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Most transgender nonbinary (TGNB) persons are unaware of cervical cancer screening recommendations for their sex assigned at birth or their gender, according to a recent survey.

Little data exist to inform cervical cancer risks, gender-specific screening guidelines, and inclusive cancer treatment algorithms that consider gender-affirming hormone therapy (GAHT). Chandler S. Cortina, MD, MS, of Medical College of Wisconsin in Milwaukee, and colleagues aimed to assess TGNB persons' perceptions on breast and cervical cancer development, screening knowledge and practices, and attitude toward GAHT in the setting of a hormone receptor–positive breast cancer diagnosis.

The single-institution survey study, published in , was conducted through an LGBTQ+ focused clinic from 2021 to 2022. A total of 86 participants completed the survey, composed of transgender men (43% of the total), transgender women (24%), and nonbinary individuals (20%). Most (84.9%) were under age 40, and 86% were non-Hispanic white.

The survey assessed participants' level of concern regarding cancer development, and they were also asked about their knowledge of breast and cervical cancer screening options, screening practices, preferences on screening mammography versus automated breast ultrasonography, and whether they would consider stopping GAHT if they were hypothetically diagnosed with a hormone receptor–positive breast cancer.

In the following interview, Cortina, a breast surgical oncologist and health services researcher, elaborates on the details.

What does the study add to the literature?

Cortina: This article demonstrates that there is a huge need for patients and providers on screening options for TGNB persons, but perhaps an even bigger need for data to guide evidence-based screening guidelines specific to TGNB persons.

The study has three major highlights: (1) most TGNB persons are unaware of how or if they should be screened for breast or cervical cancer; (2) most are not undergoing screening; and (3) there are going to be increasing challenges in how patients and cancer care providers balance gender-affirming hormone therapy and adjuvant endocrine therapy for TGNB persons with hormone-receptor positive breast cancer.

We found that 47% of those with an intact cervix were concerned about developing cervical cancer. Most (55.8%) were not aware of cervical cancer screening recommendations. Of those over age 40 with an intact cervix, only 51.2% had had a Papanicolaou smear within the past 5 years. Nearly all (87.2%) were on GAHT, and 35.1% reported that they would not consider stopping GAHT if diagnosed with a hormone receptor–positive breast cancer.

Why are most TGNB persons unaware of cervical cancer screening recommendations for their sex assigned at birth or their gender?

Cortina: My hypothesis is that it's a trickle-down effect from the knowledge deficits we have in research and provider education. If providers are unsure about what recommendations and options exist for patients, they are likely not to bring up the topic of cancer screening recommendations to patients.

Additionally, national guidelines currently don't include screening recommendations specific to TGNB persons. A transmasculine person may still have a cervix, but providers may not be considering an individual's organ inventory when discussing cancer screening recommendations.

The incidence of cervical cancer in TG men is comparable to that of cisgender women, and the American College of Obstetricians and Gynecologists recommends . In our survey, 46.4% of TG men with an intact cervix reported undergoing cervical cancer screening within the past 5 years, and this is that found screening rates in TG men to be 56%, compared with 72% for cisgender women.

TG men with an intact cervix reported that gender dysphoria and healthcare anxiety were the primary reasons they had not undergone cervical cancer screening, coinciding with previous reports. This illustrates the importance for healthcare professionals to be sensitive, inclusive, and respectful toward gender diverse patients by using patients' preferred pronouns, name, and anatomical terms.

What type of education is needed for healthcare providers on methods to assess individual cancer risk before initiating gender-affirming therapy and cancer screening options?

Cortina: Identifying trends in family history that suggest a familial hereditary cancer syndrome and using validated risk models to calculate lifetime risk – especially for breast cancer – are simple methods that providers can employ to explore risk before starting gender-affirming therapy. Building this education into medical training programs is the ideal way to integrate this into standard clinical practice.

What future research is needed to determine long-term cervical cancer risk for TGNB persons?

Cortina: Large, prospective, cohort studies would be the best way to identify long-term cervical cancer risk in TGNB persons and would require supportive collaboration between TGNB persons, healthcare providers, and cancer researchers.

What is your main message for practicing oncologists?

Cortina: Practicing oncologists can support inclusive screening practices in their communities and healthcare systems by educating the providers ordering screening tests for TGNB persons. Additionally, the role of endocrine therapy and gender-affirming hormone therapy for patients with hormone-receptor positive breast cancer is a data-free zone and requires a thoughtful and supportive discussion with patients about optimizing oncologic and gender-affirming care.

Read the study here.