Prostate Cancer in Cisgender Gay and Bisexual Men and Trans Women
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Prostate Cancer in Cisgender Gay and Bisexual Men
and Trans Women
Channa A. Amarasekera, MD
Assistant Professor of Urology
Director, Gay and Bisexual Men’s Urology Program
Feinberg School of Medicine, Northwestern University
Chicago, IL
This activity is jointly provided by Physicians’ Research
Network and the Medical Society of the State of New York.
I have no conflicts of interest to report.
Objectives • Learn about the current clinical terminology used to identify sexual minority patients. • The unique impacts of prostate cancer on gay and bisexual men. • How HIV infection influences prostate cancer screening and treatment.
• History • Disparities • Prostate cancer in gay and bisexual men • Prostate cancer and HIV • Transgender patients and prostate cancer
LGBT Rights in the US – a Timeline
Secretary of
Nation’s 1st gay rights Transportation Pete
organization – Chicago’s Patrons at Stonewall Inn Buttigieg becomes the
Society for Human fight back during a first openly gay member
Rights police raid of the Cabinet
1962 2015
1924 1969 2021
IL is the 1st state in the
US to decriminalize US Supreme Court rules
homosexual acts that same-sex couples
between consenting have a fundamental
adults in private right to marriage
STIGMA, DISCRIMINATION AND HEALTH
Interpersonal Stigma Structural stigma
• societal • Homophobia
homophobia within health
• family rejection Intrapersonal Stigma
care/educational
• Peer harassment • Internalized homophobia
setting
• low self-esteem
• employment
• depression and self-harm
discrimination
• self-validation through
• housing
sex
discrimination
• religious exclusion
Stress/Anxiety/Depression
Health Disparities/Inequities
Hatzenbuehler, ML et al Soc Sci Med 2014 Feb
Health Disparities
RR (95% CI) for non-heterosexual
compared to heterosexual males
Health Outcomes
Hypertension 1.21 (1.03-1.43)
Heart disease 1.39 (1.02-1.88)
Functional limitation 1.24 (1.05-1.46)
Mental stress 1.77 (1.28-2.45)
Poor physical health 1.38 (1.04-1.83)
Access to healthcare
Insurance status 1.12 (0.86-1.45)
Likelihood to delay care due to costs 1.40 (1.08-1.81)
Health risk behaviors
Current drinker 1.09 (1.06-1.13)
Current smoker 1.39 (1.14-1.70)
Jackson et al, BMC Public Health, 2016
Fredriksen-Goldsen et al, The Aging and Health Report, Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults, 2011
• Gay men 1.9x more likely to have a cancer
diagnosis
• CA Health Interview Survey with ~50,000
respondents, ~1500 GBM (Boehmer, 2011)
• More head and neck cancer in MSM who have
oral sex (Heck, 2010)
• Higher rates of anal cancer in MSM who have anal
Rates of cancer sex (Daling, 2004)
• Higher rates of cancer may be explained by:
• More AIDS-defining cancers like Kaposi’s
sarcoma and non-Hodgkin’s Lymphoma
• Cancers associated with HIV, such as anal and
lung cancer, and Hodgkin’s lymphoma
Prostate Cancer in Gay and Bisexual Men • New area of research, beginning in 2000 • Entire literature ~ 100 papers, mostly qualitative or case reports • Data on sexual orientation not captured in cancer registries
PSA Screening and Prostate Cancer
Large study using NHIS (22,825 men, 574 MSM):
• No differences in PSA screening rates between gay, bisexual and
straight men in 2018; prior to this gay men screened at higher rates
(OR 1.56)
• AA gay men
• 14% less likely to have PSA compared to AA heterosexual men
• 28% less likely to test than gay white men
• SEER Cancer Registry data from WA
• No change CaP risk by sexual orientation, history of male partners, anal sex
Wilcox, Urology , 2021
Fredriksen-Goldsen, Am J Public Health, 2013
Heslin, Med Care , 2008PSA screening
• Several studies report an earlier diagnosis of prostate cancer in gay
men compared to heterosexual men
• Cross sectional study of 92 men (Hart, 2014)
• Gay men diagnosed at 58.7yo vs 66yo in heterosexual men
• 119 gay, bisexual men and 224 HSM (Ussher, 2016)
• Gay men diagnosed at 64.25yo vs 71.5yo for heterosexual men
• May be related to differences in sexual practices
• Elevation of PSA with receptive anal intercourse (vigorous prostate
stimulation)
• Older men less likely to be “out” – sampling bias in studies, younger cohorts
enriched with gay men• Assessed treatment patterns in 460 HSM, 92 MSM • Similar rates of treatment • 79% HSM vs. 84% MSM underwent surgery (p=.34) • 26% HSM vs. 28% MSM underwent radiation (p=.49) • Some advocate asking patients about role in sex to assist with treatment choice (Rosser, 2018) • Surgery for receptive partners • Radiation for insertive partners • Discussing risks and benefits of both if they practice both
Meaningful differences in side effects early on
There are no long term differences in erectile function or bowel urgency between men getting surgery or radiation
Health Related Quality of Life
• Overall, gay prostate cancer patients
experience lower HRQOL (Ussher, 2016)
• 124 GBM, 225 HSM – GBM scored
lower on the FACT-P and had greater
degree of psychological distress
(anxiety, panic, depression)
• Thought to be due to greater bother
from side effects
• Fear of recurrence
• Lower satisfaction with care
*Extent to which lower HRQOL is from
CaP unclear. GBM have greater levels of
depression and psychological distress at
baseline.Erectile Dysfunction
• MSM report better erectile function
• 124 GBM and 225 heterosexual men
(Ussher, 2016)
• EPIC EF score 21.15 vs. 16.49,
pBother from ED
• High levels of bother seen in MSM (81% in
study by Ussher)
• Expectation of having an active sex life into
their later years
• Loss of opportunity to explore recently
accepted sexuality
• Gay men more sexually active, more likely to
be non-monogamous
• Survey of 1000 gay and 2000 straight men
(Gotta, 2011)
• 56-61% of gay men have sex outside their
relationship vs. 10-15% of straight men, pEjaculatory function and bother • Gay men consistently report poorer ejaculatory function after CaP • CSFQ-14 scores 4.24 vs 2.33, p
Impact of ADT on sexual function
• Bicalutamide administered to 17 HSM and 12 gay men (matched for
baseline erectile function)
• Poorer sexual function in gay men with ADT (IIEF 28.7 vs 56.1)
• Hypothesized gay men specifically require testosterone for arousal
• Prior studies showed that estrogen mediates arousal in HSM
• Progesterone derivative (AND) found in male sweat ! activation of regions in the
hypothalamus associated with sexual behavior in gay men
• Estrogen-like compound (EST) found in female urine did not activate these
hypothalamic regions in gay men; activated nonsexual olfactory regions
• EST leads to activation of hypothalamic regions associated with sexual activity in
heterosexual menSexual changes with treatment • In a study of 193 GBM, the most common sexual problems were: • Loss of ejaculate (93.8%) • ED (89.6%) • change in sense of orgasm (87.0%) • loss of sexual confidence (76.7%) • penile changes (65.8%) • increased pain with receptive anal sex (64.8%) • urinary problems during sex or at orgasm (49.2%) • Of these, only loss of ejaculate and ED were discussed pre-treatment
Sexual rehab after treatment • Retrospective study of 166 GBM (Rosser, 2018) • 22% reported erections firm enough for insertive anal intercourse (6 yrs post-treatment) • 33.8% reported pain with receptive anal intercourse • Rehab tools commonly discussed: • Oral medications • Penile injections • Vacuum erection devices • Pelvic floor PT for urinary incontinence
Sexual rehab post-treatment • Many men used rehab tools beyond what was recommended • Penile implants • Dildos • Pornography • Sex therapy • Greater degree of satisfaction reported when using these, compared to what was more commonly discussed by their providers
Assistive aids • GBM more likely to use assistive aids vs HSM • 73.4% versus 51.1%, P < 0.001 • GBM more likely to try more than one assistive aid • mean of 1.65 aids versus 0.83, P < 0.001 • No difference in satisfaction with the use of assistive aids
Changes in role in sex • Treatment can lead to changes in sexual roles—insertive or receptive partner Study by Ussher et al. • Pre-treatment • 31% insertive, 19% receptive, 20% both • Post-treatment • 12% insertive, 24% receptive, 8% both • Loss of sexual identity • Insertive partners did not switch because they perceived it a submissive role • Did not find new position pleasurable • In relationships with partners exclusively interested in one role • Not universally viewed as negative – repositioning allows sexual engagement after treatment
Measuring sexual function in MSM
• Instruments measuring SF were validated in mostly straight cohorts
• EPIC – all men presumed to be straight
• MSHQ – 179/8000 participants were MSM
• IIEF-MSM – modified IIEF for erectile function for MSM (Coyne, 2010)
• No instruments exist to measure sexual function for receptive
partners (Lee, 2015)
• Pleasure likely multifactorial: pudendal nerve (anus), pelvic nerves
(rectum) and the hypogastric nerve (prostate)
• Unclear how prostatectomy/radiation impacts functionUrinary symptoms with CaP treatment
• Climacturia and arousal incontinence can occur with treatment
• 22.6% after treatment in a study of 412 men
• No quantitative data on differences between HSM and MSM
• In qualitative studies, MSM who reported urinary leakage and climacturia
found it to be such a humiliating problem that they avoided certain sexual
practices such as oral sex or avoided sex altogether
• Patients who practiced nonpenetrative sex, such as oral sex, felt particularly
anxious as the leakage is more problematicLoss of masculine self-esteem • Gay men display lower levels of masculine self-esteem after treatment for CaP (Ussher, 2016) • 55.79 in gay men vs 66.69 in heterosexual men, p
Social support and QOL • 170 gay and 16 bisexual men examined, online support group (Capistrant, 2018) • 46% men got support from their partner (54% of participants partnered) • 40% got support from chosen family • 22% received support from biological family • Men who reported low levels of social support • Scored lower on the hormonal QOL assessment • Lower bowel QOL assessment • Lower mental health QOL • No difference in sexual and physical health QOL • Men who wanted more types of social support had lower QOL • Men with broader support networks, and more types of support had better QOL
Impact of relationship status on CaP • Marital status of particular importance to cancer survivorship • Being married is associated with (Aizer, 2013): • A reduced incidence of presenting with metastatic prostate cancer (HR 0.52) • Increased rates of prostate cancer treatment (HR 1.60) • Decreased rates of death from prostate cancer (HR 0.74) • CaP studies that include GBM and HSM consistently show lower rates of marriage/partnerships in gay and bisexual men • 90% HSM were married, vs. 72% GBM (460 HSM and 96 GBM) • 86.2% HSM vs. 49.6% GBM (225 HSM and 124 GBM) • In qualitative studies, gay men voice concerns over CaP changing the dynamics of their intimate partnerships (exclusive to non-exclusive) • Not apparent among HSM
Support groups for sexual minorities • Dearth of prostate cancer support groups tailored to sexual minority men • Tailored support groups offer a forum where GBM can be at ease discussing issues specific to them • General support groups sometimes have a negative effect on GBM if these groups alienate GBM further with regard to discussing sexual concerns
Satisfaction with care
• GBM have greater dissatisfaction with care compared to HSM
• Might be caused by increased psychological distress
• Declines in HRQOL
• Perceived negative reactions from healthcare providers and fear of reprisal
• Healthcare providers perceived as unwilling to discuss queer issues due to a
lack of resources geared toward sexual minorities
• HCPs make assumptions of heterosexuality – alienates patients
• HCPs report a lack of confidence, comfort and knowledge of LGBT sexuality
and a lack of understanding of how prostate cancer can differentially affect
GBMSpecial considerations
• Study out of MSK, 2016 • Looked at radiation doses from brachytherapy with I 125 and Pd 103 intrarectally using an US probe as a proxy for the human penis to estimate the radiation received • 102 patients in total, 20 treated with I 125 monotherapy (144 Gy), 34 treated with Pd 103 monotherapy (125 Gy) and 48 got Pd 103 (100 Gy) and XRT combo • I 125 T1/2 is 59.4 days, Pd 103 T 1/2 is 17 days • Penile tissues radiation dose limit was calculated to be 2cGy (5mSv whole body dose with gonad tissue weighting factor of 0.25)
Results • Recommend waiting two months for Pd 103, six months for I125 • Pd 103 should be recommended to sexually active gay and bisexual men engaging in RAI
When can RAI be resumed after surgery?
Prostate Cancer in Men with HIV • MSM disproportionately affected, 67% new HIV infections (CDC, 2017) • HAART therapy delays progression of HIV ! increased opportunity for development of malignancy • AIDS-defining malignancies: KS, aggressive B cell non-Hodgkin lymphoma • Non AIDS-defining malignancies – Hodgkin disease, anal cancer, basal and squamous cell carcinomas
HIV and Screening for Prostate Cancer
• USPSTF recommends shared decision making for PSA screening in
men 55-69
• No specific recommendations for men with HIV or AIDS
• Vianna et al. recruited 534 men (310 with HIV, 224 without)
• Cross sectional analysis
• Only older age (>61) was a risk factor for elevated PSA levels
• No difference in rates of elevated PSA levels (4 ng/dL) in HIV-infected vs
non-infected men (3% vs 5%, p 0.28)
• Crum et al. initiated CaP screening in a large clinic for HIV infected
men > 35yo
• CaP uncommon among young men with HIV
• No benefit to screening at an earlier age than the general populationProstate cancer incidence and HIV status
• Grulich et al. - meta-analysis including 444,172 men (HIV and/or AIDS)
• HIV infected men at higher risk of developing 20/28 cancers studied
• Reduced relative risk of CaP (RR 0.7)
• Similar results in a registry-linkage study
• 448,258 people with HIV from 8 US states, Puerto Rico
• Standardized incidence ratio (SIR) of CaP in HIV infected vs uninfected men
was 0.48
• Stratified by HIV only and AIDS only, SIRs were 0.55 and 0.46Reasons for lower incidence of CaP
• No clear biological or epidemiological explanation
• Possibly lower levels of PSA screening
• Baltimore residents with HIV/AIDS from 2000-2008, 18.7% of men > 40 had a PSA
test vs 57% in the general population
• Robbins et al. used data from the US HIV/AIDS Cancer Match Study
• Increase in incidence of CaP of 9.8% per year in HIV-positive men from 1996-2010.
• Suggests incidence of CaP will rise to population levels as HIV-infected men age and
live longer with improved therapy
• HIV protease inhibitors have anti-neoplastic effects
• Ritonavir, saquinavir, nelfinavir – in preclinical studies, inhibit cancer cell growth
• Inhibits Nf-KB DNA-binding activity (involved with cell survival)
• Suppresses P13K-AKT survival pathway
• No clinical trials to show evidence of this against CaPOutcomes with treatment
• Prostate cancer specific mortality is higher in HIV-infected men
• Cohort study using data from Kaiser Permanente, CA 1996-2011
(Marcus, 2015)
• 24,768 men with HIV, demographically matched with 257,600
• 5-year survival 86% in men with HIV vs 92% in those without (p = 0.074)
• Another registry-linkage study of 1,816,461 patients (6459 HIV
infected)
• CaP specific mortality high in HIV positive men, RR 1.57
• When adjusting for whether pts received treatment – HIV not associated with
higher CaP specific mortality
• Disparities in whether patients received cancer treatment influence differences in cancer
specific mortalityDisparities in cancer treatment
• Suneja et al. (2013) – used HIV and cancer registry data to highlight
disparities in CaP treatment
• HIV-infected patients more likely not to receive treatment, OR 1.79
• Additional risk factors for not receiving treatment include:
• Late or unknown cancer stage
• Male
• IVDU as cause of HIV infection
• African American race
• Low CD4 count
• Age 45-64Differences in cancer therapy
• Retrospective cohort study of 43 HIV-infected men and 86 age and
race-matched HIV negative men
• Men with HIV less likely to choose surgery, 39.5% vs 71% (p=0.004)
• More likely to choose radiation, 26% vs 16%
• Similarly, the cohort study of 24,768 men with HIV, demographically
matched with 257,600 (Kaiser Permanente)
• HIV-infected men more likely to receive radiation (31% vs 18%)
• Less likely to receive a radical prostatectomy (25% vs 42%)
• Possible reasons for the differences:
• Prioritizing radiation owing to lower rates of ED in the short term
• General negative perception of surgery within the community
• Physician bias, fear of performing surgery on HIV-infected individualsResponse to therapy
• Patients with HIV have similar therapeutic benefits with treatment
• Majority of patients disease-free at follow-up in all studies
• Patients with HIV have similar therapeutic benefits with treatment
• 4-year biochemical-failure-free survival 87% (HIV+) vs 89% (HIV-) after EBRT
• Patients with HIV who chose surgery had undetectable PSAs at 32 months
post-op
• Limited data on watchful waiting – patients with HIV found to have stable
PSAs at 1.4 years of follow-upTreatment adverse effects • No increase in opportunistic infections in HIV infected men before or after surgery (Huang, 2006) • EBRT leads to decreased CD4+ counts • Average decline of 193-213 cells/mm • Recover to baseline 24-48 months • Current studies show no appreciable difference in outcomes for HIV- positive and negative men
CaP in transgender patients
Prostate cancer in transgender women • Transgender women who choose gender-affirming hormone therapy • Body deprived of androgens, supplemented with estrogens • CaP reported, albeit rarely (12 case reports) • 60% metastatic at presentation • Some CaP not dependent on testosterone • Some CaP tissue found to express estrogen receptors • Gooren et al examined 2306 transgender women • Prevalence of CaP 0.04% • However, these women did not undergo regular screening • Given low testosterone environment, PSA cutoff of 1 recommended • Particularly important as DRE may not be as sensitive – estrogen causes shrinkage of the prostate, nodules less prominent
Are physicians uncomfortable with LGBT patients/colleagues?
• 1982 survey of San Diego 1982 1999 2017
County Med. Society’s Would not admit highly 30% 3% 0.4%
physicians, repeated in
1999, 2017 qualified gay applicant
to med school
• More recent graduates
less likely to be Would not refer to gay 46% 9% 3%
homophobic and HIV- pediatrician
phobic. Homophobia also Would not admit HIV - 37% 6%
correlated with fear of student whose disease
HIV-infected people. was well controlled
Would not refer to HIV+ - 59% 27%
general surgeon
Marlin et al. LGBT Health, 2018
Smith et al. J Homosex, 2007Survey of 154 Academic Urologists (2019)
Do gay/bisexual patients have different
health-concerns concerning prostate
cancer than straight patients? Percentage of respondents
Concerns are similar 52.3%
Unique differences in how GBM and 47.7%
straight men experience prostate cancer
Percentage responding correctly
Gay men show more bother with
anejaculation than straight men 20.9%
GBM at increased risk for anal cancer 64.7%
LGBT patients may avoid accessing
healthcare due to difficulty
communicating with providers 60.9%Comfort discussing sexual health Comfort describing sexual health
with straight patients with gay patients
Comfortable 87.6% 87.0%
Neutral 1.3% 2.6%
Uncomfortable 11.1% 10.4%
In clinical training (med Would like more
school and continuing educational events
education), hours of through professional
formal education on LGBT organizations about LGBT
health health needs
0 19.0% Agree 43.0%
10 11.8%Gay and bisexual men’s urology program
• Idea conceived in 2018 after preliminary departmental research
showing urologic disparities in LGBT patients
• Vision
• To partner with PCPs, social work and sex therapists within the NM system and
provide LGBTQ affirming, culturally appropriate urologic care
• Obtain data on urologic health care needs of gay and bisexual men
• Create a blueprint to set up similar clinics nationwideClinic structure
• Mondays and Fridays in Urology Clinic, 20th floor, Galter
• Social worker on site
• Clinic and procedural visits
• Tuesdays and Thursday - multidisciplinary clinic, 1333 W Belmont
(Northalsted)
• Partner with 17 PCPs with patient panels enriched in LGBT patients
• Collaborative environment, seeing patients side-by-side
• Partner with sex therapists within the NM system as well as LGBT-
focused therapists in the communityMedia approach
Gay and Bisexual Men’s Urology Program Landing Page
https://www.nm.org/conditions-and-care-areas/urology/gay-and-bisexual-mens-urology-programGay and Bisexual Men’s Urology Program Landing Page
Listen to the podcast
https://www.nm.org/conditions-and-care-areas/urology/gay-and-bisexual-mens-urology-programRapid growth in number patients seen in urology clinic • Higher numbers of LGBT patients are presenting to the Gay and Bisexual Men’s Urology Program • 5% in August 2021 ! ~50% January 2022 (Lakeview location) • Telehealth is expanding reach – NYC, LA, SF, Las Vegas, Florida, DC, rural Illinois, WI
Future directions • Expand program to include more doctors, APPs, trainees • Create an interdisciplinary clinical team with internal medicine, psychiatry and other related disciplines • Cross collaboration with other departments • Build on research infrastructure to collect prospective data on LGBT patients, and encourage patient participation in research
Summary
• Rates of screening for CaP • Tools to measure SF sometimes
similar inadequate
• MSM and HSM have similar • Counseling brachytherapy
rates of treatment patients regarding radiation
• Lower HRQOL safety esp. important
• Lower rates of ED • Patients with HIV have worse
outcomes when dx with CaP
• Higher rates of bother from ED,
EjD • Trans women also affected by
CaP, PSA cutoff 1 recommended
• Treatment can lead to changes in
role in sex - identity • More education is desired by
HCPsUpdate on IAS-Durban: Focus on ART
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