Cancer screening is a critical part of primary care practice, and most of us can recite guidelines in our sleep. That said, cancer screening can feel a little tricky in our transgender population, especially when we are still learning to navigate this sensitive topic as a general part of our practice.
The #1 Consideration for Transgender Patients
The primary thing to keep in mind with transgender patients is the organ inventory. Many EHRs have this built into the system, but it’s the clinician’s job to make sure it’s correct and up to date.
Regardless of gender identity, the rule of thumb is: If there is a particular organ that meets criteria for screening based on risk factors or symptoms, it's important to proceed with the screening regardless of hormone use. Approaching this discussion with humility and sensitivity will strengthen the clinician-patient relationship and build trust. As with all preventive care, shared decision-making and patient education is key.
Breast Cancer Screening Considerations
Let’s start with breast cancer screening. In transgender men, it’s important to remember that exogenous testosterone increases breast cancer risk. If the patient has not had a mastectomy, the recommendations are the same breast cancer screening guidelines as cisgender women with a mammogram - every 1-2 years depending on the guidelines you choose to follow. If the patient has had a mastectomy, no screening is needed. For transgender women, exogenous estrogen brings increased risk of breast cancer, so if they have breasts, consider screening every 1-2 years starting at age 50.
Cervical Cancer Screening Considerations
Cervical cancer screening especially requires a trauma-informed approach. It’s important to consider that there may be psychological dysphoria as well as physical discomfort associated with pelvic exams. It may be better to schedule this appointment on a separate day in order to allow enough time, and remember to use appropriate language such as “foot rests” instead of “stirrups.”
Prostate Cancer Screening Considerations
Prostate cancer screening guidelines are confusing at the best of times, but even more so for a transgender patient! As with cisgender men, we should use shared decision-making and risk level to guide our decision. An important thing to remember is that transgender women may be on 5-alpha reductase inhibitors, which can reduce the baseline PSA.
Anal Pap Smear Considerations
The last cancer screening to consider is anal pap smears for anal cancer. There are, unfortunately, no universal guidelines to point to, so the decision should be made based on risk factors and patient preference.
For a deeper dive on cancer screening recommendations in transgender health, listen to the Cancer Screening Considerations for Transgender Patients episode on the Primary Care RAP podcast. See our full chapter summary here.