Prostate Cancer in the Transgender Community

This section of our website has been designed to provide information about prostate cancer for male-to-female (MTF) individuals and their health care providers.  For clarity we will refer to these individuals as transgender women, or trans women, but recognize that many individuals identify along a spectrum and may not chose to identify in this manner.
 
The Prostate and Prostate Cancer
Transgender woman will have a prostate, regardless of whether or not she has undergone a gender-confirming surgery, such as orchiectomy or vaginoplasty. During gender confirming surgery, the prostate is typically spared, as its removal is intricate and can lead to complications including urinary incontinence[i]. Therefore, for women who have or have not had genital surgery, it is possible for prostate cancer to develop.
 
As part of feminizing hormone therapy, trans women often receive estrogen as well as either or both antiandrogens and 5-alpha-reductase inhibitor therapies. This creates an environment in which the prostate is androgen-deprived[ii]. There are conflicting theories about whether this environment reduces prostate cancer development or whether it may lead to more aggressive prostate cancers[iii].  There is also speculation about whether the age at which feminizing hormone therapy begins may have an impact on the development of prostate cancer[iv]. Additional research is needed into the effects of feminizing hormone therapy and the risk of prostate cancer.
 
While there are some anecdotal reports and case studies of prostate cancer among trans women, these number less than ten cases in total [v], and suggests that the incidence of prostate cancer among transgender women may be lower than among cis-gendered men.  However, it should be noted that these reported cases were not based on disease screening but detected based on clinical symptoms. Hence, the natural incidence of prostate cancer among trans women remains unknown. Both under-diagnosis and delayed-diagnosis of prostate cancer can occur from a lack of routine prostate cancer screening and from the fact that feminizing hormone therapy lowers Prostate Specific Antigen (PSA) levels- a key indicator used in prostate cancer screening. Delayed diagnosis could account for the fact that many of the reported cases of prostate cancer among trans women appear to reflect a higher-grade (more aggressive) cancer[vi]. Furthermore, research suggests that the incidence of prostate cancer is higher among transgender women who initiated feminizing hormone therapy after age 40, versus before age 40[vii]. Widespread use of feminizing hormone therapy began only in the 1970’s. Hence, a potential confounding factor may be that, if feminizing hormone does indeed lower the risk of prostate cancer (or at a minimum clinically symptomatic prostate cancer), then it may be that only a limited number of trans women have yet reached old age- when prostate cancer risk is known to naturally increase.   Overall, there remains limited data on which to base prostate cancer screening guidelines specifically for trans women at this time[viii].
 
Screening for Prostate Cancer
In the absence of large-scale studies, health care providers may not have enough clinical evidence on which to base recommendations for a specific type and frequency of prostate cancer screenings specifically for trans women[ix]. However, in light of the fact that prostate cancer can occur in trans women, the conversation about screening should be approached thoughtfully and as an opportunity for the healthcare provider and patient to discuss, in necessary detail, the importance of well-health screenings and medical follow-up[x]
The decision to screen may also be impacted by the risk profile of a trans woman, including risk factors such as having a family history of prostate cancer or being of African or Caribbean decent.  Therefore, until more robust clinical and epidemiologic data is available related to prostate cancer specifically among trans women, having prostate cancer risk factors should prompt especially careful attention to prostate cancer screening. For individuals at increased risk, regular PSA tests and annual digital exams of the prostate may be reasonable, at least until clearer guidelines are available. More information on the risk factors for prostate cancer can be found here. (link to http://prostatecancer.ca/Prostate-Cancer/About-Prostate-Cancer/Risk-Factors)      
 
Prostate cancer screening may be considered not gender affirming for some transgender women, and screening may be both physically and emotionally painful for some patients[xi]. The decision to screen for prostate cancer, and how to do so, should be made by the patient in the context of a dedicated care-discussion with their healthcare provider.
 
Prostate Cancer Canada recommends that all individuals with a prostate receive a baseline PSA test. The baseline PSA number can be used as part of a prostate cancer risk profile, along with age, family history and ethnicity to determine when a subsequent PSA test is necessary. For more information about the PSA test visit our FAQ page here.
 
Physical Exam of the Prostate
For transgender women with a neo-vagina, the prostate is located anterior to, or in front of, the neo-vagina. Studies have shown that a neo-vaginal exam can allow for prostate examination in some women, depending on the length and rigidity of her neo-vagina.[xii] If a neo-vaginal exam is not possible, a digital rectal exam would allow for prostate palpation if the patient is comfortable to do so. Transvaginal ultrasound for prostate volume has been shown to be less uncomfortable than digital exam in one study, so this may be a more acceptable tool.[xiii] In studies measuring prostate volume in trans women, the prostate size is smaller than anticipated.[xiv] As such, digital exam alone may be falsely reassuring to providers who are not familiar with the technique as applied with trans women.
 
PSA Test Results
If the decision to screen is made, the results of a PSA test may be impacted by exposure to feminizing hormone therapy[xv]. Additionally, PSA levels will be decreased following orchiectomy and results >1.0ng mL-1 should indicate a need for further testing.[xvi]
 
Resources
For trans women experiencing prostate cancer, Prostate Cancer UK is trialling an online community support group. More information can be found here.
 
 
Prostate Cancer Canada encourages more research in this area to gain a better understanding of population level risk and the personal experience of trans women undergoing testing, diagnosis and treatment of prostate cancer.
 
 
Glossary
Feminizing Hormone Therapy: the use of medications (e.g. estrogen, anti-androgens, progestins) to develop physical characteristics that are in line with one’s gender or gender expression, including breast development, more fat on the hips, thighs, and buttocks, and softer skin. (PHSA)
 
Gender Affirming Surgery, Gender Confirming Surgery: range of surgeries that create physical characteristics that are in line with one’s gender identity, including vaginoplasty, orchiectomy, breast augmentation, chest surgery, and phalloplasty; sometimes referred to as sex reassignment surgery. (PHSA)
 
Male-to-Female (MTF): used to refer to a person assigned male at birth whose gender is female all or part of the time; transitioning-to-female; female-to-male spectrum. (QMUNITY, PHSA)
 
Orchiectomy: is a gender-affirming, feminizing, lower/bottom surgery a surgery to remove the testes (PHSA)
 
Trans women: used to describe someone who identifies as transgender and whose gender identity is female. (QMUNITY)
 
Transgender:  often abbreviated to ‘trans’, is an umbrella term that describes a wide range of people whose gender identity and/or expression differs from conventional expectations based on their assigned biological birth sex. Identifying as transgender is something that can only be decided by an individual for themselves and does not depend on criteria such as surgery or hormone treatment status. (QMUNITY)
 
Vaginoplasty: a gender-affirming, feminizing, lower surgery to create a vagina and vulva (including mons, labia, clitoris, and urethral opening) and remove the penis, scrotal sac and testes. (PHSA)
 
 
Our definitions are adapted from:
Provincial Health Services Authority (PHSA), Transgender Health Information Program, Glossary. Available here.
 
QMUNITY, Queer Terminology from A to Q. Available here.
 
[i] Holz, L. E. (2015). Epidemiology of advanced prostate cancer: Overview of known and less explored disparities in prostate cancer prognosis. Current Problems in Cancer, 39, 11-16.
[ii] Holz, L. E. (2015). Epidemiology of advanced prostate cancer: Overview of known and less explored disparities in prostate cancer prognosis. Current Problems in Cancer, 39, 11-16.
[iii] Gooren, L. Morgentaler, A. (2013). Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia, 46(10), 1156-1160.
[iv] Holz, L. E. (2015). Epidemiology of advanced prostate cancer: Overview of known and less explored disparities in prostate cancer prognosis. Current Problems in Cancer, 39, 11-16.
[v] Garcia, M.M., Christopher, N.A., Thomas, P., and Ralph, D.J.; Genital Gender Affirming Surgery for Transgender Patients; American Urologic Association (AUA Updates Series); Accepted for publication, July 2016)
[vi] Gooren L, Morgentaler A. Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia. 2014;46(10):1156-60
[vii] Gooren L, Morgentaler A. Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia. 2014;46(10):1156-60
[viii] Holz, L. E. (2015). Epidemiology of advanced prostate cancer: Overview of known and less explored disparities in prostate cancer prognosis. Current Problems in Cancer, 39, 11-16.
[ix] The World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Version.
[x] Gooren L, Morgentaler A. Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia. 2014;46(10):1156-60
[xi] The World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, 7th Version.
[xii] Weyers, S., De Sutter, P., Hoebeke, S., Monstrey, G., 'T Sjoen, G., Verstraelen, H. (2010). Gynaecological aspects of the treatment and follow-up of transsexual men and women. Facts Views Vis ObGyn., 2(1), 35-54.
[xiii] Weyers, S., De Sutter, P., Hoebeke, S., Monstrey, G., 'T Sjoen, G., Verstraelen, H. (2010). Gynaecological aspects of the treatment and follow-up of transsexual men and women. Facts Views Vis ObGyn., 2(1), 35-54.
[xiv] Jin, B., Turner, L., Walters, W.A.W., et al. (1996). Androgen or estrogen effect on human prostate. J Clin Endocrin Metabol. 81, 4290-4295.
[xv] Holz, L. E. (2015). Epidemiology of advanced prostate cancer: Overview of known and less explored disparities in prostate cancer prognosis. Current Problems in Cancer, 39, 11-16.
[xvi] Gooren, L. Morgentaler, A. (2013). Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia, 46(10), 1156-1160.




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