• Posted May 2, 2023

An Overlooked Issue: Prostate Cancer in Transgender Women

Transgender women have a risk of prostate cancer, even after gender-affirming surgeries, yet aren't “on the radar” for screening by clinicians, new research finds.

"The entire medical literature on prostate cancer in transgender women, prior to this study, consisted of 10 case reports, leading some to believe it was rare. But this paper shows it isn't as rare as those case reports suggest," said Dr. Stephen Freedland, associate director for training and education at Cedars-Sinai Cancer Institute in Los Angeles.

"Transgender women, no matter what gender-affirming surgeries they may or may not have had, have prostates and are at risk of prostate cancer," he said in a hospital news release.

Freedland's research report details the first large case series of transgender women with prostate cancer.

“Despite advances in screening and treatment, prostate cancer remains one of the deadliest cancers,” Freedland said. “In these studies, we identify practice-changing new treatment options and shed light on a group of patients who are not on the radar for most clinicians.”

Prostate cancer occurs in a gland near the bladder. Its role is to produce seminal fluid. The cancer can grow slowly or be aggressive and resistant to treatment.

Researchers reviewed data on prostate cancer patients from the U.S. Department of Veterans Affairs for 2000 through 2022, finding 155 transgender women with prostate cancer.

The number of cancers experienced by transgender women was lower than rates in cisgender (non-transgender) veterans. Also, while about 28% of cisgender male veterans with prostate cancer were Black, only 8% of transgender women with prostate cancer were Black.

Another finding was that transgender women who were taking estrogen, a common feminization therapy, had the most aggressive prostate cancer.

Researchers could not come to formal scientific conclusions because the number of patients was too small. They suggested that a lack of PSA (prostate specific antigen) testing in transgender women could help explain their lower rates of prostate cancer diagnosis.

"When a woman walks into a clinician's office, the doctor doesn't necessarily think of screening them for prostate cancer," Freedland said. "But even among patients who have had gender-affirming surgery, we do not remove the prostate, which is a nuance that people don't always think about."

One issue faced by transgender women is that it's not entirely clear what level PSA should be concerning because estrogen therapy can cause PSA levels to drop.

"In cisgender men, we have traditionally considered PSA levels below 4 to be safe," Freedland said, "but for patients on gender-affirming hormone therapy, PSA levels decrease dramatically and can even go down to zero. We don't yet have data to determine where the cutoff value for PSA should be in transgender women, but we suspect that some of these cancers are currently being missed because the cutoff value being used is too high.”

Freedland also suggested that the lower rates of diagnosis among Black transgender women could be due to a reluctance to identify as transgender to their doctors, who are then not screening them.

"We hope this report is eye-opening to people for whom this disease wasn't even on the radar," Freedland said. "The most important thing for transgender women and their health care providers to remember is that prostate cancer screening shouldn't be neglected."

The research was presented this weekend at the American Urological Association annual meeting in Chicago, and published April 29 in the Journal of the American Medical Association.

More information

The American Cancer Society has more on prostate cancer.

SOURCE: Cedars-Sinai, news release, April 29, 2023