Open, Non-Judgmental Communication Is Key in Transgender Cancer Care

Transgender patients with cancer may have unique risks as well as difficulties accessing proper care from medical institutions, creating a patient population whose needs are “not optimally addressed,” especially with a lack of open, non-judgmental communication between providers and patients, according to a recent study.

The data, published in JAMA Oncology, suggest that transgender patients experience different risk factors for specific cancer types depending on their gender identity and whether they receive hormone replacement therapy (HRT), a common method of transitioning by receiving the secondary sex hormone that most closely aligns with an individual’s desired physical attributes. Typically, transgender men will receive testosterone and transgender women will receive estrogen, but people of any gender identity may be inclined to undergo HRT and many transgender individuals have no desire to receive any hormones.

Transgender women were found to have 46-fold higher risk of breast cancer than cisgender (a term used to refer to anyone who identifies with the gender they were assigned at birth) men, while transgender men reported a reduced incidence of breast cancer than cisgender women. Transgender people were also indicated to have an increased risk of death from neoplasms, non-Hodgkin lymphoma, prostate cancer and bladder cancer, research found.

Other lifestyle factors of a high incidence in transgender populations that coincide with an increased cancer risk include smoking and drinking, while transgender women were found to be at higher risk of sexual-related risk factors, like HPV infection. Some data also suggest HRT usage may be a risk factor, but this has not been confirmed.

Study authors Dr. Leone Alberto Giovanni, medical oncologist at Istituto Nazionale dei Tumori (a major treatment and research center) in Milan and Dr.Dario Trapani, medical oncologist at the European Institute of Oncology in Milan and research fellow in medicine at the Dana-Farber Cancer Institute in Boston, spoke with CURE® about the importance of open patient-provider communication for this population.

In particular, hormone therapies could affect how cancer treatments work, so it is crucial for the health care team to know what other medications patients are taking.

“I must confess that gender-affirming hormone therapy (GAHT) represents a challenge for medical oncologists for several reasons. This is emerging in the ongoing surveys we are collecting. The changing hormonal environment might affect the pharmacokinetics and pharmacodynamics (the way drugs work and distribute in the body) of anti-cancer medications and it might be necessary to adjust doses by gender (identity) rather than by sex assigned at birth,” Giovanni explained. “At this point this is not very common: we know that many clinical trials in the past have favored men and sometimes post-menopausal women – meaning that we are not very cognizant of the sex (hormone) differences in medicine dosing, we are even less precise when it is about genders.”

He went on to explain that while an oncologist might push for a patient to stop HRT for the sake of their medical treatment, the extreme psychological distress this may elicit in some patients may not be worthwhile to quality of life.

“Sometimes the interruption of GAHT might be recommended from an oncologic point of view; this can be the case for tumors that can grow quickly under hormone stimulation and can regress with anti-hormone (drugs). However, it must be taken into account that GAHT interruption is not necessarily accepted by patients, related to an increased risk of mental health issues and distress for the self-perception. Therefore, my strong take is that we must avoid any form of paternalism or judgmental attitude and always share therapeutic decision with patients – showing the trade-off, the risks and the caveats of certain decisions.”

While the medical history of transgender patients may be important in creating a treatment plan, Trapani was adamant that a specific “transgender treatment model” would not be of benefit to patients, due to the wide variety of gender identities and expressions the term “transgender” encompasses. He said that any attempt to pigeonhole patients or their treatment decisions may be to their detriment.

As such, he noted that the ONCOGENDER task force of the Italian Association of Medical Oncology — which was founded through this research — believes that there should not be a specific transgender cancer care plan. Establishing one may lead clinicians to make certain assumptions, such as whether or not a patient underwent gender-affirming surgeries or treatment.

“HRT and information on previous surgery and other gender-affirming interventions must be accounted in the overall clinical decision making, to navigate options and inform on implications,” he explained. “We need to value what patients choose, not what we feel is more acceptable or appropriate. We don’t need a ‘transgender oncology,’ I believe, when you learn to be non-judgmental and objective in your practice.”

Instead, transgender care — and care of all patients — should “be based on the principles of equity, to assure that all patients will access best treatments, in an environment where they feel accepted for what they are.”

Trapani went on to highlight some cisgender people will take supplemental hormones as they age, and this fact would not necessarily change the treatment they receive from their oncologist.

“Probably, we wouldn’t be that interested (in asking) the same question to a postmenopausal woman who is taking (estrogen), we wouldn’t think about a separate care pathway – but still, we will be very interested to medically know what treatments someone is taking, to deliver the best fully informed and safest therapies.”

While research and health care policy for transgender individuals will need additional attention in years to come, patients with cancer are always encouraged to be as open as possible with their care teams and to receive regular disease screenings, the researchers noted.

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