Prostate cancer among transgender women may be more common than thought
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Key takeaways:
- Researchers estimated risk at approximately 14 cases per 10,000 people.
- Estrogen therapy use may delay prostate cancer diagnosis among transgender women.
Prostate cancer may be more common among transgender women than case reports suggest, according to a study published in JAMA that estimated risk at approximately 14 cases per 10,000 people.
The findings, based on Veterans Affairs Health System data, also showed transgender women who take estrogen therapy may experience delayed prostate cancer diagnosis.
Rationale and methodology
Transgender people remain incredibly marginalized and much remains to be learned about their health outcomes and how best to care for them, Farnoosh Nik-Ahd, MD, resident physician in the department of urology at University of California, San Francisco, told Healio.
“One important area of research is how to best perform screening of birth organs, such as the prostate,” Nik-Ahd said. “We wanted to focus on prostate cancer in transgender women as only 10 case reports had been published on this subject — there was a great need for more research on this.”
Researchers pooled data from the VA Health System for all adults with an International Classification of Diseases code for prostate cancer and at least one code for transgender identity at any time between January 2000 and November 2022.
Data collected at diagnosis included gender-affirming hormone therapies used, PSA, PSA density, bilateral orchiectomy status, biopsy grade group and disease stage.
Researchers grouped patients by use of estrogen therapy — which lowers testosterone and suppresses prostate cancer — as never used, formerly used but stopped prior to prostate cancer diagnosis, or actively used at diagnosis.
Findings
Overall, 449 patients (median age at diagnosis, 61 years; 88% white; median PSA, 6.8 ng/mL) had prostate cancer and transgender identity codes, of whom 155 patients (35%) were confirmed transgender women with prostate cancer.
Among them, 116 reported never using estrogen, 17 reported prior use and 22 reported active use of estrogen at diagnosis. Median duration of estrogen use was 32 months among former and active estrogen users. Researchers found 43% of patients had biopsy grade 1 and 45% clinical stage T1 disease. Nearly all patients (98%) had not undergone bilateral orchiectomy.
Further analysis showed biopsy grade group 1 or 2 disease in 58 of 82 patients (71%) with no previous estrogen use, nine out of 16 (56%) who had former estrogen use, and nine out of 17 (53%) who reported estrogen use at diagnosis. Results also showed biopsy grade group 4 or 5 disease among 23% of patients who reported never using estrogen, 25% of patients who reported former use and 35% who reported active estrogen use.
In addition, researchers observed median PSA density of 0.21 ng/mL/g among those who reported never using estrogen, 0.26 ng/mL/g among those who formerly used estrogen and 0.31 ng/mL/g among those who reported active use.
Implications
Researchers are only beginning to understand prostate cancer in this population, Nik-Ahd told Healio.
“Transgender women should still be considered for prostate cancer screening, and PSA values should be interpreted with caution for those on gender-affirming hormones,” she said. “Next steps are understanding how best to screen transgender women on gender-affirming hormones, establishing the formal incidence of prostate cancer in this population, and understanding PSA values as a function of gender-affirming hormones. We hope that one day there will be prostate cancer screening guidelines that are inclusive of transgender women.”
References:
- Nik-Ahd F, et al. JAMA. 2023;doi:10.1001/jama.2023.6028.
- Transgender women are still at risk for prostate cancer (press release). Available at: https://www.eurekalert.org/news-releases/987817. Published April 29, 2023. Accessed May 11, 2023.
For more information:
Farnoosh Nik-Ahd, MD, can be reached at farnoosh.nik-ahd@ucsf.edu.
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