Transgender patients: considerations for routine gynecologic care and cancer screening

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.

Gynecologic health care for LGBTQIA+ people

Gender relations are a set of socially determined norms and rules that assign values, characteristics, and expectations to individuals based on their biological sex. These aspects also influence the clinician-patient relationship, since it has been for a long time based on cisheteronormativity. However, this attitude alienated the LGBTQIA+ community from health services. Global and specific gynecologic care needs to be offered to the LGBTQIA+ population, which has demands for sexual and reproductive health care. In this narrative review, we bring conceptual aspects, gender identity and expression, sexual history, screening for cancer and other care to the community.

Using AI and Social Media to Understand Health Disparities for Transgender Cancer Care

This qualitative study used an artificial intelligence (AI) large language model and social media to investigate challenges encountered by transgender individuals during breast and gynecological cancer care.

Review of Breast Imaging in Transgender and Gender-Diverse Patients: Gender-Affirming Care, Histopathologic Findings, Breast Cancer Risk, and Screening Recommendations

Gender diversity, especially pertaining to transgender and gender-diverse (TGD) populations, is often stigmatized. A small but not insignificant number of adults in the United States identify as TGD, including transgender, nonbinary, and other gender identities than cisgender. Accessing health care remains a significant challenge for TGD individuals because many health care systems adhere to a gender binary model and many TGD individuals experience negative interactions when interfacing with health care. There is also a scarcity of literature addressing their unique health care needs, limiting our current understanding of breast cancer risks and screening recommendations for TGD patients. This article reviews important considerations when providing care to TGD patients. It covers background information on gender identity and sexuality, explores gender-affirming care, discusses histopathologic findings of breast biopsy specimens, examines breast cancer risks, and presents current breast cancer screening recommendations for TGD patients. Education on TGD breast cancer risks and screening and creating a standardized screening protocol for TGD patients who may receive gender-affirming care through hormonal and surgical therapies could help improve their health care equity and access.

Breast Cancer Screening Referral Patterns and Compliance in Transgender Male Patients

Purpose

Screening guidelines for breast cancer (BC) in transgender male (TM) patients are not well defined. This study describes referral patterns and compliance with referral for BC screening among TM patients receiving care at a tertiary care center.

Methods

This was a retrospective cohort study of TM patients, 40-74 years of age, presenting for care between 2017 and 2020. The electronic medical record was queried for medical history and cancer screening data. Compliance with referral and screening was defined as occurring within 2 years of when screening would be expected.

Results

Of the 266 patients identified, 45 met inclusion criteria. One (2.2%) had a history of BC, 0 (0%) had hereditary BC risk, and 11 (24.4%) had a family history of BC. Of the patients, 18 (40%) were referred for BC screening, of whom 13 (72.2%) were compliant with screening. Ten (55.6%) were referred by a primary care provider, 2 (11.1%) were referred by a transgender medicine specialist, and 6 (33.3%) were referred by both. Of the cohort, 27 (60%) had undergone masculinizing mastectomy. Six (22.2%) of these patients were referred for screening, of whom 0 (0%) had pre-screening clinical findings indicating need for screening. Of the 18 (40%) patients who had not undergone masculinizing mastectomy, 12 (66.7%) were referred for BC screening.

Conclusions

There was heterogeneity in referral patterns for BC screening between TM patients who had undergone masculinizing mastectomy and those who had not. BC screening guidelines should be established for TM patients who have undergone masculinizing mastectomy.

Treatment patterns and outcomes for primary uterine leiomyosarcoma with synchronous isolated lung metastases: A National Cancer Database study of primary resection and metastasectomy

Background

One third of patients with uterine leiomyosarcomas (uLMS) present with distant metastases. Current guidelines do not include recommendations around surgery for metastatic uLMS. Patients with distant metastases commonly receive primary tumor resection for symptoms and so oncologic outcomes after surgery warrant exploration. We describe treatment patterns and outcomes for uLMS patients with synchronous isolated lung metastases (SILM).

Methods

This retrospective analysis of the National Cancer Database identified patients with uLMS and SILM. Patients with non-pulmonary metastases were excluded. We collected demographic, disease, and treatment characteristics and assessed clinicopathologic factors associated with the receipt of surgery on multivariate regression. Median, 1-year, and 5-year overall survival (OS) across treatment approaches were compared using Kaplan-Meier curves and log-rank tests. Multivariate Cox proportional hazard regressions identified independent predictors of survival.

Results

We identified 905 patients with uLMS and SILM between 2004 and 2017. 600 patients had primary tumor resection; 63 also had curative intent surgery with metastasectomy. Patients who did not receive chemotherapy were older (p<0.01) with a higher comorbidity index (p<0.05). Women with private health insurance were more likely to receive chemotherapy (p<0.01) and primary tumor resection (p<0.01). Patients who underwent curative intent surgery had 1-year OS of 71.2% and 5-year survival of 18% compared to 1-year survival of 35.6 % and 5-year survival of 5.16 % for patients who had no surgery. Black women had poorer survival on multivariate regression.

Conclusions

Primary tumor resection and curative intent surgery are associated with improved OS in uLMS with SILM and may be a reasonable treatment option in appropriately selected patients.

Breast care considerations for transgender and gender-diverse patients

Transgender and gender-diverse (TGD) persons represent a small but growing population in the United States. Accessing inclusive, equitable, and evidence-based healthcare remains a challenge for this patient population. Many TGD persons seek gender-affirming care, including gender-affirming hormonal therapy (GAHT) and gender-affirming surgery (GAS), to help ameliorate the physical and mental aspects of their gender incongruence. Both GAHT and GAS induce clinically important histopathologic and anatomic changes in breast tissue. Consequently, breast care in TGD persons has become an increasingly recognized topic of importance in gender-affirming care. However, there remains a scarce but growing base of literature specifically addressing the unique healthcare needs of breast care in TGD patients. This article will review how to establish trusting patient-provider relationships for TGD patients, gender inclusivity in breast clinics and imaging centers, the influence of GAHT and GAS on breast tissue, breast cancer screening recommendations and barriers, and breast cancer risk and treatment considerations in TGD persons.

Self-Reported Sexual Behavior of Transgender Youth

INTRODUCTION

Research indicates transgender/gender diverse (TGD) youth are more likely to engage in sexual behavior, have more sexual partners, and initiate sexual behavior earlier than their cisgender peers. However, no gender-inclusive self-report survey questionnaires (i.e., those that do not assume the gender of sexual partners or body parts used for sex) exist to assess sexual behavior of TGD youth. The current study illustrates a questionnaire with nuanced wording to more accurately portray the sexual behavior of TGD youth presenting for gender-affirming medical care compared to national adolescent norms.

METHODS

Retrospective chart review of 323 youth, ages 13-18, presenting to a pediatric gender clinic between 2015-2021. Youth self-reported their gender identity (i.e., masculine, feminine, gender queer, questioning/unsure), sexual behaviors, and partners via a REDCAP survey.

RESULTS

Rates of dating among TGD youth were significantly lower than national norms (33.7% v 68.3%; X2=172.644, p< 0.0001), as was sexual behavior (14.9% vs. 39.5% X2=80.419, p< 0.0001). Rates of self-reported involuntary sexual activity among TGD youth did not differ significantly from national norms (7.1% vs. 6.9%, ns). Body parts used for sex, the number of sexual partners, and the gender identity of sexual partners are reported.

DISCUSSION

Results suggest that rates of dating and sexual behavior among TGD youth are significantly lower than national norms, supporting a need for screening of sexual health among TGD youth utilizing gender-inclusive measures. A standardized gender-inclusive questionnaire of sexual behavior is needed to improve data accuracy and help develop inclusive programs to address the sexual health needs of TGD youth.

Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of gynecologic cancer

Advanced gynecologic cancers have historically lacked effective treatment options. Recently, immune checkpoint inhibitors (ICIs) have been approved by the US Food and Drug Administration for the treatment of cervical cancer and endometrial cancer, offering durable responses for some patients. In addition, many immunotherapy strategies are under investigation for the treatment of earlier stages of disease or in other gynecologic cancers, such as ovarian cancer and rare gynecologic tumors. While the integration of ICIs into the standard of care has improved outcomes for patients, their use requires a nuanced understanding of biomarker testing, treatment selection, patient selection, response evaluation and surveillance, and patient quality of life considerations, among other topics. To address this need for guidance, the Society for Immunotherapy of Cancer (SITC) convened a multidisciplinary panel of experts to develop a clinical practice guideline. The Expert Panel drew on the published literature as well as their own clinical experience to develop evidence- and consensus-based recommendations to provide guidance to cancer care professionals treating patients with gynecologic cancer.

Uptake, experiences and barriers to cervical screening for trans and non-binary people in Aotearoa New Zealand

Little is known about experiences and barriers for trans and non-binary (TGNB) people eligible for cervical screening in Aotearoa New Zealand.

AIMS

To identify uptake, barriers and reasons for delaying cervical cancer screening among TGNB people in Aotearoa.

MATERIALS AND METHODS

The 2018 Counting Ourselves data on TGNB people assigned female at birth aged 20-69 years who had ever had sex, were analysed to report on experiences of those who were eligible for cervical screening (n = 318). Participants answered questions about whether they had taken part in cervical screening and reasons behind any delays in receiving the test.

RESULTS

Trans men were more likely than non-binary participants to report that they did not require cervical screening or were unsure if they needed it. For those who had delayed cervical screening, 30% did so due to feeling worried about how they would be treated as a trans or non-binary person and 35% due to another reason. Other reasons for delay related to general and gender-related discomfort, previous traumatic experiences, anxiety or fear of the test and pain. Material barriers to access included cost and lack of information.

CONCLUSIONS

The current cervical screening program in Aotearoa does not consider the needs of TGNB people, leading to delayed and reduced uptake of cervical screening. Health providers require education on the reasons TGNB people delay or avoid cervical screening in order to provide appropriate information and affirmative healthcare environments. The human papillomavirus self-swab may address some of the existing barriers.

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.

Determining the Sex Assigned at Birth of Transgender and Nonbinary Populations in Administrative Claims Databases Utilizing Diagnostic and Procedure Codes

Purpose

Widespread conflation of sex assigned at birth and gender has hindered the identification of transgender and nonbinary people in large datasets. The study objective was to develop a method of determining the sex assigned at birth of transgender and nonbinary patients utilizing sex-specific diagnostic and procedural codes, for future use in administrative claims databases, with a goal of expanding the available datasets for exploring sex-specific conditions among transgender and nonbinary people.

Methods

Authors reviewed indexes of International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes, and medical record data from a single institution's gender-affirming clinics. Sex-specific ICD and CPT codes were identified through author review and consultation with subject experts. Patient's sex assigned at birth determined by chart review, as a gold standard, was compared with sex assigned at birth determined by querying their electronic health records for natal sex-specific codes.

Results

Sex-specific codes correctly identified 53.5% (n=364) of transgender and nonbinary patients assigned female sex at birth, and 17.3% (n=108) of those assigned male sex at birth. Codes were 95.7% and 98.3% specific for assigned female and male sex at birth, respectively.

Conclusions

ICD and CPT codes can be used to specifically determine the sex assigned at birth in databases where this information is not recorded. This methodology has novel potential for use in exploring sex-specific conditions among transgender and nonbinary patients in administrative claims data.

A case of endometrial intraepithelial neoplasia in a transgender man on testosterone therapy

•

Reports of endometrial cancer in transmasculine individuals taking testosterone are rare.

•

The relationship between testosterone therapy and endometrial cancer requires further study.

•

Studies of hormone receptor positive cancers are needed to assess the prevalence of and risk factors for gynecologic cancers in transmasculine individuals on testosterone therapy.

Testosterone is commonly used as gender-affirming therapy to induce masculinization in transmasculine individuals. The effects of testosterone therapy on endometrial tissue are complex, and while some patients experience endometrial atrophy while taking testosterone, others do not. Reports of gynecologic malignancies, and endometrial cancer in particular, in transmasculine patients taking testosterone are extremely rare (Urban et al., May 2011, Jeevananthan and Iyengar, 2021, Agnieszka Bobola, 2021). Here we report a case of endometrial intraepithelial neoplasia in a transgender man taking testosterone.

Creating Breast and Gynecologic Cancer Guidelines for Transgender Patients With BRCA Mutations

More than 1.5 million individuals in the United States identify as transgender. Transgender individuals have lower rates of health care utilization and higher rates of health care discrimination than cisgender patients. With a growing interest in providing comprehensive and compassionate care to the transgender community, there has been a concurrent increase in research on transgender health. However, lack of long-term data limits understanding the effects of hormone therapy on cancer risk factors in this population. This is particularly relevant for patients with hormonally mediated cancers and those at elevated risk from hereditary breast and ovarian cancer syndromes. Few cancer-screening and management guidelines currently exist for this population. Specific practices guided by the nuances of gender identity and gender-affirming care are essential to improve clinical management and to avoid further alienating a population that is already marginalized from the health care system. This commentary summarizes screening, management, and surveillance strategies devised for cisgender patients to offer corresponding recommendations tailored for transgender BRCA mutation carriers. In doing so, it highlights critical unanswered questions pertaining to the care of these patients. To address these questions, we must prioritize this population and adopt more inclusive frameworks in medicine and research.