During a panel discussion Monday morning, two investigators will share novel prostate cancer research with practical implications for all urologists. The 30-minute session, titled Prostate Cancer Screening, Diagnosis and Treatment in the Gay, Bisexual and Transgender Population, will begin at 9 am during the Next Frontier plenary session in Hall E at Moscone North.
Aria Olumi, MD, professor of Surgery/Urology at Harvard Medical School and Chief of Urologic Surgery at Beth Israel Deaconess Medical Center, said urologists are seeing more gay and bisexual men and transgender women in their practices as these communities become more accepted by society. But until recently, there has been no significant research regarding urological conditions like prostate cancer specific to these populations, he said.
Dr. Olumi, who is also Chair of Research for the AUA, said urologists have seen a significant uptick in male-to-female transgender patients being diagnosed with prostate cancer.
“Prostate cancer poses a unique risk for this population,” he said. “These patients have been on hormone ablation treatment for a good portion of their lives. Standard guidelines for prostate cancer don’t apply to this population.”
Dr. Olumi will review new data to help urologists make better treatment decisions for transgender patients.
“Studies suggest that the lifelong estrogenic treatments common in transgender women may be protective for prostate cancer,” he said. “The data available suggest that prostate cancer is only detected in about 0.04 percent of the transgender population. It’s unclear if there’s truly a protective effect, as many in the transgender population still do not seek comprehensive health care.”
However, when transgender patients are diagnosed, the data suggest they are at risk of more advanced prostate cancer.
“These patients are essentially diagnosed with hormone resistant or castration resistant prostate cancer because they’ve been on lifelong hormones,” Dr. Olumi said. “Their prostate cancer is progressing through hormonal ablation treatments. This poses a whole new challenge for urologists.”
Dr. Olumi will discuss systemic therapies that should be considered when traditional, first line options are ineffective for patients who have undergone long-term androgen deprivation. Physicians may need to consider therapies that are traditionally second or third line options, he said.
Once a treatment plan has been determined, there are other unique challenges to consider.
“With radiation, for example, oftentimes the size of the prostate in the transgender population is extremely small,” Dr. Olumi said. “If the patient is being treated with brachytherapy seeds, it can be quite challenging to place the seeds while minimizing toxicity to the surrounding organs, including the neovagina if the patient has had sex reassignment surgery. If undergoing radical prostatectomy, special anatomical evaluation of the organs adjacent to the prostate need to be carefully considered perioperatively to minimize the risk of surgical complications.”
The session’s other presenter, B.R. Simon Rosser, PhD, MPH, LP, Director of the HIV/STI Intervention and Prevention Studies Program in the School of Public Health at the University of Minnesota, will present findings from the first-ever National Institutes of Health (NIH) funded exploratory research project examining prostate cancer in gay and bisexual men. The results of this study, which was conducted in 2015-16, will be published soon.
“Prostate cancer is the most common cancer in men, including [those] in gay and bisexual populations,” said Dr. Rosser, who is also Chair of the Behavioral and Social Sciences Prevention of HIV study section at NIH. “We’re filling an important gap in the medical literature, and it’s smart science. I’ve long argued that it’s important to study cancers in different communities because it invites discovery. It invites us to compare and contrast results. Epidemiologically, it’s essential.”
Dr. Rosser’s research includes data from a study of 193 gay and bisexual men in North America who survived prostate cancer. He said the research findings have several practical implications for clinicians.
“We discovered that when gay and bisexual men are warned about the potential effects of prostate cancer treatment, they adjust well,” Dr. Rosser said. “But patients reported many instances where they were not warned about changes. There were even cases where the physicians challenged them about side effects. In those cases the patients retreat into anger and lasting resentment.”
Dr. Rosser said it’s important for clinicians to understand that gay and bisexual men have different questions, especially about the sexual side effects of prostate cancer treatment. None of the study participants reported having their questions adequately answered.
He offered examples of questions distinct to gay and bisexual patients: How long after surgery should I wait before anal stimulation? If I’ve had brachytherapy, can the seeds get pushed into my partner’s urethra?
“These questions don’t appear in the heterosexual literature, which illustrates the need for research that includes patients from the gay and bisexual community,” Dr. Rosser said. “We have a critical problem in this field, which is poor identification and recruitment of patients from this population. It’s time for gay men with prostate cancer to be visible. That can only occur if clinics collect sexual orientation data as a standard demographic.”
The study also led to concerns about how prostate cancer treatment may affect HIV transmission.
“Gay and bisexual men are a high risk group for HIV, so we were concerned about the impact of cancer treatment on condom use,” Dr. Rosser said. “In our cohort 61 percent of gay and bisexual men who engage in insertive anal sex reported erection concerns as their primary reason why they weren’t using condoms.”
“Additionally, we had three men seroconvert after prostate cancer treatment,” he continued. “When you look at this cohort, these are men who made it through the worst of the AIDS epidemic without seroconverting, and now they’re converting after treatment. So we’re concerned about the impact of treatment on HIV transmission.”
Dr. Rosser will review several other notable findings from the study and discuss future interventions and research possibilities for this population.