Cancer Screening in Transgender Individuals

Last year, one of our 4^th year Pathway students (Kelly Guttman) created a very informative presentation on Cancer Screening Health Disparities Among Transgender Patients – a topic worth revisiting here.  Many transgender individuals have had negative experiences with the healthcare system, often due to discrimination and lack of provider knowledge.  Many healthcare providers don’t know how to screen transgender patients for potential cancers so they are often overlooked.                                                                                                                                                                                   Bottom line:  If they have the “part” (e.g. breast, cervix, prostate), check it!

CERVICAL CANCER

Approximately 80% of transgender men [female-to-male (FTM) patients] have a uterus and cervix and therefore need screening.  Unfortunately, being transgender has been associated with 37% lower odds of being up-to-date with recommended cervical cancer screening.  Inadequate Paps have been over 8 times higher among transgender men, likely due to a combination of factors including histological changes induced by testosterone and patient/provider discomfort. 

BREAST CANCER

Approximately half of transgender men have surgery to remove their breasts while 80% of transgender women [male-to-female (MTF) patients] use estrogens to help grow the size of their breasts.  MTF patients taking exogenous estrogen and androgen antagonists develop breast tissue histologically identical to that of a cis-gender female.  Although studies have failed to show that MTF patients taking exogenous estrogen have an increased risk of breast cancer, there have been cases so individuals still need to be screened.  In addition, for transgender men who have undergone mastectomies, providers need to be aware that not all breast tissue may be removed, especially in a nipple-sparing procedure.

PROSTATE CANCER

Transgender women should be given all the same information provided to cis-males and be allowed to make an informed decision regarding screening.  Although guidelines for prostate cancer screening have changed and prostate-specific antigen (PSA) is no longer routinely recommended, it’s important to note that in the setting of prolonged estrogen exposure, as is the case with many transgender women patients, the PSA may be falsely low and therefore especially unreliable as a screening tool.  Rectal or transvaginal (if a neovagina has been created) exam of the prostate is recommended. 

 

SUMMARY

The American College of Obstetricians and Gynecologists recommends the following:

For FTM Patients - age appropriate screening for breast and cervical cancer unless complete mastectomy or hysterectomy has been performed.  Patients on androgen therapy who have not had a hysterectomy may be at increased risk for endometrial and ovarian cancer and should have a bimanual pelvic exam as recommended.

For FTM Patients - age appropriate screening for breast and prostate cancer

                                                     What you can do for a transgender patient

                                                             Create a welcoming environment.

                                 Be knowledgeable, non-judgmental and don’t make assumptions.

                Have an open discussion with patients about their cancer screening needs and schedule.

                                                                                                                   Judith Wolf, MD  Associate Director, WHEP