Barriers to cancer screening in transgender women

To the Editor: I read with great interest the review article by Drs. Vasilev, Kling, and Carroll in the July issue.¹ In addition to reviewing breast cancer risk and screening for transgender and gender-diverse individuals, the authors highlight important barriers to screening, including denial of coverage for screening mammography by insurers due to incongruence between recorded sex and gender identity.¹

There is a similar barrier to prostate cancer screening in transgender women. The prostate gland is not removed during gender-affirming surgery, and therefore all transgender women remain at risk for prostate cancer, especially those who have not received gender-affirming hormone therapy.² Although cases of prostate cancer have been reported in transgender women,² there currently are no established guidelines for prostate-specific a ntigen (PSA) testing or prostate cancer screening in this population.³ A recent study found that many transgender women and transfeminine individuals have never undergone PSA screening.⁴

At our clinic, we follow the United States Preventive Services Task Force recommendations⁵ for prostate cancer screening in average-risk men. We routinely discuss prostate cancer screening with transgender women age 55 to 69 years and proceed with PSA testing when the patient opts for screening. In addition to challenges related to insurance coverage, we have encountered 2 recurring barriers:

• Our electronic medical record system triggers an alert stating, “Encounter for screening for malignant neoplasm of prostate is not valid for this patient’s sex,” preventing the order from being processed electronically

• When patients present with paper orders for PSA screening, laboratory staff frequently question the necessity of the test based on the patient’s gender presentation.

Further research is urgently needed to clarify the relationship between gender-affirming hormone therapy and prostate cancer risk in transgender women. Such evidence is critical for developing screening guidelines that can help address these barriers and promote health equity for this underserved population.

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