A cancer screening or diagnosis can bring fear and uncertainty. It is a time when patients rely on providers for the highest quality guidance and treatment strategies. For transgender patients, whose experiences of discrimination and stigma in health care are documented in research, a cancer diagnosis can bring additional stress and compound the hurdles they must face to receive care.
Training providers on trans-inclusive and trans-specific issues and practices is one of the first steps to reducing those barriers. To help envision cancer care standards that are inclusive of trans people and sensitive to their needs, researchers from UNC-Chapel Hill and the Center for Applied Transgender Studies recently published a commentary in Nature Reviews Clinical Oncology that pinpoints areas where providers and researchers can confront inequity, especially for breast, prostate and gynecological cancers.
“Particularly for cancers that vary by sex assigned at birth, there are many unknowns in terms of how certain aspects of gender-affirming care, like hormone use, may affect cancer detection, treatment and survivorship,” said Mya Roberson, PhD, MSPH, assistant professor of health policy and management at the UNC Gillings School of Global Public Health and member of the UNC Lineberger Comprehensive Cancer Center. “The fields of cancer research and clinical oncology need to evolve beyond binaries and build up more robust research so that evidence-based care can truly be provided for all.”
In the commentary, Roberson and co-authors Elle Lett, PhD, MA, and Joannie Ivory, MD, MSPH, a UNC School of Medicine fellow of hematology and oncology, identify six areas where gaps in care should be addressed:
- Etiology (causation): The medical community needs more data to understand how cancer develops in trans patients and whether hormone therapy may interact with genetic variants to influence cancer.
- Prevention: Providers can play a role in increasing human papillomavirus (HPV) vaccination and screening for inherited genetic traits that may be linked to cancer.
- Detection: Cancer screening practices can be optimized to the specific needs of each patient. This may include, for example, creating mammography screening practices that reflect the needs of trans-women or expanding HPV at-home testing for trans-men to reduce gender dysphoria and discomfort.
- Diagnosis: Because many diagnostic markers for cancer were developed based on data from cisgender patients, this may lead to diagnostic uncertainty for trans patients.
- Treatment: Providers must understand how cancer treatment might conflict with ongoing gender-affirming care, including hormone therapy or surgery, and reconcile the most appropriate treatment strategies with the mitigation of gender dysphoria.
- Survivorship: While information-sharing and support programs are often designed based on cisgender and heteronormative relationships, trans people are more likely to form relationships outside their family or community of origin. The medical field should expand its conceptions of the traditional support network in order to include a trans patient’s chosen family.
“Put simply, I hope that this piece reminds people that trans folks get cancer, too, and our current bodies of evidence, by and large, do not serve them,” Roberson said. “That needs to change. All health care providers involved in the cancer care continuum from screening to treatment to survivorship have an important role in providing inclusive cancer care.”
Roberson said the next steps are to move these key areas from commentary to empirical analysis to build the evidence base that is so sorely missing to properly serve trans patients. Envisioning a future of optimal cancer care for transgender patients requires acknowledging the current policies preventing transgender youth and adults from obtaining care and criminalizing its provision.
—Meghan Palmer, UNC Gillings School of Global Public Health