What Transgender Women and Transfeminine People Should Know About Prostate and Testicular Cancer

Your history of gender-affirming hormone therapy and surgery may impact your risk.

What Transgender Women and Transfeminine People Should Know About Prostate and Testicular Cancer

If you are a transgender woman or a transfeminine person, screening for prostate and testicular cancer may not be at the top of your medical to-do list, particularly if you've had gender-affirming surgery or you've been on gender-affirming hormone therapy (GAHT) for some time. But the reality is that anyone assigned male at birth can develop either of these cancers.

The good news is that early detection can increase the likelihood of favorable outcomes. Here’s what you need to know about your risk—and the latest screening recommendations—to help you get the care you need and deserve.

Knowing your risk
Research is still needed to better illustrate how often transfeminine people, including people on feminizing hormones or with a history of feminizing surgery, develop prostate and testicular cancer. Here’s what we do know:

Prostate cancer seems less common in transfeminine people than in cisgender men. Prostate cancer is the second most common cancer diagnosed in cisgender men in the United States, and the American Cancer Society estimates that 1 in 8 cisgender men will be diagnosed in their lifetimes. Certain people are at a higher risk, particularly cisgender men who are Black and/or have a family history of prostate cancer. Understanding how common it is in transfeminine people, however, is difficult due to limited data.

"We know that testosterone can actually worsen some prostate cancers, and one of the treatments for prostate cancer includes blocking the action of testosterone on the prostate," explains Christina Milano, MD, a family physician and co-founder and medical director of the Transgender Health Program at Oregon Health & Science University. It would make sense, therefore, that being on GAHT that suppresses or blocks testosterone "may actually have a benefit on that person’s likelihood of experiencing prostate cancer," she adds.

So how does gender-affirming surgery play into your risk of prostate cancer?

"The creation of the vaginal canal during gender-affirming surgery does not involve removal of the prostate,” says Dr. Milano. Because the prostate is left behind for those procedures, your risk for future prostate cancer would not be eliminated. If somebody has a gender-affirming surgery that involves removal of the testes and that natural source of testosterone in the body, she adds, “that would have a beneficial impact of limiting testosterone exposure were somebody to have prostate cancer." 

Unfortunately, there is limited data on the rate of prostate cancer in transfeminine people. One large retrospective cohort study in the Netherlands published in 2020 in The Journal of Clinical Endocrinology and Metabolism found six prostate cancers when following 2,281 transgender women on hormone treatment who had visited a particular gender identity clinic between 1972 and 2016. Four of those cases were in transgender women who had undergone orchiectomy (surgery to remove the testes).

The researchers concluded that the risk of prostate cancer in transfeminine people on hormone therapy was significantly lower than the risk in cisgender men, but the risk wasn't eliminated completely.

Testicular cancer is very rare in transfeminine people, but it can happen. Testicular cancer is already relatively rare, with an estimated 1 in 250 cisgender men diagnosed in their lifetimes. When it is diagnosed, it usually occurs in young people between the ages of 15 and 34.

There have been very few reported cases of testicular cancer in transfeminine people on GAHT, but it's a possibility if you haven't had surgery to remove the testicles. (If you have had that surgery, your risk of testicular cancer is effectively reduced to zero.)

Understanding the screening guidelines
In general, screening recommendations for prostate and testicular cancer in transfeminine people follow the guidelines for cisgender men, though there are additional factors to consider.

Prostate cancer screening is something to discuss with a trusted healthcare provider. Prostate cancer screening can be done with a blood test called the prostate specific antigen (PSA) test, which measures how much of that protein is in your blood. Depending on your level, your healthcare provider (HCP) might advise further testing or a biopsy to determine if prostate cancer is actually present.

That said, there is some controversy around the usefulness of routine PSA tests in people with an average risk of prostate cancer, both because the test can lead to unnecessary biopsies and because the cancer progresses so slowly. Because of this, the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention recommend that people at average risk of prostate cancer discuss with their HCP whether screening is right for them. This conversation would ideally include the potential benefits, risks and uncertainties associated with screening.

The American Cancer Society recommends starting prostate cancer screening discussions at age 50 if you're at average risk, but echoes the importance of making a cost-benefit analysis with your HCP.

Given that transfeminine people on GAHT with otherwise average risk have even lower than average risk of prostate cancer, the decision to screen will likely involve a discussion of your medical history, risk factors and any symptoms (like new urinary problems) with your provider. Finding a knowledgeable HCP to help you make this decision is key.

There are no recommended screening guidelines or tests for testicular cancer. When it comes to testicular cancer, the USPSTF recommends against routine screening for cisgender men, which experts would extend to transfeminine individuals, too. That said, if you have not had an orchiectomy, keep in mind that you may be at risk for testicular cancer. Many providers include an examination of a person’s testicles as part of a routine physical exam and often recommend that people do checks at home. It's important to see an HCP if you notice anything out of the ordinary in that area, including irregularities on the surface of your testes or any pain, swelling or discoloration that doesn't go away, explains Milano.

What to expect from screening
Much of the advice around screening hinges on having conversations with a trusted HCP, which may not be something that all people have access to. If you don’t have a regular HCP, you can find affirming and knowledgeable providers near you by searching online databases like those from OutCare and GLMA, or asking people in your community for recommendations.

"We have to create environments where it's easy for patients to say, ‘I am a person who still has a prostate and I want to know what to do about taking care of my prostate,’ and, ‘What are symptoms of prostate illness or issues?’ and being able to have a safe, comfortable dialogue around that," says Milano. "That begins with a gender-affirming care environment where it's easy for patients to self-identity as transgender if they wish to do so, it's comfortable and safe for them to raise those kinds of questions and to have exams with people with whom they feel safe and who they trust."

If you and your HCP decide to move forward with prostate cancer screening, that may include both a PSA test and a physical exam. If you've had vaginoplasty, your provider may examine the prostate through the neovaginal canal, rather than through the rectum, explains Milano. If your provider is concerned about testicular cancer, they will likely start with a physical exam and may order further tests based on your symptoms.

While more research is needed to understand the risk of prostate and testicular conditions in transfeminine people, the best place to start is by seeking sensitive, evidence-based care from an HCP with whom you can speak openly and comfortably.

Medically reviewed in July 2021.

Sources:

Centers for Disease Control and Prevention. Prostate Cancer Statistics. Page last reviewed June 8, 2021.
American Cancer Society. Key Statistics for Prostate Cancer. Last revised January 12, 2021
American Cancer Society. Prostate Cancer Risk Factors. Last revised June 9, 2020.
de Nie I, de Blok CJM, van der Sluis TM, et al. Prostate cancer incidence under androgen deprivation: nationwide cohort study in trans women receiving hormone treatment. J Clin Endocrinol Metab. Published online June 27, 2020.
American Cancer Society. Key Statistics for Testicular Cancer. Last revised January 12, 2021.
National Cancer Institute. Testicular Cancer Screening (PDQ®)–Patient Version. Updated June 12, 2019.
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.
Centers for Disease Control and Prevention. Should I Get Screened for Prostate Cancer? Page last reviewed August 18, 2020.
American Cancer Society. American Cancer Society Recommendations for Prostate Cancer Early Detection. Last revised April 23, 2021.
U.S. Preventive Services Task Force. Final Recommendation Statement. Testicular Cancer: Screening. April 15, 2011.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Prostate and testicular cancer considerations in transgender women. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016.  

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