Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy

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.

Cancer screening and management in the transgender population: Review of literature and special considerations for gender affirmation surgery

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.

Prostate cancer in transgender women: considerations for screening, diagnosis and management

Transgender individuals represent 0.55% of the US population, equivalent to 1.4 million transgender adults. In transgender women, feminisation can include a number of medical and surgical interventions. The main goal is to deprive the phenotypically masculine body of androgens and simultaneously provide oestrogen therapy for feminisation. In gender-confirming surgery (GCS) for transgender females, the prostate is usually not removed. Due to limitations of existing cohort studies, the true incidence of prostate cancer in transgender females is unknown but is thought to be less than the incidence among cis-gender males. It is unclear how prostate cancer develops in androgen-deprived conditions in these patients. Six out of eleven case reports in the literature presented with metastatic disease. It is thought that androgen receptor-mediated mechanisms or tumour-promoting effects of oestrogen may be responsible. Due to the low incidence of prostate cancer identified in transgender women, there is little evidence to drive specific screening recommendations in this patient subpopulation. The treatment of early and locally advanced prostate cancer in these patients warrants an individualised thoughtful approach with input from patients' reconstructive surgeons. Both surgical and radiation treatment for prostate cancer in these patients can profoundly impact the patient's quality of life. In this review, we discuss the evidence surrounding screening and treatment of prostate cancer in transgender women and consider the current gaps in our knowledge in providing evidence-based guidance at the molecular, genomic and epidemiological level, for clinical decision-making in the management of these patients.

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.

Prostate Cancer in Male-to-Female Transgender Individuals: Histopathologic Findings and Association With Gender-affirming Hormonal Therapy

Male-to-female (MtF) transgender individuals are at risk for prostate cancer, although guidelines for screening and management in this population are not well established. We describe a series of 9 MtF transgender patients who underwent prostate tissue sampling and highlight histopathologic features and challenges related to pathologic interpretation of prostate tissue in this patient population. Seven of 9 total patients were diagnosed with prostate cancer and all had elevated prostate-specific antigen at the time of diagnosis. Three of the 7 patients diagnosed with prostate cancer had received different types of hormone therapy for gender affirmation before the diagnosis of prostate cancer, and in all 3 of these patients, there was histologic evidence of hormone therapy effect in both benign prostate tissue and/or the adenocarcinoma. The 2 patients with benign prostate tissue underwent transurethral resection for lower urinary tract symptoms and were previously on hormone therapy for gender affirmation. Both of these specimens showed diffuse glandular atrophy and basal cell hyperplasia, indicative of hormone therapy effect on benign prostatic tissue. In the patients diagnosed with prostate cancer, a spectrum of grades was observed, ranging from Grade Group 1 to Grade Group 5. Four patients underwent radical prostatectomy, with 2 cases showing extraprostatic extension and Grade Group 5 prostatic adenocarcinoma, and 2 showing Grade Group 2 prostatic adenocarcinoma. Three of the 4 patients who underwent radical prostatectomy had received gender-affirming hormone therapy before surgery, and all 3 of these specimens showed hormone therapy effect in non-neoplastic prostate tissue and focal hormone therapy effect in prostatic adenocarcinoma. The presence of areas of viable carcinoma without hormone therapy effect enabled the assignment of a Gleason score and Grade Group in these 3 cases. Hormone therapy administered for gender identity affirmation induces histopathologic changes to both benign prostate tissue (nonkeratinizing squamous metaplasia, diffuse atrophy, basal cell hyperplasia, and stromal dominance with decreased numbers of glands) and prostatic adenocarcinoma (nuclear pyknosis, atrophy, cytoplasmic vacuolization, and architectural patterns that would qualify for Gleason 4 and 5 in the absence of hormone therapy effect) that have been traditionally seen in cis-male prostate cancer patients receiving hormone therapy. In the absence of hormone therapy, the morphology of prostatic adenocarcinoma in transgender patients shows classic morphologic features similar to those seen in cis-male patients not on hormone therapy. Prostate cancer with hormone therapy effect may not only be histologically quite subtle and may be overlooked if not suspected, but also should not be assigned a Gleason score because the Gleason score would substantially overstate its biologic potential. Therefore, similar to cis-male patients who have received androgen deprivation therapy for prostate cancer, transgender patients on hormone therapy for gender affirmation may be at risk for both underrecognition and over-grading of prostate cancer, particularly if the pathologist is not aware of the clinical history.

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.

Review on the Transgender Literature: Where Are We Now and a Step beyond the Current Practice?

The transgender concept is described as a clinically significant distress due to the incongruity between the experienced gender and assigned gender. A transgender person carries a gender identity that is different from their assigned sex at birth. Transgender people may be binary: male to female (transgender women) or female to male (transgender men) or genderqueer (non-binary, fluid or variable gender expression). The binary concept has been described in transgender population, where the term transwomen is used to describe people assigned male at birth (AMAB) who are recognized as females during gender transition; with the term transmen where they are assigned female at birth (AFAB) and are then recognized as males in gender transition. According to the DSM-5 classification, gender dysphoria is described when a transgender person develops clinically relevant bio-psychosocial suffering. Currently, the transgender population has gained massive public awareness through social media and gained a considerable level of attention globally. Several studies on transgender populations from different parts of the world have shown real discrimination and stigma towards transgender people, which sometimes acts as a barrier to the provision of the required care for them. Lack of access to the required information, legal issues, lack of solutions to fertility problems, financial constraints, and psychological and emotional obstacles, together with risk of sexually transmitted infections, including human immunodeficiency virus (HIV), all make the life of a transgender person more complicated. Testosterone therapy is a hormone-based therapy for transgender men that provides a body image tallying with the favored gender identification, whereas estrogen and androgen-suppressing agents are used in transgender females to produce changes compatible with their required gender identity. Gender affirmation surgery is a broad term, under which the genital reconstruction is described as a major component. Psychological conditions such as depression, substance abuse, suicidal deaths, and sexually transmitted infections, particularly among males having sex with males, are reported at a significantly higher rate among transgender populations. Cardiovascular morbidity is higher among this population, and continuous medical surveillance is warranted. Medical care provision to transgender populations should be handled with great care, while attending to the unmet needs of this population, as this care should extend beyond routine hormonal therapy and gender reassignment surgery.

An Evaluation of Sex- and Gender-Based Analyses in Oncology Clinical Trials

BACKGROUND

The objective of this study was to evaluate whether sex- and gender-based analyses and proper sex- and gender-terminology were used in oncology trials leading to regulatory drug approval.

METHODS

The Food and Drug Administration (FDA) Hematology/Oncology Approvals and Safety Notifications page was used to identify all anti-cancer therapies that received FDA approval between 2012 and 2019. The trials used to support FDA-drug approval were collected along with all available supplemental tables and study protocols. Documents were reviewed to determine if there was a plan to analyze results according to sex and gender and to determine if consistent sex and gender terminology were used.

RESULTS

128 randomized-controlled trials were identified corresponding to a cancer medicine which received FDA-approval. No study specified how sex and gender were collected or analyzed. No study reported any information on the gender of participants. Sex and gender terminology was used inconsistently at least once in 76% (97/128) of studies. Among the 102 trials for non-sex-specific cancer sites, 89% (91/102) presented disaggregated survival outcome data by sex. No study presented disaggregated toxicity data by sex or gender.

CONCLUSION

The majority of pivotal clinical trials in oncology fail to account for the important distinction between sex and gender and conflate sex and gender terminology. More rigor in designing clinical trials to include sex and gender based analyses and more care in using sex and gender terms in the cancer literature is needed. These efforts are essential to improve the reproducibility, generalizability, and inclusiveness of cancer research.

Embryologic and hormonal contributors to prostate cancer in transgender women

Transgender women, who were assigned male at birth but identify as women, may take several steps to merge their physical and psychological identities, including gender-affirming surgeries and hormone therapy. With the presence of the mature prostate gland there persists a risk for malignant transformation in this population. The recognition by the medical community and society at large that transgender women are at risk of developing prostate cancer has recently been supported by investigative efforts. The slowly emerging clinical evidence suggests that the disease is likely to be more aggressive than in cisgender men, with 6 of 9 published cases discussing metastasis reporting metastatic disease on presentation. Currently the overall prevalence appears low, pointing to evolving awareness, educational status, socioeconomic status, and late presentation. This commentary focuses on exploring the factors contributing to the incidence of prostate cancer and the biochemical and endocrine mechanisms that lead to aggressive prostate tumor development in transgender women.

Encouraging patients to disclose their lesbian, gay, bisexual, or transgender (LGBT) status: oncology health care providers' perspectives

A compelling touted strategy for reducing discrimination towards lesbian, gay, bisexual, and transgender (LGBT) patients is improving communicative competence of health care providers (HCPs); however, evidence base for describing communication practices between HCPs and LGBT patients is scarce. The purpose of this study was to qualitatively examine HCP experiences and perspectives as they relate to patient sexual orientation and gender identity (SOGI) disclosure, perceived communication and structural/administrative challenges in interactions with LGBT patients, and suggestions for improving care of LGBT patients. The sample consisted of 1,253 HCPs, who provided open-ended responses to an online cross-sectional survey conducted at a Comprehensive Cancer Center in the Northeastern United States. The open-ended responses were inductively and deductively coded for key themes and sub-themes. The results demonstrated an array of useful communication strategies employed by oncology HCPs to encourage LGBT patients' SOGI disclosure (direct questions regarding sexual orientation, use of the term "partner," and using correct pronouns), communication and structural/administrative challenges faced by HCPs in providing care (HCP own fears and biases, transgender patient care, insurance issues, and procedural challenges for LGBT patients), and suggested recommendations from oncology HCPs to improve their care delivery for LGBT patients (more provider-based training, improving awareness of LGBT-friendly resources, establishing trusting relationships, and not assuming sexuality or gender identity). These findings have implications for developing and evaluating training programs to improve LGBT sensitivity and communication among HCPs, and encourage SOGI disclosure in an open and judgment-free health care environment.

Every urologist and oncologist should know about treating sexual and gender minority prostate cancer patients: translating research findings into clinical practice

In 2016, the NIH designated sexual and gender minorities (SGM) a health disparity population. The next year, the American Society of Clinical Oncology highlighted the need to improve the suboptimal cancer and survivorship care received by SGM populations. There are currently no evidence-based training programs in culturally competent care of prostate cancer patients who are gay, bisexual and/or transgender. In this selective review, we summarize findings from the largest quantitative studies focused on sexual minority prostate cancer survivors and from 65 interviews with NIH staff, clinicians, and cancer clinics in 11 US cities. The report is divided into three parts and uses a question and answer format to address 21 questions relevant to clinicians providing care to SGM prostate cancer patients. First, we identify population-specific issues that are culturally relevant in the care of SGM patients with prostate cancer. While a body of research has emerged on sexual minority prostate cancer patients, the literature on gender minorities is limited to single case reports and inadequate to inform practice. This review covers definitions, population size, cultural and historical context, sexual behavior, population invisibility, sexual orientation and gender identity (SOGI) in the electronic medical record, disparities and evidence of discrimination in treatment provision. The second part focuses on promoting evidence-informed, patient-centered care. This includes current practices in assessing sexual orientation, management of disclosure of sexual orientation, how to address common problems sexual minority men experience post-treatment, common questions sexual minority patients have, management of urinary incontinence, HIV and STI risk during and post-treatment, and sub-groups of sexual minority patients with worse outcomes. It then identifies how male partners differ in prostate cancer support, current research on rehabilitation for sexual minority men, issues in advanced prostate cancer, and things to avoid with minority patients. Finally, we examine the cultural divide between provider and patient, advocating for cultural humility when working with minority patients. Training programs and continuing education can help providers both to become more aware of their own cultural assumptions, informed about health disparities, and able to provide quality care, and to make clinics more welcoming to SGM patients.

Prostate cancer in transgender women: what does a urologist need to know?

OBJECTIVE

To review of the existing literature, current guidelines and standard of practice related to prostate cancer in transgender women, as the transgender population share many of the same healthcare needs as their cisgender counterparts, but may have additional specialist needs.

MATERIALS AND METHODS

We performed a non-systematic review of the literature, current guidelines and standard of practice related to prostate cancer in transgender women.

RESULTS

Our search revealed 10 case reports of prostate cancer in transgender women, four specialist opinion papers, six cohort studies, and four systematic reviews. The information in these publications were assimilated to produce a review of prostate cancer in transgender women.

CONCLUSION

The risk of prostate cancer in transgender women who are not on gender-affirming hormone therapy (GAHT) or who have not had gender-affirming surgery (GAS) and gender non-conforming individuals (who may never commence GAHT or have GAS) is the same as that in the cis male population. In these patients, healthcare professionals need to be able to discuss screening, diagnostic and treatment options considering future wishes for gender-affirming treatment. Prostate cancer incidence in transgender women on GAHT or following GAS is lower than age-matched cis-male counterparts, but diagnosis and treatment is more nuanced. The present review discusses the existing literature about development and incidence of prostate cancer in this population, and makes recommendations about screening, the usefulness of diagnostic tools e.g. prostate-specific antigen and magnetic resonance imaging, and considerations when formulating treatment. Potential directions for future research are discussed, which will hopefully lead to development of robust evidence-based guidelines for the diagnosis and management of prostate cancer in transgender women.

Prostate Cancer From a Sex and Gender Perspective: A Review

INTRODUCTION

Factors influencing patient behavior regarding risk of prostate cancer (PCa) and outcomes of PCa treatments are poorly understood. Similarly, how PCa treatments affect patient sexual function and sense of their masculinity has not been fully investigated. A better understanding of the relationship between sex and gender for patients with PCa could significantly improve their care and quality of life.

OBJECTIVES

To review how concerns about sex and gender influence men's attitudes toward PCa screening, diagnosis, and treatment. To explore how PCa influences sexual function and self-perceived masculine identity. To examine contexts for PSA screening for transgender individuals.

METHODS

We reviewed biomedical and sociological literature exploring the impact of PCa on patient sexual function and self-perceived masculinity using OVID, PubMed, and other databases. We similarly reviewed how masculine gender norms influence patient willingness to engage with PCa screening, diagnoses, and treatment.

RESULTS

Gender norms and sexual function concerns influence patient engagement in all aspects of PCa care. This includes PSA screening, digital rectal examinations, active surveillance, and androgen deprivation therapy (ADT) amongst others. ADT is particularly challenging to sexual function, self-esteem, and masculine identity. Our research suggests that sex and gender are not separate concepts, but rather tightly intertwined, particularly when dealing with the realities experienced by patients with PCa.

CONCLUSION

Interventions to help patients deal with the challenges of PCa and its treatment are likely to be most effective if they concurrently address patients' sexual needs and understanding of gender norms. PSA screening should be considered for transgender individuals who are at greater risk of cancer and on long-term hormone therapy. More research is needed on how concerns over sex and gender influence PCa screening, diagnosis, and treatment. There is also a need for long term data on the oncological outcomes of prolonged exposure to hormone therapy for patients who are transgender. Muermann MM, Wassersug RJ. Prostate Cancer From a Sex and Gender Perspective: A Review. Sex Med Rev 2021;XX:XXX-XXX.

Histologic Findings in Surgical Pathology Specimens From Individuals Taking Feminizing Hormone Therapy for the Purpose of Gender Transition: A Systematic Scoping Review

CONTEXT.—

Transgender women experience health disparities in all areas of medicine. Within surgical pathology, knowledge gaps relating to the concepts of transgender care exist. Medical transition for transgender women and transfeminine persons may involve hormone therapy and/or surgery to feminize the body. Understanding the common histologic changes in specimens from feminizing surgeries, as well as other specimens from patients on feminizing hormone therapy, will aid surgical pathologists in providing better care to this unique patient population.

OBJECTIVE.—

To summarize histologic findings in surgical pathology specimens from transgender women taking feminizing hormones.

DATA SOURCES.—

A systematic review of the OVID Medline and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender women from 1946 to 2019.

CONCLUSIONS.—

Much of the literature to date describing histologic findings in transgender women comes from the examination of genitourinary specimens removed during feminizing surgeries. Common benign changes associated with feminizing hormone therapy include the development of acini and lobules in the breast, testicular tubular changes, and squamous metaplasia of the prostate and urethra. Neoplastic cases include breast adenocarcinoma and fibroepithelial lesions, testicular germ cell tumors, prostatic adenocarcinoma, anal squamous cell carcinoma, pituitary adenomas, and meningiomas. Additional studies assessing the findings in other organ systems as well as population-based studies assessing rates of neoplasia are needed. However, future research relies on engagement within the surgical pathology community as well as collaboration with clinicians and patients to achieve optimal results.

Sexual and Gender Minority Communication Skills (SGM Comskil) Training for Oncology Clinicians: Development, Implementation, and Preliminary Efficacy

Enhancing communicative competence of healthcare providers (HCPs) is a critical initiative for improving the healthcare experience of sexual and gender minority (SGM) cancer patients. This study presents the development, implementation, and preliminary efficacy of a new training curriculum for improving oncology HCPs' skills in providing a safe and welcoming environment for SGM cancer patients (SGM Comskil training). Thirty-three (N = 33) oncology HCPs including nurses, nurse leaders, and nurse practitioners participated in a 4.25-hour SGM Comskil Training between July and August 2019. Overall, participants reported highly favorable evaluations of the training, with more than 80% of the participants reacting positively to 12 of the 15 evaluation items assessing engagement and reflectiveness for experiential role-plays with lesbian, gay, bisexual (LGB) and transgender standardized patients (SPs), respectively. Participants also demonstrated significant improvements in SGM healthcare knowledge, self-efficacy, beliefs toward LGB and transgender persons, and SGM-sensitive language use skills following the training. Encouraged by the feasibility of conducting this experiential training with busy cancer care HCPs and the initial favorable participant evaluation of the SGM Comskil training, results clearly indicate that this training can be rolled out into clinical settings to ensure its translational potential. The next steps should assess observable changes in communication skills and SGM-sensitive language skills with SGM patients and improvements in SGM patients' healthcare experience.

Research gaps in medical treatment of transgender/nonbinary people

With the growing number of transgender and gender-nonbinary individuals who are becoming visible, it is clear that there is a need to develop a rigorous evidence base to inform care practice. Transgender health research is often limited to HIV/AIDS or mental health research and is typically subsumed in larger studies with general LGBTQ focus. Although the number of knowledgeable health care providers remains modest, the model for the medical approach to transgender health is shifting owing to growing social awareness and an appreciation of a biological component. Gender-affirming medicine facilitates aligning the body of the transgender person with the gender identity; typical treatment regimens include hormone therapy and/or surgical interventions. While broadly safe, hormone treatments require some monitoring for safety. Exogenous estrogens are associated with a dose-dependent increase in venous thromboembolic risk, and androgens stimulate erythropoiesis. The degree to which progressing gender-affirming hormone treatment changes cancer risk, cardiac heart disease risk, and/or bone health remains unknown. Guidelines referencing the potential exacerbation of cancer, heart disease, or other disease risk often rely on physiology models, because conclusive clinical data do not exist. Dedicated research infrastructure and funding are needed to address the knowledge gap in the field.

Endocrine Management of Transgender Adults: A Clinical Approach

The attention to transgender medicine has changed over the last decade and the interest is most likely going to increase in the future due to the fact that gender-affirming treatments are now being requested by an increasing number of transgender people. Even if gender-affirming hormone therapy (GAHT) is based on a multidisciplinary approach, this review is going to focus on the procedures adopted by the endocrinologist in an out-clinic setting once an adult patient is referred by another specialist for ‘gender affirming’ therapy. Before commencing this latter treatment, several background information on unmet needs regarding medical and surgical outcomes should be investigated. We summarized our endocrinological clinical and therapeutic approaches to adult transgender individuals before and during GAHT based on a non-systematic review. Moreover, the possible relationships between GAHT, gender-related pharmacology, and COVID-19 are also reported.

Replacement Hormone Therapy for Gender Dysphoria and Congenital Sexual Anomalies

What is it about sexuality that makes it such a burning matter since the dawn of mankind? Much was lost of humankind heritage because of society's attitude toward sex and gender, but we've made progress. Medical knowledge progressed incredibly and so did social and cultural norms. In these days, on most places on the planet, there is acceptance. Still, gender issues take a center stage, often inflaming the social and political milieu everywhere. So how informed and prepared is the medical community to deal with these issues? Aside from medical treatments, gender dysphoric patients need mental health and social support throughout life. Do we have enough guidelines for treatments that have life-long effects? Do we actually know all of those effects? There are many issues to consider, like fertility preservation, puberty suppression with its adverse effects, and not in the least, the effects of the hormonal therapy on the target tissues.

Prostate cancer in sexual minorities and the influence of HIV status

Prostate cancer is the second most common cause of cancer-related death in men in the USA, but the effect of prostate cancer diagnosis and treatment on men in a sexual minority group, including men who have sex with men and transgender women, is poorly understood. Efforts to study this population are complicated, as cancer registries do not routinely collect information on sexual orientation. As a result, epidemiological data regarding this population have come from small studies that have included disparate rates of prostate cancer screening, diagnosis and treatment. Qualitative studies indicate that prostate cancer is experienced differently by sexual minorities, with distinct health-care needs that arise owing to differences in sexual practices, social support systems and relationships with the medical community. Notably, sexual minorities have been reported to experience poorer health-related quality of life outcomes than heterosexual men, and tend to have less robust social support systems, experience increased psychological distress caused by sexual dysfunction (areas of which are unmeasured after treatment), experience isolation within the health-care system and express increased levels of dissatisfaction with treatment. The incidence of prostate cancer actually seems to be decreased in men from sexual minorities living with HIV, despite there being no differences in screening and treatment, with poor cancer-specific mortality. Although the literature on patients with prostate cancer in men from sexual minority groups has historically been sparse, peer-reviewed research in this area has grown considerably during the past decade and has become an important field of study.

Understanding Prostate Cancer in Gay, Bisexual, and Other Men Who Have Sex with Men and Transgender Women: A Review of the Literature

PURPOSE OF REVIEW

a)Prostate cancer in sexual and gender minorities is an emerging medical and public health concern. The purpose of this review is to summarize the state of the science on prostate cancer in gay, bisexual, and other men who have sex with men (GBM) and transgender women (TGW). We undertook a literature review of all publications on this topic through February 2017. With 88 unique papers (83) on prostate cancer in GBM and 5 case reports of prostate cancer in TGW), a small but robust literature has emerged.

RECENT FINDINGS

b)The first half of this review critiques the literature to date, identifying gaps in approaches to study. The second half summarizes the key findings in eleven areas. In light of this admittedly limited literature, GBM appear to be screened for prostate cancer less than other men, but they are diagnosed with prostate cancer at about the same rate.

SUMMARY

c)Compared to other men, GBM have poorer urinary, bowel, and overall quality-of-life outcomes but better sexual outcomes after treatment; all these findings need more research. Prostate cancer in TGW remains rare and under researched, as the literature is limited to single-case clinical reports.

Transfeminine Hormone Therapy

Transgender women often seek hormone therapy to attain feminine physical features congruent with their gender identity. The aim of feminizing hormone therapy (FHT) is to provide suppression of endogenous testosterone and to maintain estradiol levels within the normal female range. Overall, FHT is safe if provided under supervision of an experienced health care provider and has been shown to improve quality of life. Data on care of transgender women are scarce and high-quality evidence-based recommendations are lacking. This article aims to review the published literature on FHT and provide guidance to clinicians caring for transgender women.

Primary Care in Transgender Persons

The preventive health care needs of transgender persons are nearly identical to the rest of the population. Special consideration should be given, however, to the impact of gender-affirming hormone regimens and surgical care on preventive screenings. Providers should integrate a more comprehensive view of health when caring for transgender persons and address the impact of social determinants and other barriers to accessing affirming, inclusive health care. In individual interactions, providers must consider the unique impact that a gender identity and expression different from the assigned gender at birth affects patient-provider interactions, including the history, physical examination, and diagnostic testing.

Gender-affirming hormone therapy and the risk of sex hormone-dependent tumours in transgender individuals-A systematic review

BACKGROUND

Cancers are a leading cause of death worldwide, and transgender individuals are no exception. The effects of gender-affirming hormone therapy (GAHT) on sex hormone-dependent tumours are unclear. Therefore, this review seeks to determine whether tumour risk in transgender individuals differs from the general population, to guide clinical screening recommendations.

METHODS

We performed a systematic review based on the PRISMA guidelines. MEDLINE, Embase and PsycINFO databases were searched for studies examining tumour incidence, prevalence or cancer-related mortality in transgender individuals. All English peer-reviewed publications were included if histological type and temporal relation to GAHT were reported. Case reports were included if there were ≥2 cases of the same histological type.

RESULTS

The search strategy identified 307 studies. Excluding those that did not meet inclusion criteria, 43 studies (7 cohort studies, 2 cross-sectional studies and 34 case reports) were reviewed. Retrospective cohort studies suggest no increase in risk of tumour development in transgender individuals receiving GAHT compared to the general population. Notably, the mean ages of cohorts were young and were treated with GAHT for insufficient durations to assess tumour risk. Case reports raise potential associations between high-dose oestradiol and anti-androgen therapy with prolactinoma and meningioma, respectively.

CONCLUSIONS

Further longitudinal studies are required to assess the risk of GAHT and hormone-dependent tumour development. Until further evidence is available, tumour screening should be based on guidelines for the general population and the presence of organs in transgender individuals rather than gender identity or hormonal therapy status.

Inflammation and NF-κB Signaling in Prostate Cancer: Mechanisms and Clinical Implications

Prostate cancer is a highly prevalent form of cancer that is usually slow-developing and benign. Due to its high prevalence, it is, however, still the second most common cause of death by cancer in men in the West. The higher prevalence of prostate cancer in the West might be due to elevated inflammation from metabolic syndrome or associated comorbidities. NF-κB activation and many other signals associated with inflammation are known to contribute to prostate cancer malignancy. Inflammatory signals have also been associated with the development of castration resistance and resistance against other androgen depletion strategies, which is a major therapeutic challenge. Here, we review the role of inflammation and its link with androgen signaling in prostate cancer. We further describe the role of NF-κB in prostate cancer cell survival and proliferation, major NF-κB signaling pathways in prostate cancer, and the crosstalk between NF-κB and androgen receptor signaling. Several NF-κB-induced risk factors in prostate cancer and their potential for therapeutic targeting in the clinic are described. A better understanding of the inflammatory mechanisms that control the development of prostate cancer and resistance to androgen-deprivation therapy will eventually lead to novel treatment options for patients.

Transgender Care in the Primary Care Setting: A Review of Guidelines and Literature

For patients who desire transgender care, providers must use appropriate language, know the basics of cross-sex hormone therapy, and understand the risks and adverse effects of treatment options.

Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery

BACKGROUND

Gender dysphoria is the experience of marked distress due to incongruence between genetically determined gender and experienced gender. Treatment of gender dysphoria should be individualized and multidisciplinary, involving a combination of psychotherapy, social gender transition, cross-sex hormone therapy, gender-affirming surgery, and/or ancillary procedures and services. The goal of all treatment modalities is to alleviate distress and affirm the patient's experienced gender identity. This article is the first in a 3-part series focused on the diagnostic assessment and non-operative treatment of gender dysphoria. Parts 2 and 3 focus on operative aspects of gender dysphoria treatment.

AIM

To summarize the recommendations of the World Professional Association for Transgender Health (WPATH) and the Endocrine Society (ES), as well as review published literature regarding the non-operative treatment of gender dysphoria.

METHODS

A review of relevant literature through January 2017 was performed via PubMed.

OUTCOMES

WPATH guidelines regarding diagnosis and non-surgical treatment of gender dysphoria, specifically regimens and risks of cross-sex hormone therapy were reviewed.

RESULTS

Few physicians have experience with the diagnosis or treatment of gender dysphoria, although the number of patients seeking treatment has risen substantially in recent years. As a result, clinicians have turned to published recommendations from WPATH and ES, both of which promote high-quality, evidence-based care for patients with gender dysphoria. Successful treatment requires an individualized multidisciplinary approach. Non-operative treatment is both safe and effective for the majority of patients with gender dysphoria.

CONCLUSIONS

Guidelines from WPATH and ES, along with published literature pertaining to the diagnosis and non-operative treatment of gender dysphoria, were reviewed and summarized. Hadj-Moussa M, Ohl DA, Kuzon WM. Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery. Sex Med Rev 2018;6:607-617.

Sex Differences and Bone Metastases of Breast, Lung, and Prostate Cancers: Do Bone Homing Cancers Favor Feminized Bone Marrow?

Sex-associated differences in bone metastasis formation from breast, lung, and prostate cancer exist in clinical studies, but have not been systematically reviewed. Differences in the bone marrow niche can be attributed to sexual dimorphism, to genetic variations that affect sex hormone levels, or to the direct effects of sex hormones, natural or exogenously delivered. This review describes the present understanding of sex-associated and sex hormone level differences in the marrow niche and in formation of bone metastasis during the transition of these three cancers from treatable disease to an often untreatable, lethal metastatic one. Our purpose is to provide insight into some underlying molecular mechanisms for hormonal influence in bone metastasis formation, and to the potential influence of sexual dimorphism, genetic differences affecting sex assignment, and sex hormone level differences on the bone niche and its favorability for metastasis formation. We reviewed publications in PubMed and EMBASE, including full length manuscripts, case reports, and clinical studies of relevance to our topic. We focused on bone metastasis formation in breast, lung, and prostate cancer because all three commonly present with bone metastases. Several clear observations emerged. For breast cancer bone metastasis formation, estrogen receptor (ER) signaling pathways indicate a role for ER beta (ERβ). Estrogen influences the bone microenvironment, creating and conditioning a favorable niche for colonization and breast cancer progression. For lung cancer, studies support the hypothesis that females have a more favorable bone microenvironment for metastasis formation. For prostate cancer, a decrease in the relative androgen to estrogen balance or a “feminization” of bone marrow favors bone metastasis formation, with a potentially important role for ERβ that may be similar to that in breast cancer. Long-term estrogen administration or androgen blockade in males may feminize the bone marrow niche to one more favorable for bone metastases in prostate cancer. Administration of androgens in females, especially combined with mastectomy, may reduce risk of developing bone metastatic breast cancer. We conclude that it should be considered that females, those with female-leaning genetic variations, or hormonal states that feminize the bone marrow, may offer favorable sites for bone metastases.

The Development of Prostate Adenocarcinoma in a Transgender Male to Female Patient: Could Estrogen Therapy Have Played a Role?

BACKGROUND

Prostate adenocarcinoma (PCa) is a rare diagnosis in the male to female transgender (MtFT) population with only a few case reports published in the current medical literature. Long standing beliefs of androgen suppression conferring a protective effect against prostate cancer development have been challenged by the literature citing adenocarcinoma development in the prostate of rodent models following combined estrogen and testosterone treatment.

MATERIALS AND METHODS

We herein present a MtFT patient who presented with high grade PCa following 20 years of exogenous estrogen therapy.

RESULTS

Immunohistochemical (IHC) localization of estrogen receptor alpha (ER-α) and progesterone receptor (PR) demonstrated positive staining in stromal cells; while, androgen receptor (AR) demonstrated positive staining in malignant glands and weak scattered staining in adjacent stroma.

CONCLUSION

This pattern of staining raises concern for a possible contributing role of exogenous estrogen therapy in tumorigenesis. As awareness of gender dysphoria and acceptance of gender reassignment surgery has seen a recent increase, the unique needs of this population must be recognized. Prostate 77:824-828, 2017. © 2017 Wiley Periodicals, Inc.

Oestrogen and anti-androgen therapy for transgender women

Transgender women experience lifelong gender dysphoria due to a gender assignment at birth that is incongruent with their gender identity. They often seek hormone therapy, with or without surgery, to improve their gender dysphoria and to better align their physical and psychological features with a more feminine gender role. Some of the desired physical changes from oestrogen and anti-androgen therapy include decreased body and facial hair, decreased muscle mass, breast growth, and redistribution of fat. Overall the risks of treatment are low, but include thromboembolism, the risk of which depends on the dose and route of oestrogen administration. Other associated conditions commonly seen in transgender women include increased risks of depression and osteoporosis. The risk of hormone-sensitive cancer seems to be low in transgender women, with no increased risk of breast cancer compared with women and no increase in prostate cancer when compared with men. The evidence base for the care of transgender women is limited by the paucity of high-quality research, and long-term longitudinal studies are needed to inform future guidelines.

Cancer in Transgender People: Evidence and Methodological Considerations

Transgender people comprise a diverse group of individuals whose gender identity or expression differs from that originally assigned to them at birth. Some, but not all, transgender people elect to undergo medical gender affirmation, which may include therapy with cross-sex hormones and/or surgical change of the genitalia and other sex characteristics. As cross-sex hormones administered for the purposes of gender affirmation may be delivered at high doses and over a period of decades, the carcinogenicity of hormonal therapy in transgender people is an area of considerable concern. In addition, concerns about cancer risk in transgender patients have been linked to sexually transmitted infections, increased exposure to well-known risk factors such as smoking and alcohol use, and the lack of adequate access to screening. Several publications have identified cancer as an important priority in transgender health research and called for large-scale studies. The goals of this article are to summarize the evidence on factors that may differentially affect cancer risk in transgender people, assess the relevant cancer surveillance and epidemiologic data available to date, and offer an overview of possible methodological considerations for future studies investigating cancer incidence and mortality in this population.

Pharmacotherapy Considerations in the Management of Transgender Patients: A Brief Review

Transgender and transsexual individuals have unique health care needs and risks compared with the population at large. It is estimated that 1 in 100,000 individuals in the United States is a transgender woman and 1 in 400,000 is a transgender man, although these estimates of prevalence are likely conservative. Transgender individuals are at an increased risk of tobacco, alcohol, and substance abuse; they have an increased lifetime suicide attempt risk; and they are more likely to experience significant stressors in their lives. Transgender patients may elect to transition their appearance to the gender with which they identify. Hormone treatment (and possibly sex reassignment surgery) is a significant part of this transition, and pharmacists must understand the pharmacotherapeutic principles involved so they can better recommend therapeutic agents, provide dosing recommendations, and anticipate and manage adverse effects. It is critical to be culturally sensitive when providing care for transgender patients including using their preferred gender identity, preferred names, and preferred pronouns. It is also essential to be able to identify transgender and transsexual patients correctly within electronic health records to ensure that appropriate care and monitoring are provided. For pharmacists, this means they should know the biologic sex for performing calculations such as creatinine clearance and to prevent teratogenic agents from reaching a transgender or transsexual man who could be pregnant or is capable of becoming pregnant. Promoting knowledge of transgender health issues will enable pharmacists to provide better, more holistic care to their transgender patients.

Priorities for transgender medical and healthcare research

PURPOSE OF REVIEW

Transgender individuals experience unique health disparities but are the subject of little focused health research. This manuscript reviews current literature on transgender medical and mental health outcomes and proposes research priorities to address knowledge gaps.

RECENT FINDINGS

Published research in transgender healthcare consists primarily of case reports, retrospective and cross-sectional studies, involving largely European settings. Challenges to US-based transgender health research include a diverse population where no single center has sufficient patient base to conduct clinical research with statistical rigor. Treatment regimens are heterogeneous and warrant study for best practices. Current research suggests increased mortality and depression in transgender individuals not receiving optimal care, and possibly a modest increase in cardiovascular risk related to hormone therapy. Current evidence does not support concerns for hormone-related malignancy risk.

SUMMARY

The priorities for transgender medical outcomes research should be to determine health disparities and comorbid health conditions over the life span, along with the effects of mental health, medical, and surgical interventions on morbidity and mortality. Specific outcomes of interest based on frequency in the literature, potential severity of outcome, and patient-centered interest, include affective disorders, cardiovascular disease, malignancies, fertility, and time dose-related responses of specific interventions.

Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations

This article provides an overview of the current literature on seven cancer sites that may disproportionately affect lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. For each cancer site, the authors present and discuss the descriptive statistics, primary prevention, secondary prevention and preclinical disease, tertiary prevention and late-stage disease, and clinical implications. Finally, an overview of psychosocial factors related to cancer survivorship is offered as well as strategies for improving access to care.

Pancreatic mucinous cystic neoplasm in a transgender patient

Background

Cystic pancreatic lesions are increasingly more frequent detected clinical entities. Mucinous cystic neoplasm (MCN) is a hormone-related pancreatic tumor (HRTP) with a strong predominance in young and middle-aged females.

Case presentation

Here, we present the case of a 31-year-old surgically transgendered female-to-male patient with a history of alcoholic pancreatitis, on chronic testosterone therapy. He was found to have a pancreatic MCN and underwent distal pancreatectomy and splenectomy.

Conclusion

To our knowledge, this is the first reported case of a transgender patient with a history of hormone replacement therapy (HRT) and pancreatic MCN. We consider possible mechanisms for the pathogenesis to explain this patient’s neoplasm.

Hormone therapy in transgender adults is safe with provider supervision; A review of hormone therapy sequelae for transgender individuals

INTRODUCTION

Some providers report concern for the safety of transgender hormone therapy (HT).

METHODS

This is a systematic literature review of HT safety for transgender adults.

RESULTS

Current literature suggests HT is safe when followed carefully for certain risks. The greatest health concern for HT in transgender women is venous thromboembolism. HT among transgender men appears to cause polycythemia. Both groups experienced elevated fasting glucose. There is no increase in cancer prevalence or mortality due to transgender HT.

CONCLUSION

Although current data support the safety of transgender HT with physician supervision, larger, long-term studies are needed in transgender medicine.

A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria

This review focuses on the effect that cross-gender sex steroid therapy has on metabolic and hormonal parameters. There is an emphasis on those changes that result in significant clinical effects such as the positive effects of the development of secondary sexual characteristics and negative effects such as haemostatic effects and thromboembolism in transwomen or dyslipidaemia in transmen. There is also a description of the current hormonal regimens used at the largest UK gender identity clinic. The overall safety of these treatments in the context of long-term outcome data is reviewed.