Transgender Awareness Week: Prostate Cancer Research and Insights for Compassionate Care With Stephen Freedland, MD, and Farnoosh Nik-Ahd, MD

In honor of Transgender Awareness Week, held this year from November 13-20, Dr. Stephen Freedland, an Oncology Data Advisor Board Member and Urologist from Cedar-Sinai Medical Center, and Dr. Farnoosh Nik-Ahd, a Chief Resident at the University of California, San Francisco (UCSF) Department of Urology, engaged in a discussion on prostate cancer risks in transgender women and the importance of awareness and improved healthcare practices. Their conversation focused on the growing transgender population and the need for tailored approaches to healthcare, especially in relation to prostate cancer, a disease often perceived solely as a “male” health issue.

Transgender Women and Prostate Cancer: Risks and Challenges

Dr. Nik-Ahd shares significant findings from her recent research, highlighting the risk of prostate cancer in transgender women—individuals assigned male at birth who identify as women and may or may not undergo hormone therapy or gender affirmation surgery. Because transgender women who have had gender-affirming surgery retain their prostates, they are therefore still at risk for prostate cancer. These women may also experience delayed diagnoses, especially if actively using estrogen. The use of estrogen, intended to support gender congruity, impacts prostate-specific antigen (PSA) levels, making typical screening methods less effective for this group.

One of Dr. Nik-Ahd’s studies focused on PSA levels in transgender women without prostate cancer to gauge baseline PSA levels for those on estrogen. Findings showed that median PSA values in this population are remarkably low—0.02 ng/mL compared to an average of 1 ng/mL in age-matched cisgender men. These significantly lower PSA levels suggest that the standard threshold for PSA screening used in cisgender men is inappropriate for transgender women and could lead to missed or delayed diagnoses.

Challenges and Opportunities in Screening and Awareness

The two emphasize the psychological and physical health benefits of estrogen for transgender women, underscoring that stopping hormone therapy is not a solution to addressing cancer risks. Rather, there is a need for research-backed, adapted screening protocols. They discussed the concept of “organ-based care,” which prioritizes an individual’s anatomical health needs regardless of gender identity. This approach advocates for a standardized “organ inventory” within healthcare systems, recording the organs a person retains post-transition to help guide necessary screenings and interventions.

Compassionate Care: Insights for Healthcare Providers

Raising awareness among both patients and providers is essential. Dr. Nik-Ahd emphasizes that transgender individuals should receive healthcare as tailored and attentive as that of cisgender patients. For healthcare providers, this begins with understanding that transgender women who have retained their prostate remain at risk and should receive prostate cancer screenings, with revised PSA thresholds to account for estrogen’s impact on PSA levels.

To facilitate effective screening, the two recommend integrating organ-based records in medical systems, which could remove gender as the focal point in cancer screenings. This approach, particularly useful for providers less experienced with transgender healthcare, encourages anatomically specific care rather than gendered care. This distinction could be especially impactful in addressing organ-specific cancer risks like prostate and breast cancers without the constraints of gendered perceptions of these diseases.

Improving Transgender Patient Experiences in Healthcare

Dr. Nik-Ahd and Dr. Freedland reflect on their discussions with transgender focus groups, which highlighted past negative experiences with healthcare. Many transgender patients have encountered trauma, discrimination, and miscommunication in medical settings, leading to hesitancy and mistrust in healthcare providers. Recognizing these challenges, the panel urged providers to foster a compassionate, respectful environment by using preferred names and pronouns, being mindful of documentation, and creating an open dialogue about health needs.

For physicians, small actions—such as documenting a patient’s preferred pronouns or making personal notes to remember details discussed in previous appointments—can demonstrate respect and improve rapport. These seemingly minor efforts help transgender patients feel seen, heard, and valued.

In cases of unintentional missteps, providers should acknowledge mistakes sincerely, as patients are generally forgiving when they see genuine effort to understand and support their healthcare journey. This approach to allyship is essential in counteracting the stigma and bias that transgender patients often face, contributing to a more positive healthcare experience.

Future Directions in Research and Practice

Dr. Nik-Ahd emphasizes the need for further research to determine appropriate PSA screening guidelines for transgender women on estrogen therapy. The goal is to develop evidence-based recommendations that can be integrated into clinical guidelines, ensuring inclusive healthcare practices. Such research efforts would also encourage the adoption of broader, organ-based screening protocols, which are essential for addressing the needs of diverse patient populations.

Both experts agreed that while their research provides insights, there remains a need for continued collaboration with transgender individuals to better understand their healthcare preferences and experiences. Engaging the transgender community in shaping screening practices and healthcare policies is fundamental to achieving effective and inclusive medical care.

Conclusion

As the conversation ended, both Dr. Freedland and Dr. Nik-Ahd reflected on the importance of curiosity, empathy, and advocacy in advancing transgender healthcare. The dialogue serves as a call to action for healthcare professionals to recognize and adapt to the unique needs of transgender patients, particularly in areas like cancer screening, where organ-based care could bridge gaps in current practices.

Healthcare professionals are encouraged to approach transgender care with openness, a willingness to learn, and a commitment to equality. Through education, awareness, and patient-centered care, the medical community can make strides toward a more inclusive healthcare system where all individuals receive the comprehensive care they need.

About Dr. Freedland and Dr. Nik-Ahd

Stephen Freedland, MD, is Director of the Center for Integrated Research in Cancer and Lifestyle and Associate Director for Education and Training at the Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute in Los Angeles. He also is the Warschaw Robertson Law Families Chair in Prostate Cancer and a Professor in the Department of Urology at Cedars-Sinai. He also holds a Staff Physician appointment at the Durham VA Medical Center in Durham, North Carolina. Dr. Freedland has published over 700 articles and served on numerous AUA and ASCO guideline panels for prostate cancer. His research interests include the role of diet, lifestyle, and obesity in cancer, cancer health disparities, and cancer risk stratification.

Farnoosh Nik-Ahd, MD, is a Urology Resident Physician at the University of California, San Francisco (UCSF). Her research focuses on the risk and incidence of prostate cancer in transgender women and standards for prostate cancer screening and diagnosis in this population.