Routine screening has significantly contributed to the decrease in cancer mortality rates over the last 50 years. And though the World Professional Association of Transgender Health (WPATH) has developed Standards of Care for transgender and gender-diverse (TGD) patients, there are no specific guidelines for cancer screening.
In the absence of TGD-specific screening guidelines, cisgender protocols are recommended--this is true where organs remain in place or, in some cases, where there has been gender-confirmation surgery. However, trans and nonbinary patients may have unique considerations related to anatomy, hormone use, and surgical history, which can make it challenging to apply standard screening protocols effectively.
Breast Cancer Screening for the TGD Community
Transgender men may be at a higher risk for breast cancer than trans women and cisgender men. This may relate to early exposure to estrogen or the lack of suppression treatment.
Unlike total mastectomies, chest reconstruction methods, such as keyhole and periareolar surgery, leave some breast tissue behind. In these cases, trans men may still be at risk for breast cancer and should be evaluated on an ongoing basis.
Trans women who have used estrogen for more than five years may also face increased breast cancer risk.
A clinical breast exam of the area behind the nipple or underarm region may be required as part of an assessment. You and your doctor should discuss when additional screening is advisable.
Recommendations for transgender men and nonbinary individuals are as follows:
Mammogram usually appropriate
- Patients 25 - 30+ with a breast reduction or no chest surgery and a personal or family history of breast cancer.
- Patients 40+ with a breast reduction or no chest surgery should discuss a yearly or biennial mammogram.
- Patients who have undergone a bilateral (double) mastectomy.
Mammogram usually appropriate
- Patients 25 – 30+ years with past or current use of hormones for 5+ years and a personal or family history of cancer.
- Patients 25 – 30+ years with either no past use of hormones or hormone use for <5 years and a personal or family history of cancer.
- Patients 40+ who have been receiving hormone therapy for five+ years should discuss a yearly or biennial mammogram.
- Patients who have not had hormone therapy or who have had hormone therapy for <5 years.
Breast cancer screening recommendations are taken from The American College of Radiology and are based on sex assigned at birth, use of hormones, and risk factors.
Speak with your practitioner about what is appropriate for you.
Gynecologic Screening for the TGD Community
The American Cancer Society’s cervical cancer screening guidelines for transgender men and nonbinary individuals include the following:
- Patients 25+ should begin cervical cancer screening.
- Patients between 25 – 65 should have a primary HPV test or co-test (HPV and Pap combined) every five years or a Pap test alone every three
- Patients who have received the HPV vaccination should continue to follow guidelines for their age groups.
- Patients who have had their uterus and cervix removed do not need to continue screening unless removal was due to cancer or a serious pre-cancer.
Gender-affirming hormone therapy (GAHT) does not increase the risk of cervical cancer. However, GAHT can cause cervical atrophy, making obtaining a viable Pap result more challenging. Retesting may be required.
Transgender women who have had vaginoplasty do not need Pap smears. However, vaginal exams may be recommended to screen for sexually transmitted infections, such as HPV, and to address pelvic issues after surgery.
Data regarding the prevalence and cancer risk factors for transgender and nonbinary patients are limited. However, the link between HPV and certain types of cancer is well established. Screenings should continue, and any patient with a uterus or cervix should immediately inform their physician of any abnormal bleeding or discomfort.
Prostate Cancer Screening for the TGD Community
The incidence of prostate cancer in trans women is still being researched, but it does appear lower than that of cisgender men. This may result from androgen deprivation (suppression of hormones) combined with estrogen and progesterone therapy.
Still, anyone with a prostate gland can get prostate cancer. Even those who have undergone gender-confirming surgery will typically retain their prostate.
Cancer risk for those assigned male at birth increases at age 50+ and even earlier for Black individuals or those with a family history of prostate cancer.
The standard prostate screening for all patients born with a prostate may include:
- A digital rectal exam (DRE) to determine an unusual prostate size or shape.
- A PSA (prostate-specific androgen) test to measure PSA in the blood.
- An MRI if a more complete view is recommended.
The prostate exam may vary if the patient has had gender-confirming surgery.
Mission one is to remove barriers and provide the best care for transgender and gender-diverse patients. Finding a physician with whom you feel comfortable and who has demonstrated competency and sensitivity in TGD healthcare is essential. It’s also vital to share medical records detailing your surgical history and any developments linked to gender-affirming hormones.
Early detection and treatment can improve patient outcomes.
