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Prostate Cancer Screening in Transgender Women/Transfeminine Persons: Building on Canadian Evidence - Beyond the Abstract

Transgender women/transfeminine persons across the world face health inequities.1 Emerging evidence suggests that prostate cancer is part of this inequity landscape.2,3 Although the overall incidence of prostate cancer in this population appears lower than in cisgender men, prostate cancer diagnoses in transgender women/transfeminine persons are associated with greater morbidity and worse oncological outcomes.4,5 These disparities are thought to be multifactorial, reflecting systemic inequalities, as well as differences in how and when prostate-specific antigen (PSA) screening is discussed and undertaken.

In an editorial letter, we discussed a recent Canadian, multi-institutional study by Lacombe-Duncan and colleagues that investigated the status of PSA screening among this group.6 There was low PSA screening uptake among transgender women/transfeminine persons aged 50 years and older, with paradoxically even lower screening rates among those who had experience navigating prior healthcare barriers in accessing publicly funded vaginoplasty. We argued that these patterns likely reflect gaps from non-inclusive guidelines, provider-level uncertainty in the context of gender-affirming care, and national reliance on opportunistic PSA testing.7,8

There are further relevant gaps for transgender women/transfeminine persons that are worth considering, particularly regarding population-based reporting. Transgender populations remain mostly invisible in the administrative registries and cancer databases that underpin large-scale epidemiologic analyses. Canada’s 2021 Census was the first to formally capture gender-diverse identities;9 despite this, most healthcare registry datasets rely on older, binary sex data collection. A frequently proposed solution of a universal “two-step” approach, separately asking individuals about their current gender identity and their sex assigned at birth, could allow for more inclusive research. However, implementing such measures at scale raises legitimate concerns about privacy, potential misuse of sensitive data, and the risk that poorly handled data collection could further erode trust among transgender and gender-diverse communities.

In Ontario, previous work has tried to address these barriers using data linkages with the electronic medical records from specialized clinics. Using this method, Abramovich and colleagues found that transgender patients in Ontario had higher rates of chronic medical conditions and health service use compared to matched controls.10 However, this approach was not truly population-based, and generalizability may be limited. This linkage approach does demonstrate that more inclusive use of existing data sources is methodologically feasible and safe.

Evidently, future PSA screening policies for transgender women/transfeminine persons need to be grounded in better population-level data. Prospective accrual of sufficient numbers of transgender patients with prostate cancer for long-term outcomes research is likely infeasible at single centres and even across networks due to sample size limitations. In Canada, the creation of inclusive cross-sectional registries and administrative data linkages is therefore imperative to mitigate this concern. Data should capture not just gender identity but also details of gender-affirming hormone therapy and surgery, which are thought to affect the natural history of prostate cancer.11 Such infrastructure would not only provide a stronger foundation for tailoring PSA screening recommendations while minimizing avoidable harms, but also for investigating other healthcare disparities experienced by transgender women/transfeminine persons.

Overall, prostate cancer screening for transgender women/transfeminine persons in Canada will need to balance emerging evidence on risk with the potential harms of over-investigation.12 As Canadian data and guidelines evolve, integrating gender-affirming principles, improved data collection, and shared decision-making into PSA screening practices will be essential.

Written By: Ihtisham Ahmad,1 David-Dan Nguyen,2,3 Alexandra Millman,2,4,5 and Yonah Krakowsky2,4,5

  1. Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada;
  2. Division of Urology, University of Toronto, Toronto, ON, Canada;
  3. Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada;
  4. Division of Urology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada;
  5. Division of Urology, Women’s College Hospital, University of Toronto, Toronto, ON, Canada.
References:

  1. The Lancet Public Health (2024). Addressing health inequalities in gender diverse people. The Lancet Public Health, 9(2), e68.
  2. Nik-Ahd, F., Anger, J. T., Cooperberg, M. R., & Freedland, S. J. (2023). Prostate cancer is not just a man's concern - the use of PSA screening in transgender women. Nature Reviews Urology, 20(6), 323–324.
  3. Nik-Ahd, F., Jarjour, A., Figueiredo, J., Anger, J. T., Garcia, M., Carroll, P. R., Cooperberg, M. R., Vidal, A. C., & Freedland, S. J. (2023). Prostate-Specific Antigen Screening in Transgender Patients. European urology, 83(1), 48–54.
  4. Bertoncelli, M., Sahota, K., Burn, J., Falconer, A., Winkler, M., Ahmed, H. U., Rashid, T. G., & Gender Research Collaborative (2022). Prostate cancer in transgender women: what does a urologist need to know? BJU international, 129(1), 113–122.
  5. Nik-Ahd, F., De Hoedt, A., Butler, C., Anger, J. T., Carroll, P. R., Cooperberg, M. R., & Freedland, S. J. (2023). Prostate Cancer in Transgender Women in the Veterans Affairs Health System, 2000-2022. JAMA, 329(21), 1877–1879.
  6. Lacombe-Duncan, A., Ortiz, G. C., Underhill, A., Brundage, M., Saucier, A., Goodhew, J., Nguyen, Q., & Loutfy, M. (2025). Prostate-specific antigen screening among transgender women in clinical care: A retrospective chart review study. Urologic oncology, 43(11), 664.e1–664.e9.
  7. Nguyen, D. D., Ahmad, I., Potter, E., Millman, A., & Krakowsky, Y. (2025). Prostate cancer screening in transgender women/transfeminine persons: Building on Canadian evidence. Urologic oncology, S1078-1439(25)00360-6.
  8. Nguyen, D. D., Ahmad, I., Al-Daqqaq, Z., Rosella, L. C., Hird, A., Wallis, C. J. D., Grober, E. D., Lofters, A., Kulkarni, G. S., Millman, A., & Krakowsky, Y. (2025). Prostate cancer screening in transgender patients: Why current Canadian screening policies need to be better tailored to our patients. Canadian Urological Association journal, 19(6), 202–204.
  9. Statistics Canada. (2022, April 27). Canada is the first country to provide census data on transgender and non-binary people. The Daily. https://www150.statcan.gc.ca/n1/daily-quotidien/220427/dq220427b-eng.htm.
  10. Abramovich, A., de Oliveira, C., Kiran, T., Iwajomo, T., Ross, L. E., & Kurdyak, P. (2020). Assessment of Health Conditions and Health Service Use Among Transgender Patients in Canada. JAMA network open, 3(8), e2015036.
  11. Manfredi, C., Franco, A., Ditonno, F., Bologna, E., Licari, L. C., Leonardo, C., Antonelli, A., De Nunzio, C., Cherullo, E. E., De Sio, M., & Autorino, R. (2024). Prevalence and Factors Associated With Prostate Cancer Among Transgender Women. JAMA Oncology, 10(12), 1697–1700.
  12. Nguyen, D. D., Lofters, A., Wallis, C. J. D., Zlotta, A. R., Fleshner, N. E., Trinh, Q. D., Finelli, A., Rosella, L. C., Detsky, A. S., Roobol, M. J., & Kulkarni, G. S. (2025). Is it time for Canada to revisit its approach to prostate cancer screening? Lancet regional health Americas, 49, 101180.
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