New England Section of the American Urological Association

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The State of PSA screening in Male to Female Transgender Patients
Jorge Pereira, MD1; Ohad Kott, MD2; Keara Decotiis, MD1; Gyan Pareek, MD1; Boris Gershman, MD1; Joseph Renzulli, MD1
1Warren Alpert School of Medicine at Brown University, Division of Urology, Providence, RI; 2The Minimally Invasive Urology Institute at The Miriam Hospital, Providence, RI

Introduction:
There are over one million transgender (TG) persons in the United States. As this population grows, more TG patients will seek urologic care for prostate cancer (PCA) screening. However, the effects of hormonal manipulation used by many TG patients on the natural progression of prostate cancer and its implication on screening tests remains unclear. Prostate specific antigen (PSA) levels are lower in those on hormonal therapy, but data evaluating the normal PSA range for these patients are limited. Current recommendations for PCA screening are not tailored for TG patients making appropriate prescreening counseling regarding PSA critical in this population. As such, we sought to describe prescreening PSA counseling (PPC) rates amongst MtF-TG patients and non-TG patients using the 2016 Behavioral Risk Factor Surveillance System (BRFSS).
Methods:
We analyzed complex survey data from the 2016 BRFSS. Only respondents ages 40-79 who completed both the "Prostate Cancer Screening" and "Sexual Orientation and Gender Identity" modules were included. Respondent characteristics analyzed included education level, income level, relationship status, age, and race. Baseline characteristics were summarized using weighted percentages, and compared using Pearson chi-square test. The association of PPC with MtF-TG status was evaluated using logistic regression, adjusted for respondent features.
Results:
A total of 59,148 respondents were included, corresponding to a weighted estimate of 35 million people. Of these, 0.4% identified as MtF-TG. MtF-TG respondents were more likely to report a lower education level (p<0.01), and lower income level (p<0.01); no other statistically significant differences were noted between groups. Overall, 57.3% of respondents reported undergoing PPC. Counseling rates were lower amongst MtF-TG respondents when compared to the non-TG group, though this did not reach statistical significance (47.4% vs 57.3%, p=0.36). Multivariable analysis adjusting for the previously mentioned respondent features demonstrated no statistically significant association with MtF-TG status and PPC (OR 0.65 p=0.38). A higher income level, higher education level, and increased age were all associated with increased odds of PPC.
Conclusion:
In this survey, PPC was less frequently reported among MtF-TG respondents than in the non-TG group, though this difference did not reach statistical significance. Further data is needed to help tailor PSA screening for MtF-TG patients, but until then quality prescreening counseling regarding PSA is essential when treating members of this population.
TABLE 1. Characteristics of respondents over age 40 who had serum PSA level drawn, by transgender status.

Overall
(n=59,148)
___________
Weighted%
Identifies as Transgender Male to Female
(n=173)
_____________
Weighted% (n)
Does not Identify as Transgender
(n=58,975)
_____________
Weighted% (n)
p
PSA Counseling57.3%47.4%57.3%0.36
Race
White
Black
Other
67.3%47.0%67.4%0.19
9.9%14.7%9.9%
22.7%38.2%22.7%
Education Level
HS or less
Some College
College graduate
43.1%
28.0%
28.9%
70.8%
20.6%
8.6%
43.0%
28.0%
29.0%
0.01
Income level (USD)a
<50,000
50-75,000
>75,000
43.3%
15.6%
41.0%
73.1%
11.3%
15.6%
43.4%
15.6%
41.1%
<0.01
AUA Age Group a
40-54 years
55-69 years
70-79 years
44.1%
41.5%
14.3%
30.4%
60.0%
9.6%
44.2%
41.5%
14.4%
0.07
In a relationship69.3%63.8%69.3%0.52

TABLE 2. Unadjusted and Adjusted Odds Ratio of having a PSA counseling according to transgender status Education Level, Race, Income Level, Marital Status, Age, Diabetes status and BMI.
Underwent PSA Counseling
_______________
Unadjusted OR (95%CI)
pUnderwent PSA Counseling
_____________
Adjusted OR (95%CI)
p
Male to Female transgender a0.67 (0.28, 1.59)0.370.65 (0.25, 1.70)0.38
Race
White
Black
Other
--
1.14 (1.00, 1.29)
--
0.04
--
1.67 (1.44, 1.93)
--
<0.01
<0.01
0.57 (0.52, 0.63)<0.010.82 (0.73, 0.92)
Education Level
HS or Lower
Some College
College or Higher
--
1.57 (1.44, 1.71)
2.05 (1.90, 2.21)
--
<0.01
<0.01
--
1.36 (1.23, 1.50)
1.66 (1.50, 1.82)
--
<0.01
<0.01
Income level (USD)
<50,000
50-75,000
>75,000
--
1.48 (1.34, 1.65)
1.63 (1.51, 1.76)
--
<0.01
<0.01
--
1.39 (1.23, 1.56)
1.60 (1.44, 1.78)
--
<0.01
<0.01
AUA Age Group
40-54 years
55-69 years
70+ years
--
3.74 (3.46, 4.03)
5.30 (4.73, 5.95)
--
<0.01
<0.01
--
4.03 (3.70, 4.38)
5.97 (5.24, 6.80)
--
<0.01
<0.01
In Relationship1.57 (1.46 1.69)<0.011.34 (1.22, 1.46)<0.01

a Reference group = Non-transgender


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