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Tinajero J, Rashid T. Urologic oncology considerations in transgender and gender diverse patients. Curr Opin Urol 2024; 34:314-322. [PMID: 38932479 DOI: 10.1097/mou.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
PURPOSE OF REVIEW This review delves into the pressing issue of urologic oncology considerations within the transgender and gender-diverse (TGD) community. With estimates suggesting that TGD individuals constitute 0.3 to 0.5% of adults worldwide, and this number steadily rising, our review examines the barriers that impede the delivery of excellent quality care, particularly in the context of cancer diagnosis and treatment. RECENT FINDINGS Recent findings highlight disparities in cancer screening, diagnosis, and treatment access for TGD individuals. These challenges are compounded by a dearth of research and the failure of healthcare systems to account for gender identity and its nuances in data collection. Main themes in the literature include the impact of gender-affirming hormone therapy and surgery on cancer risk, challenges in prostate cancer screening and management, and considerations pertinent to testicular and other urological cancers in TGD patients. SUMMARY The implications for clinical practice and research are profound and emphasize the need for multidisciplinary approaches that cater to the unique healthcare needs of TGD individuals. This includes comprehensive strategies for inclusive and accurate data collection, alongside the development of evidence-based guidelines for cancer screening and management tailored specifically to this population.
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Affiliation(s)
- Juan Tinajero
- Chelsea Centre for Gender Surgery, Chelsea and Westminster Hospital
| | - Tina Rashid
- Chelsea Centre for Gender Surgery, Chelsea and Westminster Hospital
- Nuffield Health Parkside Hospital, London, UK
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Panichella JC, Araya S, Nannapaneni S, Robinson SG, You S, Gubara SM, Gebreyesus MT, Webster T, Patel SA, Hamidian Jahromi A. Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery. World J Clin Oncol 2023; 14:265-284. [PMID: 37583948 PMCID: PMC10424092 DOI: 10.5306/wjco.v14.i7.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/15/2023] [Accepted: 06/27/2023] [Indexed: 07/19/2023] Open
Abstract
BACKGROUND Literature focused on cancer screening and management is lacking in the transgender population. AIM To action to increase contributions to the scientific literature that drives the creation of cancer screening and management protocols for transgender and gender nonconforming (TGNC) patients. METHODS We performed a systematic search of PubMed on January 5th, 2022, with the following terms: "TGNC", OR "transgender", OR "gender non-conforming", OR "gender nonbinary" AND "cancer screening", AND "breast cancer", AND "cervical cancer", AND "uterine cancer", AND "ovarian cancer", AND "prostate cancer", AND "testicular cancer", AND "surveillance", AND "follow-up", AND "management". 70 unique publications were used. The findings are discussed under "Screening" and "Management" categories. RESULTS Screening: Current cancer screening recommendations default to cis-gender protocols. However, long-term gender-affirming hormone therapy and loss to follow-up from the gender-specific specialties contribute to a higher risk for cancer development and possible delayed detection. The only known screening guidelines made specifically for this population are from the American College of Radiology for breast cancer. Management: Prior to undergoing Gender Affirmation Surgery (GAS), discussion should address cancer screening and management in the organs remaining in situ. Cancer treatment in this population requires consideration for chemotherapy, radiation, surgery and/or reconstruction. Modification of hormone therapy is decided on a case-by-case basis. The use of prophylactic vs aesthetic techniques in surgery is still debated. CONCLUSION When assessing transgender individuals for GAS, a discussion on the future oncologic risk of the sex-specific organs remaining in situ is essential. Cancer management in this population requires a multidisciplinary approach while the care should be highly individualized with considerations to social, medical, surgical and gender affirming surgery related specifications. Special considerations have to be made during planning for GAS as surgery will alter the anatomy and may render the organ difficult to sample for screening purposes. A discussion with the patient regarding the oncologic risk of remaining organs is imperative prior to GAS. Other special considerations to screening such as the conscious or unconscious will to unassociated with their remaining organs is also a key point to address. We currently lack high quality studies pertinent to the cancer topic in the gender affirmation literature. Further research is required to ensure more comprehensive and individualized care for this population.
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Affiliation(s)
- Juliet C Panichella
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Sthefano Araya
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA 19111, United States
| | - Siddhartha Nannapaneni
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA 19111, United States
| | - Samuel G Robinson
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Susan You
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Sarah M Gubara
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Maria T Gebreyesus
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA 19140, United States
| | - Theresa Webster
- Department of Plastic Surgery, Temple University, Philadelphia, PA 18045, United States
| | - Sameer A Patel
- Division of Plastic and Reconstructive Surgery, Fox Chase Cancer Center, Philadelphia, PA 19111, United States
| | - Alireza Hamidian Jahromi
- Division of Plastic and Reconstructive Surgery, Temple University Hospitals, Philadelphia, PA 19140, United States
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Cornejo KM, Oliva E, Crotty R, Sadow PM, Devins K, Wintner A, Wu CL. Clinicopathologic features and proposed grossing protocol of orchiectomy specimens performed for gender affirmation surgery. Hum Pathol 2022; 127:21-27. [PMID: 35660072 PMCID: PMC9489654 DOI: 10.1016/j.humpath.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/23/2022] [Accepted: 05/25/2022] [Indexed: 01/17/2023]
Abstract
Gender affirmation surgery performed for gender dysphoria is increasing to instigate changes more closely approximating gender identity. We investigated the clinicopathologic features of gender-affirming orchiectomies performed at our institution and devised a grossing protocol for these increasingly encountered specimens. We obtained 45 orchiectomies from 23 patients and reviewed clinicopathologic features. The number of sections per case was noted and reviewed to devise an optimal grossing protocol to assess pathologic findings. Twenty-three patients had bilateral orchiectomy with 1 unilateral. The average patient age was 39.4 years (range, 21-71 years); all received hormones for a mean of 66.1 months (range, 12-348 months). The average number of slides per orchiectomy was 8 slides (range, 1-11). Aspermatogenesis occurred in 32 (71%), hypospermatogenesis in 8 (18%), and normal spermatogenesis in 5 (11%) testes. Twenty-five (56%) exhibited scattered cells with nuclear cytomegaly, concerning for germ cell neoplasia in situ (GCNIS), but OCT4 negative. Six (13%) had multinucleated stromal cells. Leydig cells were markedly reduced/absent in 38 testes (85%). Epithelial hyperplasia was identified in 15 rete testes (33%) and 24 epididymes (53%), while 18 (40%) showed periepididymal muscular hyperplasia. All findings were identified in the initial 2 slides including rete testis/epididymis, except for 3 cases, missing only focal tubular sclerosis. Despite all received treatment, only a subset showed changes of exogenous hormone therapy. The presence of nuclear cytomegaly can mimic GCNIS and may be a potential pitfall. Two sections to include rete testis/epididymis and a third of cord margin are sufficient to identify the relevant pathology and germ cell tumors overall are uncommon in orchiectomies performed for gender affirmation.
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Affiliation(s)
- Kristine M Cornejo
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02114, USA.
| | - Esther Oliva
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Rory Crotty
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Peter M Sadow
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Kyle Devins
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Anton Wintner
- Department of Urology, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Chin-Lee Wu
- Department of Pathology, Massachusetts General Hospital, Boston, MA, 02114, USA
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Incidence of Testicular Cancer in Transfeminine Patients following Vaginoplasty with Orchidectomy. Plast Reconstr Surg Glob Open 2022; 10:e4051. [PMID: 35450259 PMCID: PMC9015195 DOI: 10.1097/gox.0000000000004051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022]
Abstract
Background Little is known about the prevalence of testicular cancer in the transfeminine population. Only six cases have been reported in the literature. This case series reports six additional cases of various testicular cancers found in transfeminine patients who underwent vaginoplasty with orchidectomy in our institution. Methods In our institution, all specimens are routinely sent to pathology following vaginoplasty with orchidectomy. This permitted the identification of all positive cases of testicular cancer. A chart review was conducted to retrieve patient demographics, duration of hormonotherapy, type of neoplasm, the context of its discovery, and cancer follow-up. Results A total of 2555 patients underwent vaginoplasty with orchidectomy between January 2016 and January 2021. All specimens were sent to pathology for analysis. A total of six (0.23% of patients) specimens revealed malignant lesions. Conclusions Increased societal awareness toward the transgender population encourages recourse to gender-affirming procedures. Little is known about the incidence of testicular cancer in the transfeminine population. In total, 0.23% of patients in our cohort presented with positive pathology findings indicative of testicular cancer. All cancers were found to be only locally invasive, and all patients were successfully treated. We therefore encourage routine pathology examination for all specimens following vaginoplasty with orchidectomy.
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Bensley JG, Cheung AS, Grossmann M, Papa N. Testicular Cancer in Trans People Using Feminising Hormone Therapy- A Brief Review. Urology 2021; 160:1-4. [PMID: 34826522 DOI: 10.1016/j.urology.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Jonathan Guy Bensley
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Ada S Cheung
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Victoria, Australia
| | - Mathis Grossmann
- Department of Medicine (Austin Health), The University of Melbourne, Heidelberg, Victoria, Australia
| | - Nathan Papa
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Fine N, Abbott T, Wintner A. Testicular mixed germ cell tumor in a transgender woman. Urol Case Rep 2021; 40:101861. [PMID: 34712578 PMCID: PMC8528688 DOI: 10.1016/j.eucr.2021.101861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022] Open
Abstract
Transgender women who have not undergone orchiectomy remain at risk for the development of testicular cancer. Unfortunately, many physicians self-report a weak fund of knowledge around transgender health issues and some are uncomfortable performing proper exams or advising patients on self-exams. Here we report the first case of a testicular mixed germ cell tumor that developed in a transgender woman and discuss the salient points of caring for transgender patients.
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Affiliation(s)
- Noam Fine
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Todd Abbott
- Newton Wellesley Hospital, 2014 Washington Street, Newton, MA, 02462, USA
| | - Anton Wintner
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Maheshwari A, Nippoldt T, Davidge-Pitts C. An Approach to Nonsuppressed Testosterone in Transgender Women Receiving Gender-Affirming Feminizing Hormonal Therapy. J Endocr Soc 2021; 5:bvab068. [PMID: 34278180 PMCID: PMC8279075 DOI: 10.1210/jendso/bvab068] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Indexed: 12/14/2022] Open
Abstract
Nonsuppressed levels of testosterone are seen in up to a quarter of transgender women on gender-affirming feminizing hormonal treatment. Multiple factors contribute to this situation, including patient, medication, laboratory, and organ-specific concerns. We propose a stepwise approach to determine the etiology of nonsuppressed levels of testosterone in transgender women. This may lead to an appropriate feminizing hormonal therapy regimen and diagnosis of manageable medical conditions.
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Affiliation(s)
- Arvind Maheshwari
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Todd Nippoldt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
| | - Caroline Davidge-Pitts
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN 55905, USA
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de Nie I, Wiepjes CM, de Blok CJM, van Moorselaar RJA, Pigot GLS, van der Sluis TM, Barbé E, van der Voorn P, van Mello NM, Huirne J, den Heijer M. Incidence of testicular cancer in trans women using gender-affirming hormonal treatment: a nationwide cohort study. BJU Int 2021; 129:491-497. [PMID: 34390620 PMCID: PMC9291742 DOI: 10.1111/bju.15575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/17/2021] [Accepted: 08/07/2021] [Indexed: 11/28/2022]
Abstract
Objective To assess the incidence of testicular cancer in trans women (male sex assigned at birth, female gender identity) using gender‐affirming hormonal treatment. Patients and Methods Data of trans women starting hormonal treatment at our gender identity clinic between 1972 and 2017 were linked to the national pathology database to obtain testicular cancer diagnoses. The standardised incidence ratio (SIR) was calculated using the number of observed testicular cancer cases in our cohort and the number of expected cases based on age‐specific Dutch incidence rates. Subgroup analyses were performed in testicular tissues sent for histopathological analysis at the time of bilateral orchidectomy, and when follow‐up exceeded 5 years. Results The cohort consisted of 3026 trans women with a median follow‐up time of 2.3 interquartile range (IQR) (1.6–3.7) years. Two testicular cancer cases were identified whilst 2.4 cases were expected (SIR 0.8, 95% confidence interval 0.1–2.8). In addition, one testicular cancer case was encountered in an orchidectomy specimen (0.1%). In the 523 trans women with a follow‐up time of >5 years (median [IQR] 8.9 [6.4–13.9] years), no testicular cancer was observed. Conclusion Testicular cancer risk in trans women is similar to the risk in cis men. The testicular cancer cases occurred within the first 5 years after commencing hormonal treatment, and the percentage of cases encountered at the time of bilateral orchidectomy was low. As no testicular cancer was observed in trans women with a long follow‐up period, long‐term hormonal treatment does not seem to increase testicular cancer risk.
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Affiliation(s)
- Iris de Nie
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.,Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Chantal M Wiepjes
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.,Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Christel J M de Blok
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.,Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Garry L S Pigot
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.,Department of Urology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Tim M van der Sluis
- Department of Urology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Ellis Barbé
- Department of Pathology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Patrick van der Voorn
- Department of Pathology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Norah M van Mello
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.,Department of Obstetrics and Gynecology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Judith Huirne
- Department of Obstetrics and Gynecology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Endocrinology, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands.,Center of Expertise on Gender Dysphoria, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
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