Cancer Screening in the Transgender Population

A Review of Current Guidelines, Best Practices, and a Proposed Care Model

Joshua Sterling; Maurice M. Garcia


Transl Androl Urol. 2020;9(6):2771-2785. 

In This Article

Gender Affirming Hormone Therapy and Cancer Risk

The long-term effects of GAHT is a potential challenge unique to transgender patients. GAHT for transgender people is different from hormone replacement therapy for cis-gender people in two ways: (I) when GAHT is provided before surgical removal of their birth-sex gonads, the patient may have elevated serum levels of both masculinizing and femininizing hormones; (II) the effective dose of GAHT can vary widely by individual patient, such that some have significantly high serum levels of a particular hormone or its metabolites, which can increase (or decrease) risk with sex hormone-sensitive cancers.

The administration of sex hormones not only makes the interplay between birth-sex and cancer risk more complicated as they may not only affect the risk of sex-specific cancers but also for other cancers and/or organ systems (e.g., cardiovascular) that contain sex-receptors.

The role of estrogens and androgens in breast and prostate cancer has been well studied in cis-gender individuals and is emerging as an active area of transgender research. The presence of estrogen and progesterone receptors is a major factor in the prognosis and treatment of cis-females and cis-males with breast cancer.[27] Androgen receptors are present in most breast cancers and can have tumor suppressive or tumor proliferative effects depending on the type of breast cancer.[28] In all of these instances the effect of exogenous hormones on cancer risk or cancer treatment is still unknown.[29]

The effect of exogenous hormones has not been investigated in the US to date but there have been published studies from the Netherlands.[30,31] One study looked at over 2,300 transgender patients between 1975 and 2011 who all received GAHT. Over that time two breast cancer cases were reported in the transfeminine population, one case of breast cancer was reported in the transmasculine population, and one case of prostate cancer was reported. These rates were lower than breast cancer rates and prostate cancer rate for cis-females and cis-males respectively.[30,31]

The WPATH SOCv 7 states that the current evidence is insufficient to determine if feminizing hormones increase a patients risk of breast cancer but notes that risk of breast cancer in transfemales is not zero.[7] There is no evidence masculinizing hormones increases a patient's risk of breast or cervical, although it may increase the incidence of abnormal pap smears.[7] The current evidence is inconclusive to determine how masculinizing hormones affect the risk of ovarian, or uterine cancer.[7]