Cancer Related Clinical Care of Sexual and Fender Minorities

February 25, 2020

Sexual and gender minorities are not receiving the same standard of clinical care as other patients with cancer.

Lifestyle behaviors are thought to cause 42% of cancers (1) and evidence that SGM populations have higher rates of these known cancer risk factors is compelling. Compared to heterosexuals and after controlling for demographic characteristics, sexual minorities have higher odds of alcohol use disorder (adjusted Odds Ratio (aOR) 1.83; 95% CI 1.65-2.03)(2) and higher tobacco use (aOR 1.80; 95% CI 1.27-2.56), (3) but at age 18, sexual minorities had three times the odds of using tobacco compared to heterosexuals of the same age.(2) Similarly, transgender individuals have higher tobacco use (aOR 1.8; 95% CI 1.1-3.0) compared to cisgender individuals (4) and meta-analyses show that 47.5% of transwomen use alcohol and 39.6% of transmen. (5) Compared to heterosexual women, lesbian women have higher odds of obesity (aOR 1.50; 95% CI 1.22-1.84) (6) and the trajectory towards obesity occurs at an early age for lesbian women (aOR 1.91; 95% CI 1.10-3.32) compared to similarly aged heterosexual women. (7)

After lifestyle behaviors, the third most common cause of cancer, 15.4% of all cancers worldwide,(8) are infections, including ​human papillomaviruses (HPV), Hepatitis B and C, and human immunodeficiency virus (HIV)​, which are linked to cervical cancer, anal cancer, and AIDS-related cancers,e.g., K​aposi'ssarcomaandnon-Hodgkin'slymphoma​. SGM populations are overrepresented with respect to having these infections. (9) The high prevalence of HIV among sexual minority men (defined as men who have sex with men (MSM) is well established, in that annually 68% of the new HIV infections occur in MSM and they make up 57% of all HIV diagnoses in the US. (10) HIV is also prevalent among transgender individuals, in that 19% of transwomen are HIV positive and these rates are even higher in racial minorities (44% in black and 26% in Hispanic transwomen).(5) Bisexual women have greater odds of high risk HPV infection (aOR 2.01; 95% CI 1.47-2.75) compared to heterosexual women. (11) HPV is known to be highly prevalent in MSM, 37.2% among HIV negative, but even higher (73.5%) in HIV positive MSM. ​(10) A recent cohort study of young (between 22 and 25 years old) sexual minority men and transgender individuals who reported sex with men, showed high HPV rates among HIV negative (59%) and higher rates (88%) among HIV positive individuals. Particularly noteworthy is that HPV vaccinations were approved and recommended for this young aged cohort and nevertheless 45% had received zero doses of HPV vaccination.(12)

These elevated cancer risk factors are further compounded by SGM individuals’ low cancer screening rates. Analyses of representative US population data have shown lower screening rates for cervical cancer (Pap test in the last three years) in sexual minority (SM) women compared to heterosexual women after controlling for demographic characteristics; bisexual women’s adjusted odds ratio (aOR 0.66; 95%CI 0.47-0.93) lesbian women’s (aOR 0.57; 95%CI 0.36-0.89), women with exclusively female partners (aOR 0.10; 95%CI 0.03-0.27) compared to women with exclusively male partners. (13) These findings were echoed by a later study, which showed lesbian women’s adjusted odds ratio of cervical cancer screening (aOR 0.53; 95%CI 0.29-0.95) and in addition bisexual women’s breast cancer screening were significantly lower than heterosexual women’s (aOR 0.60; 95%CI 0.38-0.93). (14) Others have shown that compared to heterosexual individuals, SM individuals eligibility for lung cancer (LDCT) screening is significantly higher for gay men (aOR 3.58, 95%CI 1.25-10.30; ref heterosexual men) and lesbian women (aOR 4.95; 95%CI 1.82-13.4; reference group heterosexual women). (15) However, despite SM people’s significantly higher eligibility, they have CT scans at the same rate as heterosexuals. (15)

The Center of Excellence for Transgender Health at UCSF recommends gender minority (transgender) individuals should undergo cancer screening according to their anatomy. Aside from this the leading organizations that issue guidelines, e.g., American Cancer Society, lack explicit documentation on screening of transgender individuals. The US Preventive Services Taskforce and many other organizations refer to “women,” or at best “individuals with a cervix” and acknowledges that there are no cervical cancer screening data on lesbian women and transgender individuals.

The most compelling population-based data (16) indicate that compared to cisgender women, transmen had lower odds of lifetime Pap tests (aOR 0.50; 95% CI 0.26-0.97) and gender-nonconforming individuals had even lower odds (aOR 0.20; 95% CI 0.08-0.49). Transwomen had lower odds to ever had mammography breast cancer screening (aOR 0.30; 95% CI 0.15-0.72) compared to cisgender women. (16)

For gender minorities epidemiologic data on higher cancer incidence are available, showing that transgender individuals have significantly higher proportional incidence ratios for HPV-related cancers (PIR 3.2; 95%CI 2.4-4.0), AIDS-defining cancers (PIR 2.6; 95%CI 2.1-3.1) and infection-related cancers (PIR 2.3; 95%CI 2.0-2.7) than cisgender men and higher than cisgender women HPV-related cancers (PIR 2.1; 95% CI 1.6-2.7), AIDS-defining cancers (PIR 2.3; 95% CI 1.9-2.8) and viral-related cancers (PIR 3.3; 95% CI 2.8-3.7).(17) Others reported on specific cancer sites, showing that compared to cisgender individuals transgender individuals have a higher incidence of Kaposi’s sarcoma (PIR 71.7; 95% CI 47.8-107.6) and anal cancer (PIR 29.7; 95% CI 22.4-39.4). (18) Surveillance data on SM populations’ cancer incidence, on the other hand, are missing and therefore the hypothesis that SM populations have higher cancer rates and present with later-stage cancer at diagnosis cannot be confirmed. However, in an effort to fill the surveillance gap on SM populations’ cancer incidence a number of ecological analyses have been performed, showing that geographic areas with more SM women have higher incidence of breast cancer, areas with more SM men have higher incidence of lung cancer and anal cancer, while areas with more SM men and women have higher incidence of colorectal cancer. (19-23) Cancer prevalence data are available from various population-based data sources and they show with consistency SGM populations have a higher cancer prevalence compared to heterosexual and cisgender people; the likelihood of a cancer diagnosis is significantly higher for gay men (aOR 1.9; 95%CI 1.5-2.5; reference heterosexual men)(24), for bisexual women (aOR 1.70; 95% CI 1.16-2.48; reference heterosexual women)(25), for white SM women (aOR 1.40; 95%CI 1.07-1.82; reference white heterosexual women) (26, 27).

In this context, it is also important to address age differences, in that SGM populations are diagnosed with cancer at a younger age. Transgender individuals had a median age of 47.4 years at cancer diagnosis compared to cisgender individuals’ 66 years. (18) Gay men were on average 42 years old at diagnosis compared to heterosexual men who were 52 years old. (24) A later study of cancer survivors confirmed that SM cancer survivors are significantly younger by about 10 years; SM women were 52 years old compared to heterosexual women who were 62 years of age, while SM men were 58 compared to heterosexual men who were 66 years of age.(29) Research that focused on cancer survivors by sexual orientation points to SMG cancer survivors’ adverse condition, which include SM women survivors having greater access deficits (42.7% vs. 28.0%; reference heterosexual women survivors), (29) lesbian cancer survivors’ greater health care utilization (aOR 7.4; 95% CI 1.7-31.8; reference heterosexual women survivors) and bisexual men’s greater health care utilization (aOR 7.8; 95% CI 1.8-33.3; reference heterosexual men with cancer). (30) While the lack of surveillance data implies that cancer mortality data on SGM populations, these adverse situations among SGM cancer survivors may contribute towards explaining SGM populations’ greater cancer mortality, which has been established using diverse population-based data sources. Higher cancer mortality of SM populations has been shown by ecological studies (19-21) and by studying same-sex partnered women who had an age-adjusted relative risk of breast cancer mortality (3.2; 95% CI 1.01-10.21) compared to different-sex partnered women. (31)

The strength of the evidence of SGM populations’ cancer-related disparities makes a compelling case for education of and interventions with health care providers to improve their delivery of cancer-related care to SGM populations. A review of nurse's and midwives’ knowledge and attitudes regarding SGM patients concluded that there is a lack of education regarding SGM populations’ health and a culture of heteronormativity that lead to inadequate care of SGM patients. (32) Considerable evidence points to physicians not being adequately prepared to care for SGM populations due to knowledge and attitudes. A recent (2016) national survey of oncology providers showed that 83% felt comfortable treating transgender patients, but 47 % self-reported lacking knowledge about SM populations’ health needs and 60% reported lacking knowledge about gender minorities’ health needs. (33) Surveys of other physician specialties confirm these problems; a 2016 survey of emergency room physicians reported 83% had no formal training about transgender individuals, while 88% reported treating them. (34)

A 2013 survey of obstetrics and gynecology providers, reported 66% had knowledge gaps related to the care of transgender patients, 35% reported feeling comfortable treating male-to-female patients, and 29% reported comfort treating female-to-male patients. (35) Noteworthy is that neither residency training in SGM patient care nor time in practice was related to OBGYN providers’ level of comfort treating these patients. (35) The persistence of knowledge gaps regarding the care of SGM populations going forward can be inferred from a survey of panel members of the National Comprehensive Cancer Network (NCCN). NCCN seeks to lead cancer care in the US by developing guidelines that address the cancer continuum from cancer prevention to treatment and cancer survivorship. ​(36) Of the surveyed, NCCN panel members, 87% reported their current guidelines do not address SGM populations and reported they had no plans to change this in the future; moreover, 87% deemed sexual orientation not relevant for their cancer care guidelines and 90% deemed gender identity not relevant for the purpose of establishing guidelines. (36)

There are additional concerns that hinder ​adequate care of SGM populations. A proportion of health care providers may treat SGM populations without being aware of it because they do not ask about sexual orientation or gender identity; estimates indicate 80% of providers believe asking about sexual orientation would offend their patients. (37) Without being prompted, SGM patients do not necessarily self-disclose their SGM identity to providers, fears of poor treatment by the provider are among the reasons for not disclosing. (38-40) There is consistent evidence that disclosure is linked to positive direct and indirect ​health outcomes. (41) ​Direct implications in cancer-related care have been shown, in that the low rates of cervical cancer screening have been linked to providers’ heterosexism, not recommending cervical cancer screening to SM women, poor quality of communication between providers and SM patients, and to nondisclosure of sexual orientation. (42, 43) Similarly, a study of sexual minority men showed 64% had disclosed their same-sex behavior/sexual orientation to their physicians and disclosing sexual minority men had a higher likelihood ​(aPR, 2.2; 95% CI, 1.4-4.3) ​of receiving guideline-recommended medical care, including HPV, Hepatitis A and B vaccinations. (9)

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