By Lily H-A
From PHN Issue 54, Fall 2023
The goal of cancer screening is to catch cancer early, when it is more treatable and curable. Some cancer screenings, like colonoscopies, are recommended for everybody once they reach a certain age. However, other types of screening, like prostate screening and mammograms, have traditionally been recommended based on gender assuming that this matches sex assigned at birth. The medical guidelines for cancer screening do not yet reflect the needs of trans people, and there is also limited data about trans people’s risks for various cancers and how gender-affirming care like hormones and surgeries may affect these risks. As a general rule, University of California San Francisco (UCSF) Transgender Care recommends that people get cancer screenings based on the body parts they have, regardless of gender or hormones.
It can be hard for trans people to get the correct care, even on the outside, and sometimes getting cancer screening can trigger gender dysphoria (discomfort or distress about your body not matching your gender identity). Getting the right cancer screening can save lives.
Below is some information about specific cancer screening guidelines that have historically been recommended based on gender. We refocused them here based on UCSF Transgender Care recommendations. This guide doesn’t cover all types of cancer screening. Screening recommendations may also differ depending on your family history of cancer and other risk factors, so discussing these with a health care provider is important.
Breast Cancer Screening
Trans men and other people who were assigned female at birth (AFAB)
- For AFAB people who have not had top surgery, breast cancer screening is recommended.
- If you are at an average risk of breast cancer (no family history of breast cancer or personal risk factors), U.S. Preventive Services Task Force (USPSTF) guidelines recommend mammograms every two years between the ages of 50 and 74, with the option of starting them as early as 40. The American Cancer Society recommends mammograms every year between 45 and 54 and every two years after that, with the option of starting as early as 40.
- AFAB people who have had top surgery typically still have some risk of breast cancer, because not all chest tissue is removed. UCSF Transgender Care recommends AFAB people screen for breast cancer according to the guidelines for cisgender (cis) women. Doing a mammogram may not be possible if you’ve had top surgery, so another type of test, like an ultrasound or MRI, may be used for chest screening.
- If you are AFAB and have had a total mastectomy (usually done to treat or prevent breast cancer), breast cancer screening is not typically recommended. If you are considering top surgery and have a family history of breast cancer, having a mastectomy may be something to discuss with your doctor.
- It’s not clear yet how taking masculinizing hormones (testosterone/T) affects your risk of breast cancer.
Trans women and other people who were assigned male at birth (AMAB)
Trans women and other AMAB people who are on feminizing hormones (estrogen, testosterone blockers, and progesterones) are at risk for breast cancer. It’s not clear how high the risk is, but it is thought to likely be lower than for cis women. The UCSF Transgender Care treatment guidelines suggest trans women have mammograms every two years once they are over 50 and have been on feminizing hormones for at least 5 years.
Cervical Cancer Screening
Trans men and others who have a cervix
- Cervical cancer screening (Pap smear) is recommended between the ages of 21 and 65 by USPSTF, and between the ages of 25 and 65 by the American Cancer Society. This screening is recommended every 3 to 5 years, depending on the type of screening test done. More frequent testing may need to be done if you have a history of abnormal tests.
- Cervical cancer screening is not recommended for people who have had a total hysterectomy (removal of the uterus and cervix), but it is still recommended for people who have had a sub-total or partial hysterectomy.
- It’s not clear if or how taking hormones affects cervical cancer risk. People who take testosterone may be more likely to have an “unsatisfactory” or difficult-to-interpret result from a Pap smear, because of changes caused by hormones. It may help the lab interpret the results if the doctor notes that you are on testosterone therapy when they send in the sample.
Endometrial Cancer and Ovarian Cancer Screenings
Trans men and others who have a uterus and/or ovaries
- Guidelines don’t recommend routine endometrial (uterus lining) cancer screening or ovarian cancer screening in anyone.
- There is not any evidence to suggest testosterone affects endometrial or ovarian cancer risk.
- Trans men and other people with uteruses who take testosterone should tell their doctor if they have vaginal bleeding that starts after they’ve stopped having their period with testosterone.
- If you have had a total hysterectomy, you are not at risk for endometrial cancer.
- If you have had a bilateral salpingo-oophorectomy (removal of both ovaries and fallopian tubes), you are not at risk for ovarian cancer.
Prostate Cancer Screening
Trans women and others who have a prostate
- The prostate is not removed during gender-affirming bottom surgery (vaginoplasty). UCSF recommends prostate screening in trans women be done according to the guidelines for cis men, regardless of hormones.
- It is not yet known how taking feminizing hormones or having your testes removed affects prostate cancer risk, but it probably lowers it by lowering testosterone levels.
- Both USPSTF and the American Cancer Society recommend that prostate cancer screening be a personal decision made after a discussion with a doctor about its risks and benefits. The American Cancer Society recommends having this conversation at 50 (or earlier for people at higher risk), and USPSTF recommends it at 55. Prostate cancer screening is typically done with a blood test called prostatespecific antigen (PSA) and sometimes with a digital rectal exam (the doctor inserts a finger for the test).
Testicular Cancer Screening
Trans women and others who have testes (balls)
- Guidelines don’t recommend routine testicular cancer screening in anyone, because there isn’t enough evidence to say whether it prevents deaths. But anyone who has testes is at risk for testicular cancer and can learn to do a self-exam (see the article by Troy Glover in this issue).
- If you have had your testes removed, you are not at risk for testicular cancer.
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