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More than 1.6 million adults and adolescents (aged 13 to 17 years) in the United States identify as transgender, according to a report released earlier this year.1
Research has shown disparities in health status and health care between transgender and cisgender patients, with transgender patients often having worse physical and mental health and limited access to equitable health care services.2-4
“Generally, studies have demonstrated that transgender patients face more barriers to access health care for a variety of reasons, including discrimination, financial or socioeconomic barriers, health care system barriers, and lack of provider education on caring for transgender patients,” explained Kevin Liu, MD, DPhil, a resident physician in the Harvard Radiation Oncology Program in Boston.
“However, there is a dearth of data regarding the disparities in cancer outcomes and treatment among transgender patients compared to cisgender patients,” Dr Liu added.
Evidence of Disparities Among Cancer Patients
A few recent studies have provided some insights regarding transgender patients with cancer, including a population-based study published in 2021.5 The study included 589 transgender patients and 11,776,110 cisgender patients from the National Cancer Database.
The researchers found that transgender patients were more likely than cisgender patients to have lung cancer at an advanced stage at diagnosis (odds ratio [OR], 1.76; 95% CI, 0.95-3.28) and less likely to receive treatment for kidney cancer (OR, 0.19; 95% CI, 0.08-0.47) or pancreatic cancer (OR, 0.33; 95% CI, 0.11-0.95).
In addition, transgender patients had a higher risk for death after a diagnosis of non-Hodgkin lymphoma (hazard ratio [HR], 2.34; 95% CI, 1.51-3.63) and cancers of the prostate (HR, 1.91; 95% CI, 1.06-3.45) and bladder (HR, 2.86; 95% CI, 1.36-6.00).
In a study published in 2020, researchers examined data on 95,800 patients in the Behavioral Risk Factor Surveillance System, including 1877 transgender women, 1344 transgender men, 876 gender-nonconforming individuals, 540,389 cisgender women, and 410,422 cisgender men.6
Analyses revealed that transgender men had roughly twice the risk of a cancer diagnosis as cisgender men (adjusted OR [aOR], 2.29; 95% CI, 1.19-4.40; P =.01), but there was no significant difference in cancer prevalence between transgender men and cisgender women (aOR, 1.67; 95% CI, 0.87-3.22; P =.12).
The likelihood of a cancer diagnosis was similar for transgender women, gender-nonconforming individuals, and cisgender men and women.
Among the cancer survivors, transgender men were more likely than cisgender men and women to have poor physical health, cardiovascular disease, and diabetes. Transgender women were more likely than cisgender men to have diabetes and more likely than cisgender women to have cardiovascular disease and diabetes.
Gender-nonconforming cancer survivors were more likely than cisgender survivors to be depressed, engage in heavy episodic alcohol use, and be physically inactive.
“Our findings on health outcomes were alarming,” said study author Ulrike Boehmer, PhD, an adjunct associate professor of social and behavioral sciences at Boston University School of Public Health.
Dr Boehmer pointed to the need for further investigation into the reasons for these differences as well as those observed in the 2021 study.5
The Role of Cancer Screening
Emerging findings indicate that delayed cancer screening in transgender patients may be a key factor contributing to disparities in outcomes between these patients and cisgender patients.
“I did a study of transgender cancer screening experiences,7 and transgender men shared stories of avoiding care until they were in extreme pain because of bad experiences in the health care system and lack of provider knowledge of how to care for them,” said Mandi L. Pratt-Chapman, PhD, an associate professor at the George Washington University School of Medicine and Health Sciences in Washington, DC. Dr Pratt-Chapman is also the associate center director for community outreach, engagement, and equity at the GW Cancer Center.
In a retrospective case series of 37 transgender cancer patients, Dr Liu and colleagues described a patient assigned female at birth who underwent gender-affirming bilateral mastectomies and later noticed a chest wall mass, which the patient’s previous physician said was “consistent with fat redistribution after surgery.”8
This led to a diagnostic delay of more than 1 year. The patient ultimately received a diagnosis of metastatic breast cancer and died of the disease.
“This finding suggests that practitioners should continue to screen and consider diagnoses that may be associated with” a patient’s sex assigned at birth, the authors wrote.8
Dr Pratt-Chapman highlighted the importance of knowing a patient’s exogenous and endogenous hormone balance, past surgeries, and natal and present organs if clinically relevant, and she recommended that clinicians base treatment planning on these characteristics. For instance, breast cancer screening should be recommended for a patient older than 50 years who has breast tissue.9
Providing Gender-Affirming Cancer Care
Dr Pratt-Chapman advised oncology providers to “be open and affirming in your communication with transgender and gender-diverse patients,” and develop policies and protocols that support inclusive care. For example, intake forms should ask about preferred names and pronouns, sexual orientation, and gender identity. The GW Cancer Center has created downloadable patient cards to be used for this purpose.
Additionally, electronic health record templates should be designed to collect these details along with information about the patient’s present anatomy and past surgeries. Providers should be trained and monitored to ensure the systematic collection of these data, and they should be educated on the “relevance of these data to cancer prevention, screening, treatment, and survivorship,” Dr Pratt-Chapman said.
In a recent survey of American Society of Clinical Oncology members, Dr Pratt-Chapman and colleagues found that less than half of respondents reported collecting such data.10
“We know that clinicians are hesitant to ask about gender identity, don’t feel comfortable asking, or don’t know how to ask,” Dr Boehmer noted. She suggested that clinicians take the opportunity to receive training on these and other aspects of caring for transgender patients.
“Providers should have knowledge about interactions between cancer treatments and gender-affirming therapies” and discuss these issues with patients,” Dr Liu added. As an example, the induction of early menopause due to cancer treatment may influence decisions regarding gender-affirming hormone therapy.8
“In addition, multidisciplinary care between primary care, providers of gender-affirming therapy, and oncologists may be beneficial, particularly in pediatric and young adult patients,” Dr Liu said.
In considering patients’ social determinants of health as they undergo cancer treatment, clinicians may need to refer patients to social services, additional medical services, or psychosocial support, according to Dr Boehmer. “Before they make these recommendations, it is important to ensure that the intended referrals are competent and adequately trained to interact [with] and assist transgender patients,” Dr Boehmer added.
Providers should remain aware of the “background of stigma, rejection, and discrimination that transgender patients bring with them as they begin with their cancer diagnosis and treatment,” Dr Boehmer said. “Providing patient-centered care to transgender patients will require a caring, attentive, and open-minded clinician who dedicates the time and effort to address transgender patients’ preferences and needs.”
Disclosures: All interviewees reported having no relevant disclosures.
References
1. Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States? UCLA: The Williams Institute. 2022. Accessed September 21, 2022.
2. Johnson AH, Hill I, Beach-Ferrara J, Rogers BA, Bradford A. Common barriers to healthcare for transgender people in the U.S. Southeast. Int J Transgend Health. 2020;21(1):70-78. doi:10.1080/15532739.2019.1700203
3. Warner DM 2nd, Mehta AH. Identifying and addressing barriers to transgender healthcare: Where we are and what we need to do about it. J Gen Intern Med. 2021;36(11):3559-3561. doi:10.1007/s11606-021-07001-2
4. Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016;23(2):168-171. doi:10.1097/MED.0000000000000227
5. Jackson SS, Han X, Mao Z, et al. Cancer stage, treatment, and survival among transgender patients in the United States. J Natl Cancer Inst. 2021;113(9):1221-1227. doi:10.1093/jnci/djab028
6. Boehmer U, Gereige J, Winter M, Ozonoff A, Scout N. Transgender individuals’ cancer survivorship: Results of a cross-sectional study. Cancer. 2020;126(12):2829-2836. doi:10.1002/cncr.32784
7. Pratt-Chapman ML, Murphy J, Hines D, Brazinskaite R, Warren AR, Radix A. “When the pain is so acute or if I think that I’m going to die”: Health care seeking behaviors and experiences of transgender and gender diverse people in an urban area. PLoS One. 2021;16(2):e0246883. doi:10.1371/journal.pone.0246883
8. Burns ZT, Bitterman DS, Perni S, et al. Clinical characteristics, experiences, and outcomes of transgender patients with cancer. JAMA Oncol. 2021;7(1):e205671. doi:10.1001/jamaoncol.2020.5671
9. Sterling J, Garcia MM. Cancer screening in the transgender population: A review of current guidelines, best practices, and a proposed care model. Transl Androl Urol. 2020;9(6):2771-2785. doi:10.21037/tau-20-954
10. Kamen CS, Pratt-Chapman ML, Meersman SC, et al. Sexual orientation and gender identity data collection in oncology practice: Findings of an ASCO survey. JCO Oncol Pract. 2022;18(8):e1297-e1305. doi:10.1200/OP.22.00084
