Gender Identity Disparities in Cancer Screening Behaviors

Cancer screening attendance rates in transgender and gender-diverse patients: a systematic review and meta-analysis

OBJECTIVES

To examine disparities in attendance rates at cancer screening services between transgender and gender-diverse (TGD) people in comparison with their cisgender (CG) counterparts, and to determine whether these differences were based on the anatomical organ screened.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE (via Ovid), CINAHL Complete (via EBSCO) and Cochrane Library from inception to 30 September 2023.

METHODS

Studies for inclusion were case-control or cross-sectional studies with quantitative data that investigated TGD adults attending any cancer screening service. Exclusion criteria were studies with participants who were ineligible for cancer screening or without samples from TGD individuals, qualitative data and a cancer diagnosis from symptomatic presentation or incidental findings. A modified Newcastle-Ottawa Scale was used to assess risk of bias, during which seven reports were found incompatible with the inclusion criteria and excluded. Results were synthesised through random-effects meta-analysis and narrative synthesis.

RESULTS

We identified 25 eligible records, of which 18 were included in the analysis. These were cross-sectional studies, including retrospective chart reviews and survey analyses, and encompassed over 14.8 million participants. The main outcomes measured were up-to-date (UTD) and lifetime (LT) attendance. Meta-analysis found differences for UTD cervical (OR 0.37, 95% CI 0.23 to 0.60, p<0.0001) and mammography (OR 0.41, 95% CI 0.20 to 0.87, p=0.02) but not for prostate or colorectal screening. There were no meaningful differences seen in LT attendance based on quantitative synthesis. Narrative synthesis of the seven remaining articles mostly supported the meta-analysis. Reduced rates of screening engagement in TGD participants were found for UTD cervical and mammography screening, alongside LT mammography screening.

CONCLUSIONS

Compared with their CG counterparts, TGD individuals had lower rates of using cervical and mammography screening at the recommended frequencies but displayed similar prevalences of LT attendance. The greatest disparity was seen in UTD cervical screening. Limitations of this review included high risk of bias within studies, high heterogeneity and a lack of resources for further statistical testing. Bridging gaps in healthcare to improve cancer screening experiences and outcomes will require consolidated efforts including working with the TGD community.

PROSPERO REGISTRATION NUMBER

CRD42022368911.

Rationale and design of the Self-TI Study protocol: a cross-sectional human papillomavirus self-testing pilot study among transgender adults in England

INTRODUCTION

Persistent infection with high-risk human papillomavirus (HPV) is the causal agent of several cancers including cervical, anal and oropharyngeal cancer. Transgender men and transmasculine non-binary (TMNB) people with a cervix are much less likely to undergo cervical cancer screening than cisgender women. Transgender women and transfeminine non-binary (TWNB) people assigned male at birth may be at increased risk of HPV. Both TMNB and TWNB people face many barriers to HPV testing including medical mistrust due to stigma and discrimination.

METHODS AND ANALYSIS

The Self-TI Study (Self-TI) is a pilot study designed to measure acceptability and feasibility of HPV self-testing among transgender and non-binary people in England. TMNB people aged 25-65 years, with at least 1 year of testosterone, and TWNB people, aged 18 years and over, are eligible to participate. Participants self-collect up to four samples: an oral rinse, a first void urine sample, a vaginal swab (if applicable) and an anal swab. TMNB participants are asked to have an additional clinician-collected cervical swab taken following their routine Cervical Screening Programme sample. TWNB people are asked to take a self-collection kit to perform additional self-collection at home and mail the samples back to the clinic. Acceptability is assessed by a self-administered online survey and feasibility is measured as the proportion of samples returned in the clinic and from home.

ETHICS AND DISSEMINATION

Self-TI received ethical approval from the Research Ethics Committee of Wales 4 and ethical review panel within the Division of Cancer Epidemiology and Genetics at the US National Cancer Institute. Self-TI was coproduced by members of the transgender and non-binary community, who served as authors, collaborators and members of the patient and public involvement (PPI) group. Results of this study will be shared with the community prior to being published in peer-reviewed journals and the PPI group will help to design the results dissemination strategy. The evidence generated from this pilot study could be used to inform a larger, international study of HPV self-testing in the transgender and non-binary community.

TRIAL REGISTRATION NUMBER

NCT05883111.

Perceived Access to Healthcare of Indigenous Peoples in Canada With Rheumatoid Arthritis and Their First-Degree Relatives

OBJECTIVE

There are complex and interrelated factors that lead to inequitable healthcare delivery in Canada. Many of the factors that underlie these inequities for Canada's geographically dispersed Indigenous peoples remain underexamined.

METHODS

A cohort of 831 First Nations (FN) individuals from urban and remote communities were recruited into a longitudinal study of rheumatoid arthritis (RA) risk from 2005 to 2017. Data from each participant's initial enrollment visit were assessed using a survey that captured concerns with healthcare access.

RESULTS

We found that remote participants with RA reported poor access compared to remote first-degree relatives (FDRs; P < 0.001); this difference was not observed for urban participants with RA. We observed substantial differences based on sex; female participants perceived access to care to be more difficult than male participants in both urban and remote cohorts (P < 0.001). We also observed that male participants with RA reported poor access to care compared to male FDRs. Importantly, access to care in remote communities appeared to improve over the duration of the study (P = 0.01). In a logistic regression analysis, female sex, remote location, and older age were independent predictors of poor access to care. Predictors of poor access in participants with RA also included female sex, remote location, and older age.

CONCLUSION

FN peoples living in remote communities, particularly those with an established RA diagnosis, report more problems accessing health care. Sex-based inequities exist, with FN female individuals reporting greater difficulties in accessing appropriate health care, regardless of RA diagnosis. Addressing these sex-based inequities should be a high priority for improving healthcare delivery.

The implications of hormone treatment for cancer risk, screening and treatment in transgender individuals

There is evidence that gender-affirming hormone treatment (GAHT) for transgender individuals modulates their risk for specific malignancies including breast and prostate cancer, and meningiomas. However, there is insufficient data to make precise risk estimates accounting for age and inherited cancer risk. As such, screening recommendations remain broad. Even less evidence exists for best practice in the management of active or historical cancers in the transgender population. Guidance is therefore mainly extrapolated from cisgender populations but with considerations of the significant benefits of GAHT in the face of any hormonal risk. Clinical experience, the multidisciplinary team and shared decision making with the patient are vital in providing person-centred care, while further research is acquired.

Multidisciplinary management of sexual and gender minorities with bladder cancer

Bladder cancer, a common urologic malignancy, has poor morbidity and mortality in sexual and gender minority (SGM) individuals, stemming from higher risk, poor access to care and lack of quality cancer care. To begin addressing this disparity, this review offers key considerations for evaluation, diagnosis and treatment of SGM individuals with bladder cancer. In addition to thorough medical and surgical history, initial evaluation should include discussion of patient goals for sexual function and organ preservation, as well as an evaluation of sexual function. Prior gender affirming surgery and patient specific sexual function goals will impact diagnosis and treatment approaches, including surgical and radiation therapy. Throughout care for SGM individuals with bladder cancer, it is critical to acknowledge the systemic discrimination that may be experienced by these individuals and approach conversations with sensitivity and humility and incorporate mental and social support as appropriate.

Health Care Professional Education on Cancer Screening of SGM Individuals: An Integrative Review

Sexual and gender minority (SGM) individuals are disproportionately affected by cancer. Health care professional (HCP) and health sciences education rarely includes content on cancer screening in this population. This article aims to synthesize literature on educational programs for HCPs and health sciences students related to cancer screening for SGM individuals. An integrative review methodology guided a systematic search of five databases: CINAHL, PubMed, Embase, PsycInfo, and ERIC. Articles were included if they were empirically-based and described educational programs targeted at HCPs and health sciences students with content of cancer screening for SGM people. Eleven studies met the inclusion criteria. Of these, three were pilot studies and the majority of the articles (n = 9) used pre- and post-test designs. All of the interventions showed efficacy in increasing knowledge, attitudes, skills, and behavior. However, the vastly different programs and the fact that most of the cancer screening content was embedded in programs with broad SGM issues content limit the ability to make firm recommendations for any one particular program. In-person didactic content delivered multiple times incorporating modalities such as standardized patient encounters, case studies, and guest speakers increased knowledge, attitude, and skills of participants. Future studies should incorporate behavioral theories, develop more consistent aspects of educational programs, report demographic and pertinent data on participants, and utilize established instruments to measure outcomes when conducting educational interventions on HCPs and students in this area.

Sociodemographic profile, health-related behaviours and experiences of healthcare access in Italian transgender and gender diverse adult population

PURPOSE

Information on the general health of transgender and gender diverse (TGD) individuals continues to be lacking. To bridge this gap, the National Institute of Health in Italy together with the National Office against Racial Discriminations, clinical centres, and TGD organizations carried out a cross-sectional study to define the sociodemographic profile, health-related behaviours, and experiences of healthcare access in Italian TGD adult population.

METHODS

A national survey was conducted by Computer-Assisted Web Interviewing (CAWI) technique. Collected data were compared within the TGD subgroups and between TGD people and the Italian general population (IGP).

RESULTS

TGD respondents were 959: 65% assigned female at birth (AFAB) and 35% assigned male at birth (AMAB). 91.8% and 8.2% were binary and non-binary TGD respondents, respectively. More than 20% of the TGD population reported to be unemployed with the highest rate detectable in AMAB and non-binary people. Cigarette smoking and binge drinking were higher in the TGD population compared with IGP (p < 0.05), affecting TGD subgroups differently. A significant lower percentage of AFAB TGD people reported having had screening for cervical and breast cancer in comparison with AFAB IGP (p < 0.0001, in both cases). Over 40% was the percentage of AFAB and non-binary TGD people accessing healthcare who felt discriminated against because of their gender identity.

CONCLUSIONS

Our results are a first step towards a better understanding of the health needs of TGD people in Italy in order to plan the best policy choices for a more inclusive public health.

Association between the social vulnerability index and breast, cervical, and colorectal cancer screening rates in Rhode Island

BACKGROUND

Cancer screening is effective in reducing the burden of breast, cervical, and colorectal cancers, but not all communities have appropriate access to these services. In this study, we aimed to identify under-resourced communities by assessing the association between the Social Vulnerability Index (SVI) with screening rates for breast, cervical, and colorectal cancers in ZIP-code tabulation areas (ZCTAs) in Rhode Island.

METHODS

This study leveraged deidentified health insurance claims data from HealthFacts RI, the state's all-payer claims database, to calculate screening rates for breast, cervical, and colorectal cancers using Healthcare Effectiveness Data and Information Set measures. We used spatial autoregressive Tobit models to assess the association between the SVI, its four domains, and its 15 component variables with screening rates in 2019, accounting for spatial dependencies.

RESULTS

In 2019, 73.2, 65.0, and 66.1% of eligible individuals were screened for breast, cervical, and colorectal cancer, respectively. For every 1-unit increase in the SVI, screening rates for breast and colorectal cancer were lower by 0.07% (95% CI 0.01-0.08%) and 0.08% (95% CI 0.02-0.15%), respectively. With higher scores on the SVI's socioeconomic domain, screening rates for all three types of cancers were lower.

CONCLUSION

The SVI, especially its socioeconomic domain, is a useful tool for identifying areas that are under-served by current efforts to expand access to screening for breast, cervical, and colorectal cancer. These areas should be prioritized for new place-based partnerships that address barriers to screening at the individual and community level.

Utilization of electronic health record sex and gender demographic fields: a metadata and mixed methods analysis

OBJECTIVES

Despite federally mandated collection of sex and gender demographics in the electronic health record (EHR), longitudinal assessments are lacking. We assessed sex and gender demographic field utilization using EHR metadata.

MATERIALS AND METHODS

Patients ≥18 years of age in the Mass General Brigham health system with a first Legal Sex entry (registration requirement) between January 8, 2018 and January 1, 2022 were included in this retrospective study. Metadata for all sex and gender fields (Legal Sex, Sex Assigned at Birth [SAAB], Gender Identity) were quantified by completion rates, user types, and longitudinal change. A nested qualitative study of providers from specialties with high and low field use identified themes related to utilization.

RESULTS

1 576 120 patients met inclusion criteria: 100% had a Legal Sex, 20% a Gender Identity, and 19% a SAAB; 321 185 patients had field changes other than initial Legal Sex entry. About 2% of patients had a subsequent Legal Sex change, and 25% of those had ≥2 changes; 20% of patients had ≥1 update to Gender Identity and 19% to SAAB. Excluding the first Legal Sex entry, administrators made most changes (67%) across all fields, followed by patients (25%), providers (7.2%), and automated Health Level-7 (HL7) interface messages (0.7%). Provider utilization varied by subspecialty; themes related to systems barriers and personal perceptions were identified.

DISCUSSION

Sex and gender demographic fields are primarily used by administrators and raise concern about data accuracy; provider use is heterogenous and lacking. Provider awareness of field availability and variable workflows may impede use.

CONCLUSION

EHR metadata highlights areas for improvement of sex and gender field utilization.

Cervical cancer in a transgender man: lessons learnt to improve care

We describe a case of rapid progression of cervical dysplasia to stage IVB cervical cancer in a previously healthy transgender young adult man on testosterone therapy. The cancer diagnosis came 7 months after routine pap smear showed low-grade dysplasia with high-risk human papillomavirus in preparation for gender-affirming hysterectomy/bilateral-salpingo-oophorectomy. After diagnosis, our patient faced unique challenges as a transgender man receiving gynecologic oncology care. This case highlights the challenges of and barriers to cervical cancer screening and treatment that transgender men confront. This case also considers whether gender-affirming testosterone therapy is associated with cervical cancer risk. We offer suggestions on how to improve cervical cancer screening and treatment for the transgender population.

"We grow older. We also have lots of sex. I just want a doctor who will at least ask about it.": Transgender, non-binary, and intersex older adults in sexual and reproductive healthcare

Transgender, non-binary, and intersex (TNBI) older adults experience significant disparities in sexual and reproductive healthcare. Utilizing data from 50 semi-structured individual interviews with TNBI older Americans, we examine how TNBI older adults experience and mitigate inequity in sexual and reproductive healthcare. We explore elders' negotiation of inequity through what we term resourcefulness strategies - tactical processes involving marginalized communities obtaining and utilizing resources to minimize inequalities within and beyond healthcare settings. Resourcefulness strategies differ from resiliency insofar as they directly acknowledge the need for social privilege, capital, and resources - on a community level - to overcome difficult situations (e.g., inequalities in healthcare), rather than drawing upon individual coping strategies alone. Our analysis reveals medical providers' lack of cultural competency with TNBI communities and older adults as primary drivers of TNBI older adults' experiences of inequity within sexual/reproductive healthcare settings. Consequently, TNBI older adults aimed to minimize inequity in sexual/reproductive healthcare through particular resourcefulness strategies. Specifically, we found a bifurcation in respondents' strategies, wherein trans men engaged in health service avoidance while trans women and non-binary respondents engaged in health service self-advocacy. These strategies required respondents to assume primary responsibility for transforming (or avoiding) sexual/reproductive health services that were perceived as lacking or actively harmful. We argue that such approaches are neither effective nor structurally-sustainable for attaining older-age and TNBI-affirming, inclusive, and culturally-competent healthcare for TNBI older patients.

Effect of an Oncology Focused High School Outreach Event in Increasing Interest in Cancer Care and Healthcare Careers

Despite widely heralded efforts to improve diversity, equity, and inclusion in oncology, few outreach programs exist to inspire high school students to pursue a career in medicine. Doctors' Day is an event developed and organized by medical trainees that features both didactic and hands-on learning components to provide high school students with exposure to the healthcare field and knowledge about cancer and cancer screening. We investigated in the influence of Doctors' Day on students' interest in healthcare careers and oncology. On March 30, 2023, health professions students and residents organized and led Doctors' Day, a half-day educational program for eight public high schools in Nashville, TN. After the event, high school student participants were invited to complete a 21-item survey. The questionnaire collected demographic information, feedback regarding the session, and comfort with various activities related to the program. Among the 8 public high schools involved in Doctors' Day, 91 participants completed the survey. Few (9, 9.9%) participants were White or European American, and 30 (33.0%) and 23 (25.3%) were Black and Hispanic, respectively. There were 20 (22.0%) participants who identified as LGBTQI+ with 2 (2.2%) indicating they were unsure. Feedback regarding the program was positive across all domains, and students reported increased interest in healthcare careers and oncology along with an increased comfort level in describing the importance of cancer screening. Our community outreach program for high school students with backgrounds underrepresented in medicine was effective in increasing interest in healthcare careers and oncology.

Care of transgender patients by diagnostic radiographers: What can be learnt from the literature

INTRODUCTION

Transgender patients have described negative healthcare experiences, including discrimination and feeling unwelcome. Additionally, these patients are at risk of inadequate or unsafe care due to healthcare providers being unable to obtain and record transgender patients' correct gender and assigned birth sex. This literature review aims to review radiology and radiographer articles published since 2018 about transgender healthcare issues and make recommendations that can be applied by diagnostic radiographers, their managers and diagnostic radiography programme providers.

METHOD

A literature search used multiple databases containing peer-reviewed articles. Boolean operators and key words were utilised. Identified articles were searched to identify any articles not found by searching the databases. Themes and sub-themes from each paper were identified and discussed.

RESULTS

Three key themes were identified: education, systems and environment. Education sub-themes were knowledge and awareness. Systems sub-themes were recording gender correctly and discriminating/stigmatising policies. Environment sub-themes were transgender-friendly symbols and environmental dysphoria.

CONCLUSION

Transgender patients still face barriers to equitable care. Several recommendations were made based on the thematic discussion that could be applied by diagnostic radiographers, student radiographers, radiology managers, University training providers, and professional body organisations. Diagnostic radiography programmes should include training on both clinical topics and cultural competence. Radiology managers should display transgender-positive symbols in their departments and ensure their policies are non-discriminatory and non-stigmatising. Radiology hardware and software providers should provide the ability to record non-binary genders and birth-assigned sex.

IMPLICATIONS FOR PRACTICE

Transgender patients have the right to receive equitable care from diagnostic radiographers during their imaging examination and radiology attendance, and that any risks relating to their transgender status should be correctly managed with appropriate sensitivity.

Liver transplantation for people of minoritised sexual and gender identities in the USA

The number of people who report to be of minoritised sexual or gender identities in the USA, including lesbian, gay, bisexual, transgender, queer, and other sexuality-diverse and gender-diverse identities, has been increasing in the past decade. This diverse and unique population continues to experience not only health disparities but also psychosocial, economic, and legal disparities in accessing and receiving health care, including liver transplantations. As liver transplantation is life-saving for people with end-stage liver disease, understanding the factors that can affect access to and quality of liver transplantation care in people of minoritised sexual and gender identities in the USA, including differential social supports, insurance coverage, and medical and psychiatric comorbidities, is crucial. Actions, such as collecting sexual orientation and gender identity data, implementing inclusive language, recognising implicit biases, building diverse teams, providing a safer environment, and supporting further research to understand the unique health challenges are needed to ensure equitable access to high-quality liver transplantation care for people of minoritised sexual and gender identities.

Prostate Cancer in Transgender Women: Epidemiology, Clinical Characteristics, and Management Challenges

PURPOSE OF REVIEW

To systematically review the evidence on prostate cancer (PCa) in transgender women (TGW).

RECENT FINDINGS

A total of 25 studies were included. Fourteen articles were case reports or case series describing 21 TGW with PCa; 11 papers focused primarily on assessing the incidence or screening of PCa in TGW. The median (range) age of patients with PCa was 63 (45-78) years. Median (range) PSA at diagnosis was 7.5 (0.4-1710) ng/mL. Prostate biopsy detected ISUP 3-5 in 10 (67%) cases. T3-4 stages were described in 7 (64%) patients. Three (14.3%) cases of nodal involvement and 2 (9.5%) of metastases were reported at diagnosis. First-line therapy included radical prostatectomy or radiotherapy ± androgen deprivation therapy in 14 (74 %) subjects. Median (range) follow-up was 24 (2-120) months. A good response to first-line therapy was recorded in 8 (47.1%) cases. Median (range) incidence of PCa in TGW was 44.1 (4.34-140) cases per 100,000 person-years. PCa was significantly less frequent in TGW than in cisgender males (HR 0.4, 95% CI 0.2-0.9). Risk of death after PCa diagnosis was significantly higher in TGW compared to cisgender males (HR 1.91, 95% CI 1.06-3.45). TGW had lower lifetime PSA rates (48% vs. 64.6%, p = 0.048) than cisgender males. Few cases of PCa in TGW are currently reported. PCa seems significantly less frequent in TGW than in cisgender males; however, some data suggest a possible higher mortality in this cohort. TGW appear to have less access to PSA testing than cisgender men.

Demographic factors associated with healthcare avoidance and delay in the transgender population: Findings from a systematic review

Purpose

Healthcare avoidance and delay (HAD) in the transgender population has been well documented, and research has explored a range of associated factors that help to identify those most at risk of HAD. This review addresses a gap in the research by synthesizing research exploring associations between HAD and demographic factors.

Methods

A systematic search of literature published at any time up to December 2021 was conducted, using five databases (EBSCO, EMBASE, PubMed, Scopus, and Web of Science) and manually searching reference lists of included studies. After exclusion of duplicates, 608 unique records were subjected to double screening. Papers reporting statistical analyses of HAD in association with any sociodemographic variables were included in this review. Papers consisted of nineteen cross-sectional studies. Narrative synthesis was used to address findings.

Results

Nineteen studies met inclusion criteria, exploring HAD in association with a wide range of demographic factors, including sex and gender, social transition factors, age, race and ethnicity, socioeconomic factors, veteran status, education, sexuality, relationship status, citizenship, place of residence, and state demographics. Findings identified intra-community demographic risk factors, with consistent evidence for increased HAD among transmasculine, and younger, participants. Lower income and higher educational attainment were also associated with increased HAD, while remaining areas had weak or little evidence for association with HAD.

Conclusion

This review expands knowledge in this area by highlighting demographic factors associated with increased HAD in research literature, and exploring how these may be further investigated to address substantial gaps in the body of research.

Inequities in colorectal and breast cancer screening: At the intersection of race/ethnicity, sexuality, and gender

Objective

To investigate the joint impact of sexual orientation, gender identity, and race/ethnicity on colorectal and breast cancer screening disparities in the United States.

Methods

Utilizing sampling weighted data from the 2016 and 2018 Behavioral Risk Factor Surveillance System, we assessed differences in two metrics via chi-square statistics: 1) lifetime uptake, and 2) up-to-date colorectal and breast cancer screening by sexual orientation and gender identity, within and across racial/ethnic classifications.

Results

Within specific races/ethnicities, lifetime CRC screening was higher among gay/lesbian (within NH-White, Hispanic, and Asian/Pacific Islander) and bisexual individuals (Hispanic) compared to straight individuals, and lowest overall among transgender women and transgender nonconforming populations (p < 0.05). Asian transgender women had the lowest lifetime CRC screening (13.0%; w.n. = 1,428). Lifetime breast cancer screening was lowest among the Hispanic bisexual population (86.6%; w.n. = 26,940) and Hispanic transgender nonconforming population (71.8%; w.n. = 739); within all races, SGM individuals (except NH-White, Hispanic, and Black bisexual populations, and NH-White transgender men) had greater breast cancer screening adherence compared to straight individuals.

Conclusions

Due to small, unweighted sample sizes, results should be interpreted with caution. Heterogeneity in screening participation by SGM status within and across racial/ethnic groups were observed, revealing the need to disaggregate data to account for intersecting identities and for studies with larger sample sizes to increase estimate reliability.

Sexual and Gender Minority Patients' First Pelvic Examination Experiences: What Clinicians Need to Know

STUDY OBJECTIVE

The aim of this study was to identify factors that influence the first pelvic exam experiences of sexual and gender minority (SGM) adolescents and young adults who were assigned female at birth (AFAB).

METHODS

Using purposive sampling, we recruited SGM AFAB individuals, ages 18-24, who had had at least 1 pelvic examination. Semi-structured interviews and an iterative approach allowed for the emergence of factors influencing the first pelvic exam experience. Items included in the final code directory had a Krippendorff's alpha intercoder reliability score greater than 0.7. Interviews were analyzed using ATLAS.ti.

RESULTS

Thirty participants completed interviews. Fourteen participants identified as bisexual, 2 as gay, 1 as lesbian, 3 as pansexual, 8 as queer, and 2 as straight/heterosexual. Sixteen participants identified as cisgender, 9 as genderqueer/gender nonconforming, and 5 as transgender. Factors influencing the first pelvic exam experience were organized as patient- or clinician-level factors. The patient-level factors of gender identity, sexual orientation, history of sexual trauma, and participant's relationship to their body were central factors influencing the exam experience. Speculum insertion during the exam induced anxiety and pain for some. The clinician-level factors of gender, age, and race or ethnicity influenced the exam experience. Most participants preferred detailed communication. Participants offered recommendations to ensure gender-affirming, patient-centered care during the first pelvic exam.

CONCLUSION

SGM AFAB individuals identified patient- and clinician-level factors influencing their first pelvic exam experiences. This study underscores the need for changes in medical education and health systems to ensure that SGM AFAB individuals have their needs met and feel comfortable in reproductive health settings.

Sexual and Gender Minority Invisibility in Cancer Studies: A Call for Effective Recruitment Methods to Address Cancer Disparities

#LGBTQ+ people with cancer are invisibilized: A call for #intersectional cancer research (link here) #healthequity

Cancer Screening for Transgender Individuals: Guidelines, Best Practices, and a Proposed Care Model

Few transgender-specific cancer screening recommendations exist. This review aims to cover current guidelines and practice patterns of cancer screening in transgender patients and, where evidence-based data are lacking, to draw from cisgender screening guidelines to suggest best practices for transgender patients based on anatomic inventory. Sufficient evidence does not exist to determine the long-term effects of gender-affirming hormone therapy on cancer risk. In the future, cancer screening and prevention should be focused on anatomic inventory and high-risk behaviors.

Understanding Sexual and Gender Minority Populations and Organ-Based Screening Recommendations for Human Papillomavirus-Related Cancers

OBJECTIVES

Sexual gender minority (SGM) populations are at risk for human papillomavirus (HPV)-related cancers of the anogenital tract and oropharynx and often face barriers to health care. The goals of this document are to clarify language to provide inclusive care for SGM populations and to provide recommendations for screening and prevention of HPV-related cancers in SGM populations.

MATERIALS AND METHODS

An expert committee convened by the American Society for Colposcopy and Cervical Pathology performed a narrative review of the literature through February 2023. A comprehensive MEDLINE database search was performed for relevant studies. The literature review was divided into categories by organ/topic and by SGM population. Given the variability in available data for several of the categories, recommendations were made based on national guidelines where appropriate or expert opinion where there were less data to support risk-based guidelines.

RESULTS

Definitions and terminology relevant to SGM populations are presented. The authors advocate the adoption of sexual orientation gender identity data collection and an organ-based screening approach, which is possible with knowledge of patient anatomy, sexual behaviors, and clinical history. This includes screening for cervical cancer per national recommendations, as well as screening for anal, vulvar, vaginal, penile, and oral cancers based on risk factors and shared clinical decision making. The authors recommend consideration of HPV vaccination in all SGM individuals up to age 45 years old who are at risk.

CONCLUSIONS

An organ-based screening approach is part of a global strategy to create an inclusive care environment and mitigate barriers to screening and prevention of HPV-mediated cancers in SGM populations.

Cost-effective, portable, patient-dedicated three-dimensional automated breast ultrasound for point-of-care breast cancer screening

Breast cancer screening has substantially reduced mortality across screening populations. However, a clinical need persists for more accessible, cost-effective, and robust approaches for increased-risk and diverse patient populations, especially those with dense breasts where screening mammography is suboptimal. We developed and validated a cost-effective, portable, patient-dedicated three-dimensional (3D) automated breast ultrasound (ABUS) system for point-of-care breast cancer screening. The 3D ABUS system contains a wearable, rapid-prototype 3D-printed dam assembly, a compression assembly, and a computer-driven 3DUS scanner, adaptable to any commercially available US machine and transducer. Acquisition is operator-agnostic, involves a 40-second scan time, and provides multiplanar 3D visualization for whole-breast assessment. Geometric reconstruction accuracy was evaluated with a 3D grid phantom and tissue-mimicking breast phantoms, demonstrating linear measurement and volumetric reconstruction errors < 0.2 mm and < 3%, respectively. The system's capability was demonstrated in a healthy male volunteer and two healthy female volunteers, representing diverse patient geometries and breast sizes. The system enables comfortable ultrasonic coupling and tissue stabilization, with adjustable compression to improve image quality while alleviating discomfort. Moreover, the system effectively mitigates breathing and motion, since its assembly affixes directly onto the patient. While future studies are still required to evaluate the impact on current clinical practices and workflow, the 3D ABUS system shows potential for adoption as an alternative, cost-effective, dedicated point-of-care breast cancer screening approach for increased-risk populations and limited-resource settings.

Clinical Performance of Cobas 6800 for the Detection of High-Risk Human Papillomavirus in Urine Samples

Testing for high-risk human papillomavirus (HPV) as part of primary cervical cancer screening has become more common recently. The Cobas 6800, an FDA-approved cervical screening platform, detects 14 high-risk HPVs, including HPV16 and HPV18. However, this test is limited to only women, which leads to low screening rates in trans men and other non-binary people. The cervical screening of trans men and other genders, especially those lying on the female-to-male spectrum, is equally important. Furthermore, cisgender males, particularly homosexuals, are also prone to chronic HPV infections and serve as HPV carriers, transmitting it to women and other men through sexual contact. Another limitation of the test is its invasive specimen collection, which induces discomfort and genital dysphoria. Therefore, there is a need for an innovative, less invasive method that would allow the sampling process to be more comfortable. In this study, we assess the performance of the Cobas 6800 for high-risk HPV detection in urine samples spiked with HPV16, HPV18, and HPV68. The limit of detection (LOD) was calculated using a dilution series (1.25-10,000 copies/mL) over a course of three days. Furthermore, the clinical validation was performed by calculating sensitivity, specificity, and accuracy. The limit of detection ranged from 50-1000 copies/mL depending upon the genotype. Moreover, the urine test demonstrated a high clinical sensitivity of 93%, 94%, and 90% for HPV16, HPV18, and HPV68, with 100% specificity. The overall percent agreement was calculated to be 95% for both HPV16 and HPV18, and 93% for HPV68. The high concordance, reproducibility, and clinical performance of the current assay suggest that the urine-based HPV test fulfills the requirements for its use in primary cervical screening. Moreover, it has the potential to be used for mass screening to not only identify high-risk individuals, but also to monitor vaccine effectiveness.

Caring for nonbinary patients

ABSTRACT

Nonbinary is an umbrella term that encompasses any person whose gender identity is outside the binary construct of man or woman . An estimated 1.2 million people in the United States identify as nonbinary, a number that most likely will continue to increase as the visibility of people who live outside binary gender increases in our society. Healthcare providers are likely to encounter nonbinary patients but may lack confidence in treating these patients appropriately. This article describes terminology, concepts, and suggestions for clinicians to provide basic respectful and competent care for nonbinary patients.

Prostate Cancer in Sexual Minorities: Epidemiology, Screening and Diagnosis, Treatment, and Quality of Life

Prostate cancer has the highest incidence among all cancers in men. Sexual minorities, including gay and bisexual men, as well as transgender, were previously a "hidden population" that experienced prostate cancer. Although there continues to remain a paucity of data in this population, analyses from studies do not reveal whether this population is more likely to endure prostate cancer. Nonetheless, several qualitative and quantitative studies have established worse quality-of-life outcomes for sexual minorities following prostate cancer treatment. Increased awareness of this previously "hidden population" among healthcare workers, as well as more research, is warranted to gain further understanding on potential disparities faced by this growing population.

Provision of cervical screening for transmasculine patients: a review of clinical and programmatic guidelines

BACKGROUND

Most cervical cancer can be prevented through routine screening. Disparities in uptake of routine screening therefore translate into disparities in cervical cancer incidence and outcomes. Transmasculine people including transgender men experience multiple barriers to cervical screening and their uptake of screening is low compared with cisgender women. Comprehensive evidence-based guidelines are needed to improve cervical screening for this group.

METHODS

We searched for and synthesised clinical and programmatic guidelines for the provision of cervical screening for transmasculine patients.

FINDINGS

The guidelines offer recommendations addressing: (1) reception, check-in and clinic facilities; (2) patient data and invitation to screening; (3) improving inclusion in screening programmes; and (4) sexual history taking, language and identity. Guidelines offer strategies for alleviating physical and psychological discomfort during cervical screening and recommendations on what to do if the screening procedure cannot be completed. Most of the guidelines were from and for high-income countries.

DISCUSSION

The evidence base is limited, but existing guidelines provide recommendations to ensure life-saving screening services are available to all who need them. We were only able to identify one set of guidelines for a middle-income country, and none for low-income countries. We encourage the involvement of transmasculine people in the development of future guidelines.

Participation, barriers, and facilitators of cancer screening among LGBTQ+ populations: A review of the literature

The LGBTQ+ community is at higher risk of certain cancers but is less likely to participate in screening programs or engage with preventive healthcare. Despite this, the barriers and facilitators to cancer screening are not well understood in this population. We conducted a literature review of research related to LGBTQ+ participation in cancer screening, as well as barriers and facilitators to participation. Following abstract and full-text screening, 50 studies were included in the final synthesis. Compared to their heterosexual counterparts, lesbian and bisexual women were less likely to participate in cervical cancer screening and mammography, but gay and bisexual men were more likely to participate in anal and colorectal cancer screening. Transgender individuals had lower rates of screening than cisgender individuals for all cancer types. Barriers to participation were found at the individual-, provider-, and administrator-level, and good communication with a healthcare provider was the strongest facilitator. These results provide reasonable first steps toward improving participation rates for LGBTQ+ populations in cancer screening. Patient-centered approaches should draw on core guiding principles to inform the provision of care, including anticipating LGBTQ+ patients, improving knowledge about care for these patients, and confronting individually-held biases that may affect care, in order to improve care experiences and participation rates in preventive services.

Lung Cancer Screening Penetration in an Urban Underserved County

PURPOSE

To compare residential geography, sex, socioeconomic status (SES), and race/ethnicity of patients screened at Montefiore's Lung Cancer Screening Program with those of patients diagnosed with lung cancer, assessing whether screening efforts are appropriately focused.

METHODS

This retrospective cohort study involved patients within a multisite urban medical center undergoing lung cancer screening or diagnosed with lung cancer from January 1, 2015 to December 31, 2019. Inclusion criteria were residence within the Bronx, NY and age between 55 and 80 years. Institutional review board approval was obtained. Data were analyzed using the Wilcoxon two-sample t test and χ².

RESULTS

The cohorts comprised 1568 (50.3%) women and 1551 (49.7%) men (mean age 65.6 ± 6.16). The Southeast Bronx had the most diagnosed lung cancers (29.96%) and screenings (31.22%). Sex did not significantly differ (p = 0.053). Cancer and screening cohorts were from impoverished neighborhoods with mean SES of - 3.11 ± 2.78 and - 3.44 ± 2.80 (p < 0.01). The lower tier SES neighborhoods demonstrated more patients in the screening cohort than cancer cohort (p = 0.01). Both cohorts included a majority of Hispanic patients, although race/ethnicity differed significantly (p = 0.01). Lower SES neighborhoods showed no significant difference in race/ethnicity between cancer and screening cohorts (p = 0.262).

CONCLUSION

Though statistically significant differences were found between cohorts, likely due to sample size, few clinically meaningful differences were found, implying our lung cancer screening program was effective in reaching the desired population. Demographics-based programs should be considered in global efforts to screen vulnerable populations.

Results from an LGBTQ+ Community Health Needs Assessment in Nassau and Suffolk Counties of New York State

LGBTQ+ individuals experience health care disparities and difficulty accessing affirming care. Little is known regarding the health and experiences among subpopulations of specific sexual orientations and gender identities (SOGI). We implemented the first LGBTQ + health needs assessment survey in Nassau and Suffolk Counties, New York, to assess individuals' health care experiences, behaviors, access to care, and health care needs. The sample (N = 1150) consisted of many SOGI subgroups. Greater than 60% of respondents reported symptoms of chronic depression; over one third reported disrespectful health care experiences; and two thirds experienced verbal harassment. Bisexual/bicurious, pansexual, queer, gender nonconforming and transgender individuals experienced highest rates of mental health concerns and difficulty accessing care. Behavioral health concerns were also high among Black, multiracial, Hispanic, Asian, young adult, and lower-income respondents. Gaining an understanding of unique differences among LGBTQ+ subgroups can guide implementation of services targeting specific subpopulations to improve access to care and reduce disparities.

Cancer in Transgender and Gender-Diverse Persons: A Review

Importance

Transgender and gender-diverse individuals face unique challenges, including barriers to health care access and inequities in treatment, that may influence cancer risk and outcomes.

Observations

In this narrative review, a scoping review was conducted focusing on primary and secondary prevention and epidemiology of cancer, barriers to health care services, and health care practitioners' knowledge about specific issues pertaining to transgender and gender-diverse individuals. PubMed, the Cochrane Library, and Embase, were reviewed for citations from their inception to December 31, 2021. This review revealed that transgender and gender-diverse people had a high prevalence of tobacco consumption and alcohol use and high rates of infection with human papillomavirus (HPV) and HIV. Transgender and gender-diverse individuals were less likely to adhere to cancer screening programs and had a higher incidence of HIV- and HPV-associated cancers. Social and economic determinants seemed to drive these disparities in risk factors and outcomes. A lack of knowledge about gender minorities' health needs among health care practitioners was evidenced, and it represented a major hurdle to cancer prevention, care, and survivorship for transgender and gender-diverse individuals. Discrimination, discomfort caused by gender-labeled oncological services, stigma, and lack of cultural sensitivity of health care practitioners were other barriers met by transgender and gender-diverse persons in the oncology setting.

Conclusions and Relevance

The findings suggest that transgender and gender-diverse peoples' needs in the cancer care continuum are not optimally addressed. Effective solutions are needed to offer the best care to every patient in a person-centric and gender diversity-sensitive environment.

Factors Associated with Unsatisfactory Pap Tests Among Sexually Active Trans Masculine Adults

Purpose: Unsatisfactory collection of cells during Papanicolaou (Pap) tests prevents the detection of cervical cancer and dysplasia. Prior research found that trans masculine (TM) individuals are significantly more likely than cisgender women to have an unsatisfactory Pap test. The purpose of this study was to identify factors that place some TM individuals at greater risk for an unsatisfactory Pap test than others. Methods: Between 2015 and 2016, 150 TM adults were enrolled in a cross-sectional survey assessing demographics, health characteristics, health care experiences, trauma history, and unsatisfactory Pap test history. Bivariate and multivariable logistic regression analyses conducted in 2020 examined associations between age, length of time on testosterone, smoking history, having to educate a provider about transgender people to receive appropriate care, anticipated health care stigma, post-traumatic stress disorder (PTSD) symptoms, and lifetime history of unsatisfactory Pap tests. Results: Of all participants, 20.2% had an unsatisfactory test in their lifetime, age ranged from 21 to 50 years, 55.1% used testosterone for 1 year or more, and 41.3% had PTSD symptoms. In the multivariable model, older age (adjusted odds ratio [AOR] = 1.15; 95% confidence interval (CI) = 1.04-1.27; p < 0.01), 1 year or more lifetime testosterone use (AOR = 3.51; 95% CI = 1.02-12.08; p = 0.046), and PTSD symptoms (AOR = 3.48; 95% CI = 1.10-11.00, p = 0.03) were significantly associated with increased odds of having an unsatisfactory Pap test. Conclusions: Older age, testosterone use, and PTSD symptoms are associated with lifetime unsatisfactory Pap tests among TM adults. Clinicians should assess TM patients' trauma and testosterone use history before Pap tests and utilize trauma-informed practices that facilitate the collection of adequate Pap samples.

Culturally safe, appropriate, and high-quality breast cancer screening for transgender people: A scoping review

Background

There is a recognized need for evidence to inform breast cancer screening guidelines and services for transgender people, who face barriers to accessing appropriate and inclusive health care.

Aims

This review summarized evidence for breast cancer risk and screening guidelines in transgender individuals, including the potential impact of gender-affirming hormone therapy (GAHT); factors that may influence screening decision-making and behaviors; and considerations for providing culturally safe, high-quality screening services.

Methods

A protocol was developed based on the Joanna Briggs Institute scoping review methodology. Searches were performed in Medline, Emcare, Embase, Scopus, and the Cochrane Library for articles reporting information on the provision of culturally safe, high-quality breast cancer screening services for transgender people.

Results

We identified 57 sources for inclusion: 13 cross-sectional studies, 6 case reports, 2 case series, 28 review or opinion articles, 6 systematic reviews, 1 qualitative study, and 1 book chapter. Evidence on rates of breast cancer screening among transgender people and the association between GAHT and breast cancer risk was inconclusive. Factors negatively associated with cancer screening behaviors included socioeconomic barriers, stigma, and lack of health provider awareness of transgender health issues. Breast cancer screening recommendations varied and were generally based on expert opinion due to the lack of clear evidence. Considerations for providing culturally safe care to transgender people were identified and mapped to the areas of workplace policies and procedures, patient information, clinic environment, professional conduct, communication, and knowledge and competency.

Discussion

Screening recommendations for transgender individuals are complicated by the lack of robust epidemiological data and clear understanding of the role GAHT may play in breast cancer pathogenesis. Guidelines have been developed based on expert opinion and are subsequently not uniform or evidence based. Further work is required to clarify and consolidate recommendations.

Community-generated solutions to cancer inequity: recommendations from transgender, non-binary and intersex people on improving cancer screening and care

Objective

Transgender, non-binary and intersex people are less likely to receive appropriate cancer screening for their bodies and have a higher incidence of certain cancers than cisgender people. We aimed to elicit community-generated solutions to improve cancer screening for these populations.

Methods and analysis

We conducted six online, asynchronous focus groups in English and Spanish with transgender, non-binary, intersex and cisgender participants who were at least 15 years of age from across the USA. Participants shared their experiences with cancer screening and related conversations with healthcare providers and recommendations for making screening practices more inclusive of their bodies and experiences. Focus group data were exported into transcripts and analysed with thematic analysis.

Results

The 23 participants represented a diversity of races, genders, sexualities, ages and geographical locations. Transgender, non-binary and intersex participants, particularly Black, Indigenous and/or people of colour, reported having to self-advocate to receive necessary care by initiating conversations about screening with their providers, requesting specific screenings and educating providers about the appropriate care for their body. Notably, no white or cisgender participants described having to request relevant screenings or initiate conversations with their providers. Participants recommended that forms ask about body parts and allow for self-identification.

Conclusion

The ability to properly screen patients can have a direct impact on cancer outcomes. More inclusive intake forms may alleviate the need for transgender, non-binary and intersex patients to self-advocate to receive necessary care. More work should be done to educate providers on cancer risk for transgender, non-binary and intersex individuals.

Prostate-Specific Antigen Screening in Transgender Patients

CONTEXT

Approximately 0.4-1.3% of the worldwide population is transgender. Although the exact prevalence is unknown, there is an increase in open identification as transgender. Among transgender women (TW), the prostate is retained even after gender-affirmation surgery, thus necessitating ongoing screening for prostate cancer (CaP). However, little is known about CaP screening in this population.

OBJECTIVE

To assess our current understanding of CaP incidence and prostate-specific antigen (PSA) screening in TW.

EVIDENCE ACQUISITION

We performed a nonsystematic narrative review of all PubMed publications through June 2022 according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. Given the limited primary research on this subject, case reports were also included. Studies were reviewed to understand PSA screening practices and reports of CaP in this population, as applicable.

EVIDENCE SYNTHESIS

There is no consensus regarding PSA screening in TW from any of the major societies, and TW are largely absent from guidelines. Case report data suggest that TW with CaP may have more aggressive disease, and these cancers may have been pre-existing prior to present before gender-affirming hormone therapy (GAHT) or be castrate-resistant.

CONCLUSIONS

We are in the infancy of our understanding of PSA screening in TW. Important avenues for future research include understanding the risks/benefits of PSA screening in TW, how best to mitigate potential negative psychological effects of PSA screening in TW, establishing baseline PSA values for those on GAHT (and determining what values should be considered "elevated"), establishing when to initiate PSA screening for those on GAHT, and establishing the accuracy of biomarkers for those undergoing GAHT.

PATIENT SUMMARY

We examined patterns of prostate cancer screening for transgender women. Little is known about prostate cancer incidence or screening in this population. Additional research is needed to establish guidelines for screening in this population.

Patient-reported discrimination among limited-resourced cancer survivors: a brief report

PURPOSE

Healthcare discrimination has been associated with health disparities including lower cancer screenings, higher medical mistrust, and strained patient-provider relationships. Our study sought to understand patient-reported discrimination among cancer survivors with limited resources living in the United States.

DESIGN AND METHODS

We used cross-sectional survey data distributed by the Patient Advocate Foundation (PAF) in 12/2020 and 07/2021. Respondents reported source and reason of healthcare discrimination. Age, sex, race and ethnicity, annual household income, Rural-Urban Commuting Area (RUCA), Area Deprivation Index (ADI), employment status, cancer type, and number of comorbidities were independent variables of interest. The association between these variables and patient-reported healthcare discrimination was estimated using risk ratios (RRs) and 95% confidence intervals (CIs) from a multivariable modified Poisson regression model with robust standard errors.

FINDINGS

A total of 587 cancer survivors were included in our analysis. Most respondents were female (72%) and aged ≥56 (62%); while 33% were Black, Indigenous, or Person of Color. Overall, 23% reported receipt of discrimination, with the majority reporting doctor, nurse, or healthcare provider as the source (58%). Most common reasons for discrimination included disease status (42%), income/ability to pay (36%), and race and ethnicity (17%). In the adjusted model, retired survivors were 62% less likely to report discrimination compared to those employed (RR 0.38; 95% CI 0.23-0.64). Additionally, survivors with ≥3 comorbidities were 86% more likely to report discrimination compared to those survivors with no non-cancer comorbidities (RR 1.86; 95% CI 1.26-2.72).

IMPLICATIONS

Cancer survivors with limited resources reported substantial discrimination most often from a healthcare provider and most commonly for disease status and income. Discrimination should be mitigated to provide equitable and high-quality cancer care.

Cervicovaginal cytology, HPV testing and vaginal flora in transmasculine persons receiving testosterone

BACKGROUND

Testosterone is one of the strategies that transmasculine persons can elect in order to align physical traits to their gender identity. Previous studies have shown morphologic changes in the genital tract associated with testosterone. Here, we aim to evaluate cervicovaginal cytology specimens (Pap tests) and high-risk HPV (HR-HPV) testing from transmasculine individuals receiving testosterone.

METHODS

This is a retrospective cohort of 61 transmasculine individuals receiving testosterone from 2013 to 2021. Cytologic diagnoses from 65 Pap tests were correlated with HPV status and histologic follow-up and compared with the institutional data and a cohort of cisgender women with atrophic changes.

RESULTS

The median age was 28 years and median time of testosterone use was 3 years. Transmasculine persons showed significantly higher rates of HSIL (2%) and unsatisfactory (16%) when compared with the institutional data and atrophic cohort of cisgender women. After reviewing slides of 46 cases, additional findings were noted: atrophy was present in 87%, glycogenated cells were seen in 30%, and Lactobacilli were substantially decreased in 89%. Among 32 available HPV tests, 19% were positive for HR-HPV and 81% were negative. On histologic follow-up, all HR-HPV-positive cases with abnormal cytology showed HSIL, while none of the HPV-negative cases revealed HSIL.

CONCLUSION

Our study cohort demonstrated a high percentage of abnormal Pap tests in transmasculine persons receiving testosterone. Testosterone seems to induce changes in squamous cells and shifts in vaginal flora. HR-HPV testing can be a useful adjunct in the workup of abnormal Pap tests from transmasculine individuals.

The state of PSA counseling in male-to-female transgender patients in the U.S

BACKGROUND

Morbidity and mortality from prostate cancer (PCa) are known to vary heavily based on socioeconomic and demographic risk factors. We sought to describe prescreening PSA (prostate-specific antigen) counseling (PPC) rates amongst male-to-female transgender (MtF-TG) patients and non-TG patients using the behavioral risk factor surveillance system (BRFSS).

METHODS

We used the survey data from 2014, 2016, and 2018 BRFSS and included respondents aged 40-79 years who completed the "PCa screening" and "sexual orientation and gender identity" modules. We analyzed differences in age, education level, income level, marital status, and race/ethnicity using Pearson's χ² tests. The association of PPC with MtF-TG status and other patient characteristics was evaluated using multivariate logistic regression.

RESULTS

A total of 175,383 respondents were included, of which 0.3% identified as MtF-TG. Overall, 62.4% of respondents reported undergoing PPC. On univariate analysis, PPC rates were lower among MtF-TG respondents when compared to the non-TG group (58.3% vs. 62.4%, p = 0.03). MtF-TG respondents were also more likely to report lower education level (p < 0.01), lower-income level (p < 0.01), and were less likely to be white (p < 0.01) than non-TG respondents. However, multivariate analysis adjusting for these respondent features demonstrated an association between higher income and higher education levels with increased odds of PPC, but no association was demonstrated between MtF-TG status and PPC rates. PPC rates for the MtF-TG and non-TG populations did not change significantly over time.

CONCLUSIONS

Although PPC was less frequently reported among MtF-TG respondents than in the non-TG group on univariate analysis, this association was not demonstrated when controlling for confounders, including education and income levels. Instead, on multivariate analysis, low education and income levels were more predictive of PPC rates. Further research is needed to ensure equivalent access to prescreening counseling for patients across the socioeconomic and gender identity spectrum.

Sexual healthcare experiences of nonbinary young adults

Nonbinary young adults (who do not identify with a binary male or female identity and may hold diverse gender identities, including genderqueer, nonbinary and agender) may have unique and unmet sexual healthcare needs compared to binary transgender and cisgender people. However, there is limited knowledge about the sexual health and healthcare needs of nonbinary young adults. We conducted 19 semi-structured, in-depth interviews between August and November 2018 with nonbinary people aged 18-30 years in New England. Interview topics included experiences accessing sexual healthcare and engaging in sexual activity. Interviews were transcribed and transcripts were analysed using inductive and deductive thematic analysis. Three main themes were identified. First, participants described barriers to accessing high-quality sexual healthcare at both the interpersonal and institutional level. Second, participants employed strategies to meet their sexual healthcare needs despite encountering barriers. Third, participants articulated the ways nonbinary gender identities affect sexual relationships, with implications for sexual health. These findings underscore the need for research and advocacy - in collaboration with nonbinary persons themselves - to develop best practices to meet the sexual healthcare needs and advance the sexual health of nonbinary young people.

“I need more knowledge”: Qualitative analysis of oncology providers’ experiences with sexual and gender minority patients

Background

While societal acceptance for sexual and gender minority (SGM) individuals is increasing, this group continues to face barriers to quality healthcare. Little is known about clinicians’ experiences with SGM patients in the oncology setting. To address this, a mixed method survey was administered to members of the ECOG-ACRIN Cancer Research Group.

Materials and methods

We report results from the open-ended portion of the survey. Four questions asked clinicians to describe experiences with SGM patients, reservations in caring for them, suggestions for improvement in SGM cancer care, and additional comments. Data were analyzed using content analysis and the constant comparison method.

Results

The majority of respondents noted they had no or little familiarity with SGM patients. A minority of respondents noted experience with gay and lesbian patients, but not transgender patients; many who reported experience with transgender patients also noted difficulty navigating the correct use of pronouns. Many respondents also highlighted positive experiences with SGM patients. Suggestions for improvement in SGM cancer care included providing widespread training, attending to unique end-of-life care issues among SGM patients, and engaging in efforts to build trust.

Conclusion

Clinicians have minimal experiences with SGM patients with cancer but desire training. Training the entire workforce may improve trust with, outreach efforts to, and cancer care delivery to the SGM community.

Gender- and Sexual Orientation- Based Inequities: Promoting Inclusion, Visibility, and Data Accuracy in Oncology

Sexual and gender minority (SGM) people, including agender, asexual, bisexual, gay, gender diverse, genderqueer, genderfluid, intersex, lesbian, nonbinary, pansexual, queer, and transgender people, comprise approximately 10% or more of the U.S. population. Thus, most oncologists see SGM patients whether they know it or not. SGM people experience stigma and structural discrimination that lead to cancer disparities. Because of the lack of systematic and comprehensive data collection, data regarding SGM cancer incidence, outcomes, and treatment responses are limited. Collection of data regarding sexual orientation, gender identity, transgender identity and/or experience, anatomy, and serum hormone concentrations in oncology settings would drastically increase collective knowledge about the impact of stigma and biologic markers on cancer outcomes. Increasing the safety of oncology settings for SGM people will require individual, institutional, and systems changes that will likely improve oncologic care for all patients.

Disparities in Screening for Colorectal Cancer Based on Limited Language Proficiency

BACKGROUND

This study analyzes the association between limited language proficiency and screening for colorectal cancer.

METHODS

This is a retrospective cohort study from the 2015 sample of the National Health Interview Survey database utilizing univariate and multivariate regression analysis. The study population includes subjects between 50 and 75 years of age. The main outcome analyzed was rates of screening colonoscopies between limited English-language proficiency (LEP) subjects and those fluent in English. Secondary outcomes included analysis of baseline, socioeconomic, access to health care variables, and other modalities for colorectal cancer screening between the groups.

RESULTS

Incidence of limited language proficiency was 4.8% (n = 1978, count = 4 453 599). They reported lower rates of screening colonoscopies (61% vs 34%, P < .001), less physician recommendation for a colonoscopy (87 vs 60%, P < .001), fewer polyps removed in the previous 3 years (24% vs 9.1%; P < .001), and fewer fecal occult blood samples overall (P < .001). Additionally, Hispanic non-LEP subjects have higher rates of colonoscopies compared to those with language barriers (50% vs 33%, P < .001). On multivariate analysis, LEP was associated with a lower likelihood to have a screening colonoscopy (OR .67 95% CI .49-.91). A second regression model with "Spanish language" and "other language" variables included, associated Spanish speakers with a lower likelihood for a screening colonoscopy (OR .71 95% CI .52-.97) when controlling for baseline, socioeconomic, and access to health care covariates.

DISCUSSION

Patients with limited English-language proficiency are associated with lower rates of screening for colorectal cancer, in particular the Spanish speaking subgroup.

Citizenship and Social Responsibility in Surgery: A Review

Importance

Social determinants of health have been shown to be key drivers of disparities in access to surgical care and surgical outcomes. Though the concept of social responsibility has received growing attention in the medical field, little has been published contextualizing social responsibility in surgery. In this narrative review, we define social responsibility as it relates to surgery, explore the duty of surgeons to society, and provide examples of social factors associated with adverse surgical outcomes and how they can be mitigated.

Observations

The concept of social responsibility in surgery has deep roots in medical codes of ethics and evolved alongside changing views on human rights and the role of social factors in disease. The ethical duty of surgeons to society is based on the ethical principles of benevolence and justice and is grounded within the framework of the social contract. Surgeons have a responsibility to understand how factors such as patient demographics, the social environment, clinician awareness, and the health care system are associated with inequitable patient outcomes. Through education, we can empower surgeons to advocate for their patients, address the causes and consequences of surgical disparities, and incorporate social responsibility into their daily practice.

Conclusions and Relevance

One of the greatest challenges in the field of surgery is ensuring that surgical care is provided in an equitable and sustainable way. Surgeons have a duty to understand the factors that lead to health care disparities and use their knowledge, skills, and privileged position to address these issues at the individual and societal level.

Perceptions of and barriers to cancer screening by the sexual and gender minority community: a glimpse into the health care disparity

PURPOSE

A disparity exists in cancer screening rates for the Sexual and Gender Minority (SGM) community. We sought to understand the perceptions and baseline knowledge of cancer screening among SGM community members.

METHODS

Survey administered via social media from June 2018 to October 2018. We asked 31 questions focused on cancer screening, human papillomavirus, emotional distress, and experience with the health care system. Those included were 18 years or older. Cancer screening attitudes and knowledge, as well as perceptions of the health care system were investigated.

RESULTS

There were 422 respondents analyzed: 24.6% identified as female, 25.5% as male, 40.1% transgender, and 9.6% as other. 65.4% of the SGM community is not certain what cancer screening to do for themselves. Only 27.3% and 55.7% knew that HPV was a risk factor associated with head and neck cancer and anal cancer, respectively. Half stated their emotional distress prevents them from getting cancer screening. It was identified that process changes in making appointments, comforts during the visit, and formal training for physicians and nurses could increase cancer screening compliance for this community. The transgender population had a trend in more gaps in knowledge of appropriate cancer screening and significant excess emotional distress.

CONCLUSION

Gaps in cancer screening knowledge and emotional and financial distress may be responsible for the disparity of lower cancer screening rates for the SGM population and the transgender population may be most at risk. Appreciating the cancer screening concerns of the SGM population can help shape future clinical and institutional approaches to improve health care delivery.

Boys Don't Cry: Examining Sex Disparities in Behavioral Oncology Referral Rates for AYA Cancer Patients

Psychosocial distress is highly prevalent in cancer patients, approaching rates around 40% across various cancer sites according to multicenter studies. As such, distress screening procedures have been developed and implemented to identify and respond to cancer patients' psychosocial distress and concerns. However, many cancer patients continue to report unmet psychosocial needs suggesting gaps in connecting patients with psychosocial services. Presently, there is a paucity of research examining sex-based disparities in referral rates to behavioral oncology services, particularly for adolescent and young adult (AYA) cancer patients. Informed by gender role conflict and empirical literature documenting disparities in cancer care and treatment based on a variety of sociocultural variables, this study aimed to examine the presence of sex disparities in referral rates to behavioral oncology services for AYA cancer patients. Data for this study consisted of 1,700 AYA cancer patients (age 18–39) who completed a distress screening at a large cancer center of a teaching hospital in the Midwestern United. Results indicated that patient sex significantly predicted the odds of behavioral oncology referral (γ₅₀ = −0.95, Odds ratio = 2.60, p < 0.001). This finding indicates that female AYA cancer patients are 2.5 times more likely to be referred to behavioral oncology services compared to male AYA cancer patients after controlling for psychosocial distress and emotional, family, and practical problems. Additionally, we found that emotional problems significantly moderated the odds of referral for males and females (γ₆₀ = 0.37, Odds ratio = 1.44, p < 0.001), however the odds of referral for males who endorsed emotional problems were lower than males who did not endorse emotional problems. This contrasted with female AYA cancer patients where the endorsement of emotional problems increased the odds of referral to behavioral oncology services. Findings are discussed with particular focus on how to enhance equitable care and reduce sex and other sociocultural-based disparities in AYA psychosocial oncology.

Recruiting an underserved, difficult to reach population into a cancer trial: Strategies from the Restore-2 Rehabilitation Trial for gay and bisexual prostate cancer patients

BACKGROUND/AIMS

Sexual minorities are small and under-researched populations that are at disproportionate risk for cancer and poor cancer outcomes. Described as a "hidden population," the principal research challenge has been to develop effective methods to identify and recruit such cancer patients into cancer studies. Online recruitment strategies, as well as targeted clinic recruitment using patient-entered sexual orientation and gender identity data from electronic medical records have potential to transform recruitment, but studies testing the effects of how to recruit using these have not been published.

METHODS

In 2019, we conducted a naturalistic, three-arm, stratified prospective study to compare three recruitment strategies: (a) clinic based recruitment of prostate cancer patients from gay health and urology clinics; (b) directly from the gay community; and (c) online recruitment (through cancer support, sex/dating, and social sites). For each strategy, we estimated time, workload, and direct costs involved. To study how recruitment strategy may affect sampling, we tested for retention rates, demographic and outcome differences across sites. Using these methods, we successfully recruited 401 gay and bisexual prostate cancer patients into a randomized, controlled, 24-month trial testing an online sexual and urinary rehabilitation curriculum tailored for this population.

RESULTS

There were seven key results. First, it is possible to recruit substantial numbers of sexual minority men into prostate cancer studies provided online recruitment methods are used. Second, we observed big differences in dropout during study onboarding by recruitment source. Third, within online recruitment, the online sex/dating application (app) was the most successful and efficient, followed by the cancer support site, and then the social networking site. Fourth, while clinics were the cheapest source of recruitment, they were time intensive and low in yield. Fifth, the cancer support site and sex/dating app recruits differed by several characteristics, with the former being more rehabilitation-focused while the latter were younger and more sexually active. Sixth, we found almost no differences in outcomes across the three online recruitment sites. Seventh, because retention in online studies has been a concern, we confirm very low attrition at 3- and 6 months into the trial.

CONCLUSION

For sexual minority cancer research, more research on how to use sexual orientation and gender identity electronic medical record data for clinic-based recruitment is needed. For other small or hard-to-reach populations, researchers should compare and publish online versus offline recruitment strategies.

Breast and Cervical Cancer Screening Disparities in Transgender People

OBJECTIVES

The population of individuals who identify as transgender (TG) is increasing in the United States, yet disparities in cancer screening services are widening. It is imperative that interpersonal and systemic barriers to cancer care are identified and removed for this vulnerable population. Our study sought to examine the difference in self-reported breast and cervical cancer screening rates between TG and cisgender (CG) people.

MATERIALS AND METHODS

Cross-sectional data from the 2014 to 2016 and 2018 Behavioral Risk Factor Surveillance System (BRFSS) was obtained on individuals who identified as CG or TG (male-to-female [MTF] and female-to-male [FTM]), including their responses to questions regarding breast and cervical screening history and their primary care access and associated barriers.

RESULTS

Compared with the CG population, TG participants were less likely to adhere to or have undergone breast (FTM: odds ratio [OR] 0.47 and 0.32; MTF: OR 0.04 and 0.02, respectively; all P<0.001) and cervical cancer (FTM: OR 0.42 and 0.26, respectively; all P<0.001) screening. They were also less likely to have a primary care physician (FTM: OR 0.79; MTF: OR 0.58; all P<0.001) and less likely to seek primary care within a year owing to medical costs (FTM: OR 1.44; MTF: OR 1.36; all P<0.001).

CONCLUSIONS

Disparities exist in the uptake of routine cancer screening in the TG population despite their increased risk for breast and cervical cancer. Interventions are urgently needed to mitigate delays to cancer screening, close gaps in provider and patient knowledge about cancer screening, and improve health care experiences of gender minorities in the United States.