Cancer type
United States Preventive Services Task Force (USPSTF) from www.preventiveservicestaskforce.org
Specialization-specific Medical Associations
Prostate cancer
Average risk: 50 years old expecting to live more than 10 years should discuss with healthcare provider if testing is appropriate
High risk: Men ≥ 45 if African-American or if first-degree relative (father, brother, son) diagnosed with PCa before age 65, should receive a PSA test (if testing is decided) with or without DRE. PSA level determines frequency of testing
PSA
2.5 ng/mL should be retested biyearly
PSA ≥ 2.5 ng/mL should be retested yearly
Screening is harmful. Recommends against screening until better testing options are available
American Urological Association (AUA) from http://www.auanet.org/education/guidelines/prostate-cancer-detection
40: No screening.
40–54 at average risk: Routine screening not recommended (unless African-American or family history of PCa).
55–69: shared decision-making recommended.
70+: If 10–15 year life expectancy, screening should not be done
Testicular cancer
Testicular exam recommended when having a routine cancer-related checkup
No recommendation on regular testicular self-exams
Screening not recommended
NCI (National Cancer Institute):
No recommended screening
Colorectal
50 at average risk should have one of the following
Colonoscopy every 10 years
Flexible sigmoidoscopy every 5 years
Double-contrast barium enema every 5 years
CT colonography (virtual colonoscopy) every 5 years
50–75, either
Annual screening with high-sensitivity fecal occult blood testing; or
Sigmoidoscopy every 5 years, with high-sensitivity fecal occult blood testing every 3 years; or
Screening colonoscopy every 10 years
American College of Gastroenterology ACG from http://www.gi.org/guideline/colorectal-cancer-screening/
≥ 50: Colonoscopy every 10 years beginning at age 50 preferred (age 45 for African-Americans)
Alternatives to this
Flexible sigmoidoscopy every 5–10 years; or
Computed tomography (CT) colonography every 5 years; or
Fecal immunochemical test for blood (Cancer detection test)
Anal
No screening recommendations. (Stated on ACS website: some experts recommend yearly anal Pap tests in HIV+ men who have sex with men, and every 2–3 years if HIV−.)
No screening recommendations
Lung
55–74 in fairly good health: Annual low dose chest CT scan (if screening chosen) for current smokers with ≥ 30 pack-year smoking history or quit within past 15 years
50–80: Annual low-dose CT scan for current smokers with 30 pack-year smoking history or have quit within the past 15 years. Screening should terminate after 15 years no smoking
To be able to target sub-populations effectively, clinicians need to know who may be at higher risk for various cancers. Currently, however, data on if and how sexual and gender identity impacts risk and screening for male cancers is sparse, and even where these factors are examined (e.g., in work by Boehmer and her colleagues [7–9]) results differ from data set to data set. Inconsistencies may arise from the ways that samples are drawn and included under the pan-labels “sexual minorities” and “MSM,” which can obscure information, as noted earlier. Some data are known: for example, that anal cancer rates are higher in populations of MSM [10], but that is different than simply stating that self-identified gay men are at risk. Also, the risk is related to anoreceptivity, rather than simply participating in anal sex, thus indicating the need for information about individual sexual histories and behaviors. Being HIV positive also increases the likelihood to contract certain types of cancers that are clearly related to that status [11–13]. In another HIV-related finding, Shiels, Goedert, Moore, Platz, & Engels [14] reported a lower rate of prostate cancer among men with AIDS compared to the general population. These thus are some behavior-based and concomitant risk factors of importance in focusing screening efforts. Other potentially important behavior-related risk factors are higher levels of tobacco smoking, drug use, obesity, and/or hormonal use. Some of these behaviors are found to be more prevalent among some sub-segments of the GBT populations, but not all [15, 16].
In addition to considering whether GBT people have higher rates of specific risk factors, in order to screen for cancers effectively, it is important to know whether or not they are recipients of general screening at comparable levels to the general heterosexual (or presumptively heterosexual) male population. We begin by addressing the overall screening guidelines for men, with the question of whether GB men follow the screening guidelines or recommendations differently than heterosexual men. Ulrike Boehmer and her colleagues [17, 18] point out that there is very little known about sexual minorities and cancer overall, as do Heslin, Gore, King, and Fox [19], speaking specifically to prostate and colorectal cancer. That general situation is even more evident specifically relating to screening. Although Boehmer and her co-authors’ publications (and others such as Heslin et al.) take much-needed steps toward addressing the gap and gathering basic information on health behaviors, there is still much left to discover.
Thus, an emphasis on screening, at least for specific cancers, is called for, based on evidence of higher risk for at least some sexual minority male populations for several cancers. (Sometimes the risk can be traced to specific behaviors or the presence of viruses related to behaviors, sometimes not). At the same time, there does not appear to be any information about whether or not there are differential rates of cancers other than prostate, colorectal, and anal, including at least one that is very much a male cancer—testicular. If we know that there may be differential risks for at least some cancers, to what degree do those risks produce higher screening rates in vulnerable populations?
As we earlier noted, effective screening depends on both health provider and patient factors. Both are dependent on knowledge of and dissemination of that knowledge about risk factors. Some is known about both risks and screening related to HIV-defining cancers [12, 13] and quite a bit about HPV and anal cancer [20–22]. There is likely much more to know, however, about GB men who live long-term with HIV/AIDS and their risk for both HIV- and non-HIV-related cancers and the influence of HPV on other cancers. But for many cancers we do not have a knowledge base about whether more aggressive screening is appropriate or not.
A critical element in screening depends upon men getting to health care providers in the first place. California Health Interview Survey data show that gay men were much more likely than heterosexual men to have seen a physician in the past year [23], which is positive in terms of making sure their health needs are met. Unfortunately, Durso and Meyer [24] found that 40 % of bisexual men in their New York City sample and 10 % of gay men did not disclose sexual identity to their health care providers. Not disclosing such information may cause potentially pertinent screening questions to be omitted even when there is knowledge that persons with certain characteristics should be screened.
Moreover, there are the issues of GBT men’s and MSM’s own knowledge of screening procedures and their willingness and likelihood to undergo screening procedures. This has been addressed most fully in research on HPV and anal, colorectal, and prostate cancer. Concerning anal cancer, Newman, Roberts, Masongsong, & Wiley [25], working with Los Angeles focus groups of community health advocates, identified a number of barriers to anal cancer screening: perceived stigma with having an anal Pap smear, unease about the procedure and revealing the anus, concern over clinicians’ discomfort with the process, lack of concern for anal cancer relative to concern over HIV, general reluctance to seek out health care, and lack of awareness about HPV as problematic. Blackwell and Eden [26] and Seay, Sadiq, Roytburd, Menezes, & Quinlivan [27] found very poor knowledge about both HPV and anal cancer in their sample of MSM, both with and without HIV. Despite this lack of knowledge, Seay, Sadiq, Roytburd, Menezes, & Quinlivan [27] found nearly full acceptance of anal Pap smears (a swab screening method for HPV) among their sample of men with HIV. This level of acceptance may have to do with the men’s seropositive status, whether that be related to heightened concerns about health or greater familiarity with invasive testing. In a national-level study of HIV+ and HIV− MSM, conducted by D’Souza, Cook, Ostrow, Johnson-Hill, Wiley, & Silvestre [28], HIV+ men were more likely to have had an anal Pap. The work of Reed, Reiter, Smith, Palefsky, & Brewer [29] found that gay men were more likely to both get screened and to pay for the test if need be than bisexual men, highlighting the importance of identity on screening—and the need to focus attention more directly on bisexual men than has been the case.
Some aspects of the results of D’Souza et al.’s research [28], however, are of concern: 47 % of HIV+ men and 32 % of non-HIV+ men had a history of anal warts (which can be HPV- or non-HPV-related), but only 16 and 7 % respectively had ever had an anal Pap test. Factors enabling screening were awareness of available screening in the community and having health insurance [28]. Health insurance obviously matters in men’s likelihood to be screened for anal cancer: Reed, Reiter, Smith, Palefsky, & Brewer [29] conducted a survey of GB men (over 80 % of whom were HIV−) to ask about their willingness to receive anal Pap screening. Less than one-third of the sample was willing to get the test if it would cost them $150, but over 80 % were willing if it were free.
Given this, we can identify some information about whether or not GBT men are more or less likely to get standard screening. Several researchers have looked at rates of participation in screening for prostate cancer. For example, using the large-scale California Health Interview Survey (CHIS), Heslin et al. [19] found no difference between GB and heterosexual men in likelihood to undergo screening for prostate cancer. However, GB black men were less likely to have such testing than heterosexual black men or GB white men. On the other hand, GB men living alone were more likely to have the PSA (prostate-specific antigen) test than those not living alone. They also found that smokers were less likely to be tested for prostate or colorectal cancer than non-smokers, a problem as Heslin et al. note that smokers are at higher risk for both. Of concern in these findings is that the GB men who are less likely to get screening appear to be those who are at higher risk due to lifestyle or ethnicity factors and thus should be screened. This illustrates the inadequacy of paying attention only to sexual minority or racial/ethnic minority status and the need to consider the intersections of multiple identities (and the behaviors that may be related to those). Blank et al. [30] found both a high level of misinformation about prostate cancer but a high level of having been screened (PSA and digital exam) among gay men in their 40’s and 50’s. Given their lack of knowledge, the reason they were tested had to do with access to general health care (this was in a time before recommendations against general screening by the USPSTF). Thus, a key factor is access to health care, and any reduction in access will result in reduced screening efforts, not just with prostate cancer, but generally. Heslin, Gore, King, and Fox [19] and Boehmer, Miao, Linkletter, & Clark [23], using the CHIS, found a higher rate of screening for colorectal cancer among GB men than heterosexual men. Heslin et al. speculated that the rates may be related to higher likelihood to have HIV, and concomitant HIV-related health care.
Thus, overall it seems that there is scant evidence suggesting different screening levels for prostate and colorectal cancer when comparing GB men as a group to heterosexual men. Most results show little or no difference with an overall comparison of all GB men (or MSM, depending on the study) and the general population, and indeed some situations in which GB men may be better screened than general populations. At the same time, there are several indications that there appear to be problems with various specific sub-groups’ likelihood to access and receive screening, and these are the ones who are men most likely to merit aggressive screening due to specific risk factors.
Cancer Screening of Transgender and Gender Variant People
Transgender is a term usually applied to people who live their lives fully or partially in another gender than the one assigned based on anatomy at birth (natal). The term includes those who have undergone significant hormonal therapy and/or surgical procedures (transsexuals) as well as others who have had little to no physical alteration of their bodies. The latter populations, however, may be affected by how they are perceived, addressed or treated due to their gender non-conformity. Gender variant or gender non-conforming are terms used for a range of gender identifications and/or characteristics seen by society as incongruent to their natal anatomy. For a more comprehensive list of gender identities, see the information from the National Center for Transgender Equality [31].
The concerns of male to female (MtF) transgender or transsexual individuals may be different than those of female to male (FtM) transgender or transsexual people and are further complicated by issues of race, ethnicity, and socioeconomic status [32, 33]. Moreover, not all transgender, transsexual or gender variant people are gay or lesbian identified; they can also be heterosexual, bisexual, asexual, and pansexual [34] (see their Table I, p. 290). Outside of western notions of gender and sexual identity, there also exist people who are recognized within their society as third genders, such as the muxe of Oaxaca, Mexico [35], the hijras of India [36] and the bakla of the Philippines [37] and Native Americans who are reclaiming the gender identities and traditions of the two-spirit peoples of the past [36]. Therefore, gender variant populations also may be encountered as immigrant populations are located within certain geographical locations.
This range of gender identities, including transsexual identities, has major implications for receiving appropriate cancer care, including screening. It is important to stress that most surgical procedures a transsexual person may undergo do not remove natal internal organs; thus, MtF women are likely to still have prostates and FtM men to have ovaries. It is also very important to note that the massive use of hormonal alterations to suppress the sex hormones of the natal biology and to greatly increase the complementary other-sex hormones may have major effects not only on sex-related cancers such as prostate, testicular, ovarian, etc., but also on other cancers. Very little is known about the potential physical impacts of hormonal treatments [38].
There is a dearth of empirical research on specific cancer screenings with the various populations of gender variant people, with only a few articles readily found (as well as some case studies of a specific transgender or transsexual person who presented with a cancer related to natal anatomy—a good source referencing these case studies is Gooren & Asscheman, [38], pp. 287–289). Weyers, Decaestecker, Verstraelen, Monstrey, et al.’s ([39], p. 192) study of gynecological exams in Dutch transsexual women (MtF) revealed that most had not had a speculum exam, nor a vaginal ultrasound, and that none had had a vaginal digital exam. The study also showed that it was possible to use the vaginal exam for palpation of the prostate and a trans-vaginal ultra-sound to examine the prostate for cancer. This study recommended particular techniques that can assist with prostate screening in transsexual women with minimal discomfort. In another article focusing on mammography screening of Dutch transsexual women, it was noted that while there is little research on whether there is elevated breast cancer risk among transsexual women, there is no reason for not following the general guidelines with them regarding screening for all women [40]. Note that both the specific studies and general information about transgender populations [41], edited by Kreukels, Steensma, & de Vries, (which includes the Gooren & Asscheman chapter noted above) are all by Dutch researchers and clinicians, i.e., are not studies conducted with U.S. populations. There were no studies found regarding cancer screening for transsexual (FtM) or transgender men. The Transgender Discrimination Survey: Report on Health and Health Care by the National Center for Transgender Equality and the National Gay and Lesbian Task Force [42], drawing on a sample of over 7000 transgender and gender variant respondents, reported several key findings that are of relevance to cancer screening: a high percentage of those interviewed postponed medical care due to discrimination or cost; a significant number reported outright refusal of care, with gender variant people of color more likely to report refusal of care; and more upsettingly, a significant number of participants reported experiencing harassment, including violence, in the clinical setting. This report found that only 28 % of the respondents “were out to all their medical providers” [42, p. 3]. Moreover, the report also found that providers lacked sufficient knowledge about transgender people. It should be noted that the American College of Obstetricians and Gynecologists have been proactive in providing information on screening to their members [43]. Their essential point is that clinicians must treat all transgender persons with respect and should provide screening appropriate to their anatomy, and we would include, their gender.
Recommendations for Future Research, Practice and Policy
Research
In 2002, Boehmer noted that LGBT populations were vastly underrepresented in medical literature, and what was there was largely STD-related. Our review of the research related to GBT men and MSM and cancer shows that while there is certainly now some research, including on screening, that is not specifically STD-related, much of the cancer research does still focus on STD connections. The preceding discussions reveal areas that continue to need more research. The HIV-associated cancers need attention, but the cancers not related to HIV and other sexually transmitted diseases also need attention, both for the minority of GB men and T persons who are HIV+ and the majority who are not. The general question of how sexual and gender identity, and sexual practices, affect or don’t affect men’s likelihoods to develop these diverse cancers remains largely unaddressed. Until that is better known, it is difficult to assess whether and, if so, how to direct screening specifically to GB men and T people.
Related posts:
Cancer Screening in Lesbian and Bisexual Women and Trans Men
What Are the Numbers? The Epidemiology of Cancer by Sexual Orientation and Gender Identity
Gay Men and Prostate Cancer: Opportunities to Improve HRQOL and Access to Care
Breast Cancer in Lesbian and Bisexual Women
The Needs of Racial/Ethnic LGBT Individuals Across the Cancer Care Continuum
Cancer Care Needs of Transgender, Transsexual, and Other Gender Nonconforming Populations
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