Transgender women remain at risk of prostate cancer


Transgender women retain their prostate even after gender-affirmation surgery and thus remain at risk of prostate cancer. Studies to date are limited to case reports.1 We describe a large case series of transgender women with prostate cancer within the Veterans Affairs (VA) health system.

Gender-affirmation surgery (GAS) is a critical step in the transition process for transgender women, helping them align their physical appearance with their gender identity. While GAS is known to remove the testes, little is known about the impact on the prostate gland.

Recent research indicates that transgender women who undergo GAS retain their prostate gland and are therefore at risk for prostate cancer, a disease commonly associated with cisgender men. While several case reports have described the occurrence of prostate cancer in transgender women, no large-scale studies have been conducted to examine this issue.

The present study aims to fill this knowledge gap by describing a large case series of transgender women with prostate cancer within the Veterans Affairs (VA) health system.

The case series demonstrated that prostate cancer is not as rare in transgender women as previously suggested in case reports. However, the incidence rates were lower than expected based on prior estimates of prostate cancer incidence in cisgender male veterans. The age-weighted mean number of cases of prostate cancer in cisgender male veterans was 331 per 100,000 in 2011, which was the median year of transgender identity entry into the VA system.

Given estimates of 10,000 transgender women in the VA, only about 14 cases per year were observed in this population. This lower rate may be due to various factors such as less PSA screening, suppressive effects of estrogen on prostate cancer development, or misinterpretation of “normal” PSA levels among those receiving gender-affirming hormone therapies.

Transgender women receiving estrogen at diagnosis had the most aggressive disease, with higher PSA density and a higher proportion of biopsy grade group 5, which suggests delayed diagnosis or early selection of cancer cells resistant to androgen deprivation. This type of cancer tends to be more aggressive.

Moreover, 25% of transgender women overall and 35% receiving estrogen had biopsy grade group 4 or 5, compared to only 16% of cisgender male veterans. These findings suggest that there may be additional disparities at the intersection of race and gender identity, as only 8% of transgender women with prostate cancer were Black compared to 29% of cisgender male veterans with prostate cancer.

Although this case series has provided valuable insights into the incidence and characteristics of prostate cancer in transgender women, it has some limitations. The study is a case series without a formal comparison group, and the findings are restricted to the VA population.

Additionally, the inability to access records outside the VA may have resulted in an underestimation of the number of prostate cancer cases in transgender women. Associations between characteristics such as estrogen use and markers of disease severity may reflect selection on disease diagnosis (an index event).

In conclusion, this case series highlights the need for further research to optimize prostate cancer detection strategies in transgender women. It also underscores the importance of raising awareness of prostate cancer risk in this population, as well as addressing the barriers that may prevent them from accessing appropriate screening and treatment.

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