Transgender women keep their prostates after gender-affirming surgery, and as a result are still at risk for prostate cancer. But the extent to which they’re at risk has been unclear up to now. A first-of-its-kind study led by UC San Francisco estimates the risk at about 14 cases per 10,000 people.
The study drew on 22 years of data from the Veterans Affairs Health System. Although the sample size was small due to the size of the transgender population, it is still the largest study of its kind. It published April 29, 2023 in the Journal of the American Medical Association (JAMA).
"What we know about prostate cancer to date is almost exclusively based on cisgender men,” said the study’s lead author, Farnoosh Nik-Ahd, MD, a urology resident at UCSF. “This is an important first step in reshaping how clinicians think about prostate cancer in transgender women.”
Transgender people often face discrimination and disparities, and there has been a growing acknowledgment of the complexities involved in their health care.
This is an important first step in reshaping how clinicians think about prostate cancer in transgender women.Farnoosh Nik-Ahd, MDUrology Resident, UCSF
The study found 155 confirmed transgender women with prostate cancer and stratified them according to whether they had used estrogen: 116 had never used estrogen, 17 had once used estrogen but stopped before they were diagnosed with prostate cancer and 22 were actively on estrogen.
The median age of diagnosis was 61 years, and 88% of the patients were white. Just 8% were Black, suggesting possible disparities affecting this group. Black cisgender men are at higher risk of being diagnosed with and dying from prostate cancer.
Risk Remains, But Less Than for Cisgender Males
The authors found that prostate cancer occurs in transgender women more frequently than published accounts suggest, with about 14 prostate cancer cases annually per 10,000 transgender women. Still, that rate was lower than what could be expected based on cisgender males, with 33 cases annually per 10,000.
While the numbers were small in the new study, the data suggests that transgender women who take estrogen may have delayed diagnoses. The authors also said that lower rates of prostate cancer may have been due to less PSA screening, misinterpretation of PSA levels in patients on gender-affirming hormone therapies, stigma, lack of awareness of prostate cancer risk and the effects of estrogen.
“We still have a lot of work to do to determine optimal prostate cancer screening for transgender women on estrogen and related treatments,” said co-senior author Matthew R. Cooperberg, MD, MPH, of the UCSF Department of Urology. “This study should be a reminder to clinicians and patients alike that, regardless of gender, people with prostates are at risk for prostate cancer.”
Co-authors: From UCSF, co-authors include Christi Butler, MD, and Peter R. Carroll, MD, MPH. The other authors are Amanda De Hoedt, MS, of the Veterans Affairs Health Care System in Durham, North Carolina; Jennifer T. Anger, MD, of UC San Diego; and Stephen J. Freedland, MD, of Cedars-Sinai Medical Center in Los Angeles.
Funding: No financial support reported.
About UCSF Health: UCSF Health is recognized worldwide for its innovative patient care, reflecting the latest medical knowledge, advanced technologies and pioneering research. It includes the flagship UCSF Medical Center, which is ranked among the top 10 hospitals nationwide, as well as UCSF Benioff Children’s Hospitals, with campuses in San Francisco and Oakland, Langley Porter Psychiatric Hospital and Clinics, UCSF Benioff Children’s Physicians and the UCSF Faculty Practice. These hospitals serve as the academic medical center of the University of California, San Francisco, which is world-renowned for its graduate-level health sciences education and biomedical research. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area.