33] Another study out of Thailand found that 42% of transfeminine patients screened had abnormal cytology.[34] There is evidence that transfeminine patients, especially HIV+ patients, are at increased risk on anal squamous intraepithelial lesions thus, there is a clear need for a standardized, evidence-based screening process. While there is no consensus Thompson et al. proposes screening any transfeminine patients with multiple lifetime sexual partners starting at age 21.[35] Transmasculine patients that engage in anal intercourse should discuss screening options and frequency with their physician. These guidelines should also be followed for at any point in during a patient's transition.

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