How Should We Screen Transgender Patients for Cancer?

PARIS — Screening for breast, cervical, and prostate cancer should continue for transgender patients after they transition to their new identity, but the screening methods must be adapted. This was the main message of a presentation given by Gene De Haan, MD, obstetrician and gynecologist at the Kaiser Permanente Interstate Medical Office East in Portland, Oregon, at the FIGO 2023 World Congress of Gynecology and Obstetrics.

Is the hormone therapy used for gender transition, whether feminizing or masculinizing, associated with an increased risk of cancer, in particular hormone-sensitive types of disease? “The long-term data are limited, but the data that we do have are reassuring,” said De Haan in response to a growing concern among transgender patients.

The recommendations for screening should be adapted to the patient’s gender after transitioning with hormone therapy. Breast cancer screening is recommended for transgender men and women, while prostate cancer screening is still needed by transgender women.

Risk for Breast Cancer

Specific factors should be considered regarding breast cancer screening for patients who were born male and later took estrogen. According to the latest guidelines issued by the World Professional Association for Transgender Health (WPATH), “The length of time hormones are used for dosage, current age, and age at start of hormone therapy must be taken into account.”

The recommendations drawn up for cisgender women should be applied to transgender women after receiving feminizing hormone therapy for a minimum of 5 years, said De Haan. For context, screening in France is carried out every 2 years from the age of 50 years. It consists of a mammography, an ultrasound if needed, and a physical breast examination.

WPATH states that the breasts of transgender women, which develop from hormone therapy, may appear denser on a mammography. “Breast implants or injecting breasts with fillers may also make mammogram interpretation more difficult,” added De Haan, a specialist in transgender health.

The risk of breast cancer among transgender women might be lower than among cisgender women but is not negligible. A Dutch study that involved more than 2000 transgender women reported 20 or so cases of breast cancer after patients underwent hormone therapy for a median duration of 18 years, a rate that is 46-fold higher than among cisgender men but three times lower than among cisgender women.

Unwelcome Screening

Mammography screening is still recommended for transgender men if they have not undergone mastectomy. For patients who have had a mastectomy, the risk of cancer is still present because breast tissue is generally not completely removed during the procedure to get as close to masculine physiognomy as possible.

“The mastectomy carried out in transgender males is not the same as the mastectomy indicated to prevent breast cancer in at-risk women.” Mammography is technically no longer possible after the procedure, but monitoring should continue, especially with regular examination of residual breast tissue.

Screening for cervical cancer should also be continued for transgender men. This screening consists of cytology testing of a cervical smear for women aged 25 to 29 years. Patients aged 30 to 65 years who are at high risk should be tested for human papillomavirus (HPV). The examination is carried out every 3 years, then every 5 years from the age of 30 years.

Transgender men may “struggle, emotionally and physically, to accept” a cervical smear, so methods should be adapted, indicated De Haan. Since testosterone causes atrophy of the mucosa of the genital tract, the examination may be uncomfortable and painful.

“Practitioners must perform speculum examinations carefully to minimize the pain and stress felt by transgender males,” emphasizes the WPATH. If poorly tolerated, the patient may require sedation for cervical screening.

Reduced PSA Levels

Self-collected HPV DNA testing seems a more suitable screening method. Countries such as Australia and the Netherlands recommend this alternative for transgender men. A study conducted in this population showed that the test has an excellent negative predictive value (close to 95%) and that transgender men are largely in favor of self-swabbing.

De Haan noted that transgender women are still at risk of prostate cancer, even when taking estrogen. They should be advised of this risk and of the possibility of screening from age 50 years.

Yet clinicians must bear in mind that certain androgen antagonists that are prescribed as part of feminizing hormone therapy could reduce prostate-specific antigen (PSA) levels. “When requesting PSA levels for patients on estrogen or androgen antagonists, the normal threshold of 1 ng/mL should be lowered.”

If a prostate exam is indicated, a vaginal examination may be considered instead of a digital rectal examination when the former approach is possible. “In patients who have undergone vaginoplasty, the prostate is palpable via the anterior wall of the neovagina,” indicated De Haan, who estimates that this route is more appropriate for fully assessing the contours of the prostate.

This article was translated from the Medscape French edition.

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