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

Sex Organ Specific Screening Recommendations: Transmasculine Patients

With GAHT, transmasculine individuals, are often administered only exogenous testosterone. There is little evidence that testosterone increases the incidence of cancer in female reproductive organs. Olsen et al. found cisgender females that used testosterone supplements had an increased risk of ovarian cancer, but it is not clear how this data translates to the transmasculine population as follow up in transmasculine patients who still have their natal reproductive organs is small.[36] The largest such study performed histologic analysis of specimens from 112 patients who underwent at least 6 months of GAHT prior to total abdominal hysterectomy bilateral salphingo-oopherectomy. There weren't any cases of ovarian, uterine, or cervical cancer, and no observed pre-malignant changes leading the author to conclude GAHT did not pose an increase ed cancer risk.[37] There have been reported cases of transmasculine patients with female reproductive organ malignancies: six cases of ovarian cancer, three cases of cervical cancer, one case of vaginal cancer and one case of uterine cancer.

Breast Cancer

Recommendation for cis-females is they should be screened for breast cancer with annual or biennial mammograms after 50; screening can start earlier based on family history or patient preference. As previously stated, research as shown that transmasculine patients on GAHT do not have an increased risk of breast cancer. In fact, early reports suggest that their risk is similar to that of cis-males.[30,38,39] Brown et al., using data from the Veteran Health Administration, found seven cases of breast cancer in transmasculine patients, and 52% of patients had undergone some GAHT treatment. The overall incidence was 20/100,000 patient years regardless of hormone exposure, which was not higher than the expected rate.[39] Four cases of invasive breast cancer were found in 1,229 transmasculine patients, which was lower than expected compared to cisgender women (incidence ratio 0.2, 95% CI: 0.1–0.5).[40]

Breast cancer screening guidelines are an evolving area of medicine, with respect to what age to begin screening and frequency, which is made more complicated in transmasculine patients by a poor understanding of the effect of GAHT and the lack of reliable epidemiologic data. Transmasculine patients who have not undergone bilateral mastectomy or who have only undergone breast reduction should follow screening guidelines for cis-females. There is currently no reliable evidence to guide the screening of transmasculine patients after mastectomy. Annual chest wall exams, ultrasound and MRI have all been suggested but further research is needed before any recommendations for screening in this patient population can be considered evidence based.[41–44] The best recommendation for transmasculine patients at any point in their transition is, "Screen often and screen what you have".[43]

Uterine Cancer

There is currently insufficient evidence to support screening cisgender females for uterine or endometrial cancer. A 2015 survey of transmasculine patients found only 8% of respondents have their uterus and cervix removed.[45] Patients that still have a uterus should inform their physician of any abnormal vaginal bleeding. The reported case of uterine cancer was discovered during pre-operative workup for genital gender affirmation surgery, when the patient who had been amenorrhoeic for seven years had vaginal bleeding.[46] Screening or prophylactic hysterectomy for uterine or endometrial cancer are not recommended but endometrial evaluation is recommended as a part of genital gender-affirmation surgery.[46,47]

Cervical Cancer

Screening guidelines in cis-females are: patients over 21 should undergo cervical cancer screening with pap smears and after the age of 30 pap smears should be accompanied by HPV DNA tests.[6] Screening should continue until the patient no longer has a cervix or the patient is over 66 with 2 consecutive negative tests.

Compared to cis-females, 9.2% fewer transmasculine patients were up to date on their cervical cancer screening.[48,49] The use of GAHT does not increase risk of cervical cancer, however transmasculine patients do have lifestyle factors which may increase their risk. Rates of active HIV in the transgender population are 2× higher compared to cis-males and 10× higher compared to cis-females another factor confounding cervical cancer risk in transmasculine patients.[14,15,50] The strong association between cervical cancer and several types HPV may increase the overall cancer risk in transgender patients because HIV infection increases the likelihood of a persistent HPV infection. More specific research is needed to understand the impact of HPV and associated cancers on the overall health outcomes of transgender patients.[29,51,52] GAHT will cause the cervical epithelium to atrophy and thus transmasculine patients have a 10-fold increased likelihood of an inadequate test compared to cisgender females.[53] Other factors associated with inadequate pap smear were higher body mass index and longer testosterone use.[53] After an inadequate test patients were less likely to return for retesting in one year, overall it took transmasculine individuals 5 times longer to return for retesting compared to cis-females, which can explain why transmasculine patients are less likely to be compliant with screening guidelines.[52] Suggested provider techniques to optimize adequate cervical sampling include swabbing a wide circumference, using multiple sampling tools and use of low-dose topical estrogen for five nights prior to examination.[54,55]

Annual pap smear is recommended for transmasculine patients over 21 if the cervix is present.[56]

Ovarian Cancer

The USPSTF currently recommends against routine screening of cisgender women for ovarian cancer.[57] A review of the literature found no strong evidence that transmasculine patients are at increased risk of ovarian cancer.[36,58] It is recommended that transmales follow the guidelines for cis-females, routine cancer screening is not recommended, and prophylactic oophorectomy without other risk factors is unnecessary.[58]

Vulva Cancer

There is currently insufficient evidence to support screening cisgender women for vulvar cancer. Diagnosis is made with physical exam and confirmed with tissue biopsy. Based on the solitary case of vaginal cancer in the literature there is no recommendation for routine screening tests in low or high-risk patients at any point in their transition.

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