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Cancer Treatment for Sexual and Gender Minorities

February 18, 2020 | AONN+ Blog | Sexuality and Cancer
Featuring:
Mandi Pratt-Chapman, MA, PhD, HON-OPN-CG
Mandi Pratt-Chapman, MA, PhD, HON-OPN-CG
Associate Center Director,
Patient-Centered Initiatives & Health Equity,
GW Cancer Center
Washington, DC

Lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) people have unique healthcare needs from cancer prevention to screening, treatment, and survivorship. It may come as a surprise to most readers, but a person’s gender identity is a complex matter when it comes to cancer. Social determinants of health, sex-based genes, and relational differences from mainstream society all play a part.

First, members of the LGBTQI community often face routine microaggressions – comments or behaviors that are hostile or negative. In most cases, the people performing the microaggression do not realize that they appear aggressive, biased, insulting, or unwelcoming. For example, the perception that being heterosexual and/or cisgender is “normal” and that being non-heterosexual or transgender is “abnormal,” is insulting and unwelcoming to sexual and gender minorities.

System-level factors often perpetuate bias against LGBTQI. In the United States, the Movement Advance Project tracks social policies that influence LGBTQI peoples’ ability to be parents, access nondiscriminatory healthcare, and change their gender identity documents. Globally, 76 countries continue to place criminal sanctions on homosexuality, and the penalty for same-sex practices in these countries varies from discrimination to the death penalty. As a matter of fact, Oman, this year’s World Cancer Congress host country, retains a punishment of up to 3 years’ imprisonment for same-sex behavior, and disallows same-sex marriage and adoption by same-sex couples. It prohibits legal gender identity change and allows for housing discrimination.

Sadly, some members of the LGBTQI community develop maladaptive coping strategies to deal with the untoward aggression, and many are likely to smoke, drink alcohol, and abuse substances, which leads to greater risk for many cancers.

Discrepancies in cancer screening and treatment mostly affect transgender and intersex individuals, as they may be taking exogenous hormones that modify risks for cancer. As estrogen is a known risk factor for breast cancer, transgender women over age 50 who have more than 5 years of estrogen exposure should start getting mammograms. On the other hand, transgender men over age 21 who retain a cervix still need cervical exams and/or HPV testing. However, it is important to note that testosterone may alter histology, which makes pap smears difficult to read for pathologists who are inexperienced in reading transmasculine smears. In addition, hormone status and sex chromosomes may alter the effects of certain pharmacotherapies, so knowing a patient’s sex assigned at birth as well as any exogenous hormones is critical to providing quality cancer treatment.

Cancer Screening Considerations for Transgender and Intersex People

Cancer Screening Transfeminine Transmasculine Intersex
Breast
  • Screen per USPSTF guidelines for women if estrogen exposure is ≥ 5 years and age is >50 years
  • If top surgery has been performed, individualize screening based on amount of breast tissue and risk profile
  • If top surgery has not been performed, screen using USPSTF guidelines for women
  • Individualize screening based on amount of breast tissue and risk profile
Cervical
  • Not indicated
  • Screen per USPSTF guidelines for women if cervix is retained
  • Gender dysphoria is strong and gender-affirming precautions should be taken
  • Histologic changes for people on testosterone may result in false positive screening
  • Screen per USPSTF guidelines for women if cervix is present
Endometrial and Ovarian
  • Not indicated
  • If bottom surgery, not indicated
  • If no bottom surgery, inform of risks and symptoms; encourage patient to report unexpected bleeding
  • Inform patients with a uterus of risks and symptoms
  • Encourage patient to report unexpected bleeding
Prostate
  • Individualize based on risk factors, (eg, ≥ 50 years of age, African American) and benefits
  • PSA 1ng/ML is upper limit of normal if patient is on estrogen therapy
  • Not indicated
  • Research is insufficient to provide recommendation
  • Individualize based on risk and benefits if patient has a prostate

That said, it is imperative that intersex patients be given care tailored to their individual anatomy, chromosome status, and gender identity. Unfortunately, despite knowing that transgender and intersex patients require special clinical management, oncology care professionals have almost no literature to guide them through evidence-based practices in these populations.

Last, posttreatment challenges for LGBTQI patients also differ from other patients with cancer. On one hand, patients may experience greater resilience posttreatment as a result of learning to adapt to adversity. On the other hand, assuming that all patients with cancer want – and can benefit from – the same posttreatment care can be disaffirming. For example, not all LBTQ people who have had surgery for breast cancer wish for female breast reconstruction, and existing drugs are inadequate to support same-sex intercourse for prostate cancer patients. Our current resources and practices continue to fall short for LGBTQI patients. For a more in-depth look at Cancer Care Considerations for Sexual and Gender Minorities, please visit https://www.tandfonline.com/doi/abs/10.1080/10463356.2019.1667673?journalCode=uacc20&.

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