Transgender women receiving hormone therapy may skew artificially low on prostate cancer screening tests, thereby providing false reassurance and potentially delaying diagnosis and treatment, according to a recent study published by Nik-Ahd et al in JAMA. The findings indicated that transgender women and physicians should interpret standard screening guidelines with caution.
Background
Prostate-specific antigen (PSA) levels are frequently elevated in patients with prostate cancer, and PSA tests are currently the standard screening tool to detect prostate cancer.
Following gender-affirming surgery, transgender women keep their prostates, placing them at risk of prostate cancer. Often, these patients receive estrogen, the most common gender-affirming hormone; however, this treatment may be associated with an increased likelihood of developing high-grade prostate cancer that goes undetected.
“Patients and [physicians] should be aware that PSA values in transgender women on estrogen should be interpreted with caution, as they are different than those in cisgender men,” emphasized lead study author Farnoosh Nik-Ahd, MD, a resident in the Department of Urology at the University of California, San Francisco (UCSF).
Study Methods and Results
In the recent study, the investigators used Veterans Health Administration records between January 2000 and August 2023 to analyze the outcomes of 210 transgender women aged 40 years and older receiving estrogen with no history of prostate cancer.
The investigators found that transgender women receiving estrogen scored 50 times lower than typical PSA tests. The investigators suggested that the current “normal” thresholds may be too high for transgender women. They stressed that their cancer might not be identified until it progresses to later stages because these patients might not receive additional screening until their PSA levels rise.
Conclusions
The investigators emphasized that there are currently no PSA ranges specific to transgender women. Further studies may be needed to determine the risks and benefits of PSA screening among transgender women, as well as pinpoint ideal prostate cancer screening practices for this patient population.
“As more and more transwomen have appropriate access to gender-affirming care, it’s critical not to lose sight of long-term cancer risks in retained organs,” underscored co–senior study author Matthew R. Cooperberg, MD, MPH, Professor of Urology and Co-Leader of the Prostate Cancer Program at the Helen Diller Family Comprehensive Cancer Center at UCSF. “We are just starting to understand how estrogen and related treatments modulate prostate cancer risk, and how to interpret PSA values in this population—so we can evolve a rational and evidence-based screening policy,” he concluded.
Disclosure: The research in this study was supported by the National Institute on Aging; the 2023 Urology Care Foundation Residency Research Award Program; and the Robert J. Krane, MD, Urology Research Fund. For full disclosures of the study authors, visit jamanetwork.com.
