ASO Author Reflections: Opportunities to Mitigate Cancer Disparities in Transgender and Gender-Diverse Populations

PAST

A growing proportion of the population identifies as transgender or gender-diverse (TGD). Despite calls for more inclusive care, disparities persist because of traumatic patient experiences in the health care system and a lack of data informing care and guidelines.¹ Specifically in oncology, data on how gender identity and gender-affirming therapies may interact with cancer risk, screening recommendations, treatment options, and therapeutic efficacy are limited. The conspicuous absence of health care policies and clinical cancer guidelines directly related to TGD persons reflects the current lack of evidence in this space.

PRESENT

The granular data examining TGD patients with cancer are limited, with only one previous study examining gender-affirming care in the context of a cancer diagnosis for adult patients.² This single-institution series is the largest to date and uniquely reports low rates of guideline-concordant screening uptake for TGD patients.³ This disparity mirrors other health care challenges observed in the TGD population and has roots at the patient, provider, research, hospital system, and health policy levels.^4,5 Although studies are underway for a better understanding of the impact that gender-affirming therapy may have on cancer risk, therapy options, and outcomes, no high-quality data exist to support evidence-based screening and treatment guidelines. This lack of evidence has an impact on patients’ ability to get appropriate screening examinations covered by insurance, which can lead to reduced uptake of preventive cancer care for TGD patients.^3–5

In addition, 75% of the patients in this study were referenced by incorrect name/pronouns after initiation of gender-affirming therapy and declaration of their correct name/pronouns in the electronic medical record.³ The study cohort spanned 20 years and was heterogeneous in terms of age, gender presentation, and cancer history. This discordance in name/pronoun use suggests that regardless of provider generation, specialty, patient age, gender-affirming care history, or explicit communication of personal pronouns, we cancer providers are not appropriately using inclusive language in our clinical practice.

FUTURE

Unique challenges are facing TGD patients, many of which require unique approaches. However, some solutions can be easily implemented currently. At the patient and provider level, cancer screening examinations must be discussed and framed in terms of organ inventory and existing guidelines regardless of gender presentation (e.g., if a patient has a cervix, routine cervical cancer screening is needed). Fortifying organ inventory data in the electronic medical record requires little effort but can have a tremendous impact on preventive oncologic care. At the hospital system level, it is imperative that patients have the opportunity to voluntarily self-report gender in the electronic medical record and at every level of clinical care, including in clinical trials. At the health policy level, clinical guideline and insurance policy nomenclature should be changed to incorporate inclusive language. This is a necessary step to ensure that preventive care is accessible not only to cisgender patients, but to all patients regardless of gender. Finally, at the research level, focused studies can help achieve these objectives and inform guidelines and policies. Researchers should develop prospective studies and clinical trials designed to explore cancer risk, determine barriers to cancer screening, and improve access to equitable care for TGD persons.