Breast Cancer: Current Research
Open Access

Over the last fifty years, widespread cancer screening has resulted in lower cancer mortality. Screening has resulted in a 13% reduction in colorectal cancer mortality and a 14% reduction in lung cancer cancer specific mortality. Breast and cervical cancer mortality rates have both decreased since the widespread use of screening mammograms and pap smears. Although PSA screening reduces prostate cancer mortality, it is also associated with false-positive results and overtreatment. The American Cancer Society (ACS) and the US Preventative Services Task Force (USPSTF), as well as numerous professional organisations (ACS, AMA, AUA, ACOG), have made clear recommendations for the early detection of cancer in cis-gender patients at average and high risk.

When applied to the transgender community, these guidelines become less straightforward, and the World Profession Association of Transgender Health (WPATH) currently has no cancer screening guidelines. Transgender patients’ cancer screening needs will vary depending on “what stage of their transition” they are in, as the initiation of gender-affirming hormone therapy (GAHT), nongenital GAS, genital GAS, and surgical removal of some or all of their reproductive organs may all affect cancer risk. According to WPATH Standards of Care Version 7, “providers are unlikely to have enough evidence to determine the appropriate type and frequency of screening in the absence of large-scale prospective studies... Cancer screening may be gender affirming for patients, or it may be physically and emotionally painful.”

Large databases in the United States, such as the Surveillance, Epidemiology, and End Results (SEER) and the National Cancer Database (NCDB), do not include non-binary genders, making it difficult to determine whether the cancer risk of transgender people differs from that of the general population. A UK study discovered that gay and bisexual men had an increased risk of cancer diagnosis when compared to heterosexual men; however, the main driver of this difference was higher rates of viral-related cancers such as Kaposi’s sarcoma, anal cancer, and penile cancer. Studies in the United States have attempted to extrapolate any associated cancer risk by looking at cancer rates in areas with a high population of LGBT people; the results of these studies were mixed, and no firm conclusions can be drawn from them. The LGBT community’s higher cancer rates are frequently attributed to high-risk behaviours such as smoking, alcohol and drug use, obesity, and significantly higher HIV rates. According to the CDC, 1.9 percent of HIV tests performed on transgender people in 2013 were positive, compared to 0.9 percent for cis-gender males and 0.2 percent for cis-gender females. The estimated HIV prevalence among transgender women of reproductive age (range, 15–49) is 21.7 percent (95 percent CI: 18.4–25.1 percent), which is 34 times higher than the prevalence among cis-gender adults in the same age group.

Transgender patients are frequently discriminated against and stigmatised, resulting in fewer healthcare screening encounters. Transgender people have reported difficulties interacting with the US healthcare system: 19% have reported refusal of care, 28% have reported harassment, and 50% have been turned off the system due to a lack of gender nonconforming providers. Clinicians may also fail to provide appropriate screening and counselling based on the anatomy of the patient. This includes PSA tests and prostate exams for anyone who still has a prostate, as well as Pap smears for anyone who still has a cervix, regardless of gender.

Furthermore, many transgender patients seek medical care solely for the purpose of gender affirmation, avoiding primary health care concerns. Patients who seek routine medical examinations are hesitant to discuss gender-incongruous organs. As a result, transgender patients may be more reliant than cis-gender patients on their health care providers to initiate cancer screening discussions.