by Carolyn Chu, MD, MSc, AAHIVS, AAHIVM Chief Medical Officer

May 9, 2023

Featured Literature:

Nik-Ahd F, De Hoedt A, Butler C, et al.  Prostate cancer in transgender women in the Veterans Affairs Health System, 2000-2022.  JAMA.  2023 Apr 29; e236028.  doi:10.1001/jama.2023.6028.  PMID 37119522.  

This case series describes estimates and estrogen history characteristics of transwomen who received care with the Veterans Affairs (VA) health system and were diagnosed with prostate cancer.  Chart review and data extraction was performed for all cases involving adults with an ICD code for prostate cancer and at least 1 code for transgender identity between January 2000 and November 2022.  Cases were grouped by no prior use of estrogen [ever], former use of estrogen but discontinuation prior to prostate cancer diagnosis, or active use of estrogen at time of diagnosis.  Among 449 people with prostate cancer and transgender identity codes, 155 (35%, corresponding to an estimated 14 cases per year) were confirmed transwomen with prostate cancer.  116 never previously used estrogen, 17 had used estrogen, and 22 actively used estrogen at time of diagnosis.  Median age at diagnosis was 61 and median PSA was 6.8 ng/mL.  All prostate cancers were detected through screening.  98% had not undergone bilateral orchiectomy, and median duration of estrogen use was 32 months among former and active estrogen users.  Overall, 45% were clinical stage T1 and 55% were stage T2.  Compared to people with biopsy grade group 1 or 2, grade group 4 or 5 was found in 23% vs. 71% of patients with no prior estrogen use, 25% vs. 56% in people with former use, and 35% vs. 53% with estrogen use at diagnosis.

Author’s Commentary:

This brief report provides a contemporary description of prostate cancer occurrence in transgender women who received care within a large integrated health care system.  Although estimates were less than expected, authors posit findings may be due to lower rates of PSA screening attributable to factors such as lack of prostate cancer risk awareness or stigma, suppressive effects of estrogen on prostate cancer development, or prostate cancers being missed in transwomen due to provider misinterpretation of PSA levels among people receiving gender-affirming hormone therapies.  The study’s observation that transwomen taking estrogen at time of diagnosis had the most aggressive disease bears further investigation.  Some healthcare systems are encouraging adoption of a more tailored approach involving broader screening conversations, tailored intensity based on individual circumstances such as history and baseline PSA, recognition of the role of active surveillance, and high-quality treatment.  It is important that experiences and outcomes of transgender women are included in these conversations and considerations to optimize prostate health care for all.

The author has no conflicts of interest to disclose.

View archived Clinical Research Update entries here.