Chapter Summary: Cancer Screening Considerations for Transgender Patients

Pearls:

• Cancer screenings for transgender patients should take into account an organ inventory that can be obtained from history-taking, personal/family risk factors and trauma-informed approaches to sensitive exams like the pelvic exam.
• Cancer screening considerations for transgender patients:
• Cancer screening is a cornerstone of primary care yet can be more nuanced among transgender individuals based on their sex organs
• Pearl: An organ inventory is important to remember as well to ensure you know what the person has that may need cancer screening

• Breast cancer screening:

• Transgender men:
• Testosterone increases risk of breast cancer so should be factored into the conversation
• If they have NOT had a mastectomy, continue screening every 1-2 years based on general guidelines for cis women with breasts

If they have had a mastectomy, you can reassure they do not need screening and any lumps/bumps can be evaluated with MRI or ultrasound of that area

• Transgender women:
• Estrogen increases the risk of breast cancer so if they have breasts than consider starting screening at 50 every 1-2 years
• You can also take into account estrogen exposure vs. a cisgender woman who may have started menses at age 11-12 years of age vs. starting estrogen in 20’s or 30’s

• Cervical:

• Consider that pelvic exams can be associated with organs that are associated with psychological dysphoria as well as atrophy (and therefore physical discomfort)
• Inquire if they have a cervix and if they have ever had a pelvic exam
• Offer the exam on a separate day and allow enough time for it
• Tips for the exam:
• Talking through the process
• “Exam table” not “exam bed”
• “Leg holders” not “stirrups”
• Trying to keep the speculum quiet instead of ratcheting up to keep in place

• Endometrial / ovarian:

• Just as with cisgender individuals there is no recommended screening

• Testicular:

• No recommendation for routine screening just as cisgender men
• Transgender undergoing feminizing therapy may have reduction in the volume/size of the testes as an expected side effect. Important to counsel that is no a sign of cancer

• Prostate:

• Prostate cancer is based on risk factors and shared decision making
• PSA may not be a great test because transgender women may be on five alpha reductase inhibitors that reduce their baseline PSA level
• For those who have had vaginoplasty, the prostate can actually be felt at the neo vaginal anterior wall instead of via a rectal exam

• Anal cancer:

• Risk-factor-driven screening, no universal screening guidelines
• For example: person with HIV who is having anal insertive penile sex and MSM

References:

1. Compton ML, et al. Cytology and LGBT+ health: establishing inclusive cancer screening programs. J Am Soc Cytopathol. 2022;11(5):241-252. PMID: 35840516
2. Wierckx K, et al. Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study. Eur J Endocrinol. 2013;169(4):471-478. Published 2013 Sep 13. PMID: 23904280
3. Wierckx K, et al. Long-term evaluation of cross-sex hormone treatment in transsexual persons. J Sex Med. 2012;9(10):2641-2651. PMID: 22906135
4. Grynberg M, et al. Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population. Reprod Biomed Online. 2010;20(4):553-558. PMID: 20122869
5. Gooren LJG, et al. Review of studies of androgen treatment of female-to-male transsexuals: effects and risks of administration of androgens to females. J Sex Med. 2008;5(4):765-776. PMID: 17971101
6. Miksad RA, et al. Prostate cancer in a transgender woman 41 years after initiation of feminization. JAMA. 2006;296(19):2316-2317. PMID: 17105793
7. Turo R, et al. Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy. Can Urol Assoc J. 2013;7(7-8):E544-E546. PMID: 24032068
8. Camille K, et al. Invasive Breast Cancer in a Female-to-Male Transgender after Bilateral Mastectomy: case-report and Literature Review. Clinical Breast Cancer. Published online November 10, 2020. doi:https://doi.org/10.1016/j.clbc.2020.10.005. https://www.clinical-breast-cancer.com/article/S1526-8209(20)30264-0/fulltext
9. Maza M, et al. Cervical Cancer Screening with Human Papillomavirus Self-Sampling Among Transgender Men in El Salvador. LGBT Health. 2020;7(4):174-181. PMID: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301324/
10. Deutsch, MB. General approach to cancer screening in transgender people | Gender Affirming Health Program. transcare.ucsf.edu. Published June 17, 2016. Accessed February 6, 2023. https://transcare.ucsf.edu/guidelines/cancer-screening
11. Coleman E. Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People the World Professional Association for Transgender Health. World Professional Association for Transgender Health (WPATH); 2012. Accessed February 6, 2023. https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English2012.pdf?_t=1613669341

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