BJ Rimel, MD, Cedar Sinai Medical Center, Los Angeles, California, discusses cancer-related concerns for transgender and special patient populations and gives an overview on providing inclusive care for those patients, a topic she presented at the 2023 Society of Gynecological Oncology’s Annual Meeting on Women’s Cancer in Tampa, Florida.

Dr Rimel discussed cervical cancer screening, testosterone supplementation, and the importance of providing compassionate, inclusive care to transgender and special patient populations.

Transcript

Hi, I'm BJ Rimel. I'm a gynecologic oncologist at Cedar Sinai Medical Center in Los Angeles, California. I'm presenting to you to give a brief overview of cancer-related concerns for transgender and special populations. This was originally presented at the SGO 2023 annual meeting. Thank you for being here with us today.

I'd like to just briefly explain why we have these concerns and why we're talking about these special populations. When I was first asked to talk about care of the transgender population and care of special populations, what people are really asking you about is how to define populations of patients we see in gynecologic oncology that experienced gender dysphoria and may come to us either for gender-affirming surgeries, may come to us in a transgender experience, and we as people need to make sure that we are careful about how we identify them and provide them with excellent and appropriate and inclusive care. That means asking the right questions and making sure that ourselves and our office staff are well-versed in how to make sure that we use people's chosen name and chosen pronouns. These may be referred to as preferred name or preferred pronouns, but really the patient comes to us asking for that kind of care, and it's important for us to be ready to give it.

From a cancer standpoint, there are sort of 3 major areas I'd like to briefly review for the gynecologic oncologist. The first is cancer prevention care in the transgender or non-binary or gender non-conforming population. Any human with a cervix, any person assigned female at birth who has born with a cervix, has a risk of cervical cancer. We know from data from large multi-institution studies, both in the United States and in Europe, that patients who identify as gender non-conforming are less likely to experience appropriate cervical cancer screening. In fact, even patients whose sexual orientation is women-only or lesbian patients, even in that population, there was a rate of CIN3 of 1.3%. This goes against a lot of the biases that have been previously sort of discussed, thinking about that patients who did not have sexual interactions with people with a penis weren’t at risk for HPV, but this is untrue.

Anyone who is sexually active who has a cervix needs to be screened for cervical cancer. Well, how do we do that in a population of patients, either transgender or of the sexual minorities such as lesbian who may not find pelvic exams tolerable? How do we do that? The basic understanding that we can do is offer the patient several different options for appropriate screening. Obviously, we can offer them a pelvic exam in the traditional sense, but we can also offer them HPV screening alone. There's recent data that suggests that self-sampling may also be an option. Allowing the patient to take a self-sampling instrument, go into the bathroom or in a private space of their own, take the sample themselves, and then provide that sample to us. Those are effective and reasonable. Further studies are needed to validate that this is as effective as physician-related testing, but these are very acceptable to populations, and we have great data to support this. HPV testing alone, remember, is an acceptable HPV screening option, cervical cancer screening option for our patients, and don't be afraid to use this in your office.

Another potential option for patients that are having other pelvic-related concerns, such as bleeding, is the use of a pelvic examination where the patient's allowed to have a distraction, where we have extra small specula available and we've given the patient plenty of time to get to know us, our office, and our environment, and develop a rapport with our patients to make sure that we are exceptionally careful in helping them. We want to not repeat the mistakes of the past exams and be careful about doing that by asking appropriate questions like, is this hard for you? Have you had bad experiences in the past? How can I best help you? What do you think would be the easiest way for us to approach this? I find that in my practice, those kinds of things are helpful.

Moving on from cervical cancer screening, which I hope I've convinced you everyone needs to, the questions I often get about transgender patients taking testosterone supplementation. Testosterone supplementation has been associated or concerns have been raised about androgen receptors that are present on ovarian tissue and have been demonstrated to be present on ovarian cancers. The question that I've frequently been asked and has been asked of in this population, is there risk of ovarian cancer in patients who are taking a long-term high-dose testosterone? The answer is, we don't have data to support that there is this risk. There's one case report in the literature demonstrating androgen receptor presence in a transgender patient who is diagnosed with ovarian cancer, but that's one. I would submit that if this was a very common problem, I would see a lot in my practice, which I do not, and I do have many transgender patients who retain their ovaries for future use or just because they wish to, that have not developed ovarian cancer. Obviously, long-term, large population studies are truly necessary. This is going to be important as we proceed forward. We can't just use anecdotal data, however, the data that we do have does not suggest that there is significant concern for this.

Finally, endometrial cancer. For our patients that have experienced abnormal uterine bleeding who are on testosterone therapy, it's important that we do an appropriate workup for abnormal uterine bleeding. We want to rule out any pre-cancerous or cancerous changes that the patient might have. In our practice, we've identified at least one patient that had endometrial intra epithelial neoplasia or a pre-cancerous change of the uterus who is on testosterone supplementation. That was identified at the time of gender affirmation surgery, which was quite a surprise to us. This needs to be worked up. We need to make sure that patients are fully aware that if they have any bleeding on testosterone, we really need to get a workup and ensure that we've identified their risks. For post endometrial cancer treatment returning to testosterone therapy, again, there is no data for us to use, but a complex conversation really valuing the patient's preferences is important. For some patients, their mental and emotional and social health is best served by returning to their hormone supplementation with testosterone.

In closure, I really appreciate you paying attention to this video, and I hope that if you have questions that you'll reach out. There are a lot of us providers who are excited and happy to give extra attention and advice in this area if it's ever needed, and I thank you very much.

Source:

Rimel, B. “Treating Transgender Patients: Cancer Related Concerns.” Presented at SGO Annual Meeting on Women's Cancer; March 25-28, 2023; Tampa, FL