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Does prostate cancer impact people who identify as transgender?

PCFA_OC_Manager
Community Manager
Community Manager
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While we don’t have reliable figures on how many Australians identify as transgender, as a Member Organisation of the Union for International Cancer Control, PCFA is committed to the attainment of Universal Health Coverage, which is defined as the provision of quality cancer care services for all people, where and when they are needed, without the imposition of financial and other hardships, such as stigma.

In this article, we consider the risks of prostate cancer for people who have transitioned from being assigned male at birth to female in later life, who have a prostate gland which may predispose them to prostate cancer. This may be the case for people who were born with a prostate gland and have had gender affirming surgery (GAS), as well as those who identify as female, but have not had GAS.

Research into patterns of disease and risk factors for transgender people remains limited, with no clinical guidelines to prescribe optimal care pathways tailored to transgender people with unique needs.

However, a recent review by Bertoncelli Tanaka et. al. is helpful in examining some specific issues related to treating prostate cancer in this population1.

Understanding the needs of transgender people

Many transgender people share similar healthcare needs to those among the cisgender population, which is inclusive of people whose sense of personal identity and gender corresponds with their birth sex. They may, however, also have other diverse needs, including and/or related to gender-affirming hormone therapy (GAHT) and GAS. Previously GAS was referred to as “sexual reassignment” or “gender reassignment”. ‘Minority stress’ is defined as chronically high levels of stress which exists in marginalised groups due to the prejudice and discrimination resulting from their social environment. In addition to this, transgender people can struggle to experience continuity of care for various reasons: many move to different locations after transitioning to have a fresh start, some struggle with social and/or mental health issues, and some are denied access to the healthcare system. This can in-turn increase risks of other clinical conditions.

Risks of prostate cancer for transgender people

Until GAS is performed (where the testicles and supply of testosterone are removed), transgender women may receive oestrogen treatment with or without androgen deprivation therapy (similar to treatment used for advanced prostate cancer). Theoretically, this should lower the risk of prostate cancer. However, there is some evidence to say that high levels of oestrogen can also promote prostate cancer cell growth, and those exclusively on oestrogen therapy may therefore have an increased risk of prostate cancer. Currently there is no evidence to suggest that an early starting age of GAHT may increase the risk of cancer development, and may in fact reduce the risk, because it diminishes the length of time transwomen are exposed to testosterone2. Transgender people born as biological males carry the same inherent risks for prostate cancer as cisgender males, whereby those with a family history of prostate cancer are more at risk. Although still controversial, it has been proposed that perhaps screening PSA and MRI should be conducted prior to the initiation of GAHT. In the few reported cases from the literature, it appears the real incidence of prostate cancer is overall very low. Few cases have demonstrated that those who do present may have more aggressive disease, but there is no strong evidence to support this or any explanation for this.

PSA monitoring and screening for prostate cancer in transgender people

PSA monitoring can be complicated for transgender people. Medications suppressing testosterone can also suppress prostate size or enlargement, and the PSA normal reference range will be lowered (>1ng/ml). PSA testing therefore needs to be interpreted with caution. The normal reference range can be difficult to determine. Prostate MRIs are also more complex to interpret, particularly after GAHT and GAS.

Access to screening services may also be influenced by perceptions of stigma and discrimination, matters which are key to the health and wellbeing of people in the LGBTIQA+ community. It’s important for health professionals and service providers to offer inclusive and safe spaces for transgender health care to be delivered.

Physical examinations

Following vaginoplasty, which is the creation of a vagina, prostate examinations may be more difficult. Likewise, standard transperineal prostate biopsies can also be challenging and may require access through the vagina, or via the rectum.

In terms of treatment, if GAS has not been performed yet, but is being considered by the patient, and the patient has decided to have a radical prostatectomy, then a GAS surgeon should be involved in the patient’s treatment planning.

A radical prostatectomy may increase the risk of complications after GAS surgery, such as urinary incontinence, urethral strictures, and impaired sexual function. In the converse scenario, radical prostatectomies after GAS are also prone to more complications, such as fistulae formation. Focal therapy is an option, although there is limited existing evidence to recommend this treatment pathway. Radiation can be less effective if the prostate has shrunk due to the effect of GAHT.

The importance of multi-disciplinary teams

Given the number of variables that increase risk from treatment it is always advised that decisions are made through a shared decision-making process, in consultation with a multi-disciplinary health care team. For those patients with more advanced or metastatic prostate cancer who may require ADT, treating physicians should consider that these patients have already been on anti-androgen treatment as part of GAHT and may be at higher risk of treatment failure as a result of castration resistance.

Information for health professionals

Bertoncelli Tanaka et. al. offer some practical advice for those who are working in healthcare settings. Firstly, it’s important that health professionals are culturally respectful and transsensitive1 – training is a helpful way of improving outcomes in this area. It’s equally important for health professionals to be aware that patients attending the healthcare facility may not have fully transitioned, and their physical presentation may not align with staff expectations. To avoid offence, it is sometimes easier to ask the patient one of the following questions:

‘Which gender do you identify with?’

‘What is your preferred pronoun?’

‘What name do you prefer?’

It’s important too for health professionals to explain the nature of any physical examinations, and to ensure the patient is comfortable and consents to the procedure. Treatments for prostate cancer are challenging for all patients, and it’s imperative for health professionals to consider each patient’s individual physical and psychological situation, referring patients as necessary to specialised support and distress screening as provided by services such as PCFA’s Prostate Cancer Specialist Telenursing Service.

Commitment to diversity

PCFA is committed to supporting all Australians impacted by prostate cancer.

We pay our respects to those amongst the lesbian, gay, bisexual, trans, queer and intersex communities who have worked to support the improved health and wellbeing of their peers, children, families, friends, and country. We honour the diverse communities of which we are a part and we celebrate the extraordinary diversity of people's bodies, genders, sexualities, and relationships they represent.

Click here to download our booklet on Prostate Cancer for LGBTIQA+ people.

To learn more about Support Groups for LGBTIQA+ people, click here or email enquiries@pcfa.org.au.

To read our 2013 Monograph, Prostate Cancer Information Needs of Australian Gay and Bisexual Menclick here.

References

  1. Tanaka MB, Sahota K, Burn J et al. Prostate cancer in transgender women: what does a urologist need to know? BJUI 2022; 129: 113-122.
  2. Muermann MM, Wassersug RJ. Prostate cancer from a sex and gender perspective: A review. Sex Med Rev 2022; 10:142-154.

 


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About the Author

Kalli Spencer

MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)

Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.

Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.


Help is Available

Prostate Cancer Specialist Telenursing Service:

If your life has been impacted by prostate cancer, our Specialist Telenursing Service is available to help. If you would like to reach out to the PCFA Prostate Cancer Specialist Telenurse Service for any questions you have about your prostate cancer experience, please phone 1800 22 00 99 Monday - Friday 9am - 5pm, Wednesday 10am-8pm (AEST).

Prostate Cancer Support Groups:

PCFA is proud to have a national network of affiliated support groups in each state and territory of Australia consisting of men and women who have a passion for assisting others who encounter prostate cancer. This network is made up of over 170 affiliated groups who meet locally to provide one-to-one support, giving a vision of life and hope after treatment. Call us on 1800 22 00 99 to find your local group.

MatesCONNECT Telephone-based peer support:

MatesCONNECT is a telephone-based peer support program for men affected by prostate cancer. If you’ve recently been diagnosed with prostate cancer, our MatesCONNECT service can connect you to a trained volunteer who understands what you’re going through. All of our volunteers have been through prostate cancer. Simply call us on 1800 22 00 99 to be connected with a volunteer.

Newly diagnosed? or need to find more information -Access the PCFA resources here!

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