Read the Full Video Transcript

Alicia Morgans: Hi, I'm so excited to be here to talk to Dr. Stephen Freedland, who is a professor of urology at Cedars-Sinai. Thank you so much for talking with me.

Stephen Freedland: Oh, thanks so much for having me.

Alicia Morgans: Well, really exciting work that you and your team recently published as a brief report in JAMA about transgender women who were treated, who were cared for, at least within a VA cohort. I wonder if you can tell me a little bit about what you reported.

Stephen Freedland: Yeah, so just a little bit of background. I mean, up until our case series came out, there's really only a handful of case reports of transgender women diagnosed with prostate cancer. So if you, just looking at the case reports out there, you would suggest this is a very rare phenomena, not something we particularly have to worry about. So we basically said, well, is that true? So we looked through the entire VA records of patients who were diagnosed with prostate cancer and were also transgender. The challenges, you know, transgender, there shouldn't have to be a diagnosis code for transgender. It should just be who you are. There's no code that you're cisgender female or I'm cisgender male, but yet they are given diagnosis codes. There's nothing specific to transgender. So we had to go through a lot of charts, did individual level chart review. We actually had a phenomenal resident, Farnoosh Nik-Ahd, that did the work. And ultimately we were able to identify 155 transgender women diagnosed with prostate cancer in the VA. And you start to do the math and it turns out it's, it's not narrowly as rare as you would think, it's, it, it was less common than cisgender men and trying to do some comparisons. But 155 cases, it's not a rare phenomenon.

Alicia Morgans: No, it's not. And to your point, you may even have missed some in the way that the data was able to be captured. So this is absolutely something that we as clinicians are going to need to be aware of and how do we take care of these patients in a, in a sensitive way that really addresses both who they are, as you said, right. And the disease they have, which is, which is something that, that cisgender women or women in general do not have, because they don't have a prostate.

Stephen Freedland: Correct. And, and I think that's part of the challenge and, and that's what we're hoping is just to raise awareness of, you know, in terms of transgender women, you know, they may undergo hormonal therapy, gender affirming hormonal therapy, gender affirming surgeries that they have. We will remove the testicles, we can do a lot of reconstruction, but no matter what we do, we don't remove the prostate. So these are women, they look like women, they, the world sees them as women. They are women, and yet they have a prostate. So part of it is awareness to the patients that they need to be aware of this, but it's awareness to clinicians that we need to be aware of this. And just because a woman walks into your office doesn't mean we shouldn't be thinking prostate cancer. And so, you know, it raises other questions in terms of, as you say, how to screen. So there's a lot of sensitivities about those issues. But if they're on gender affirming hormone therapy, traditionally estrogen, that's gonna cause castration. So PSA is very testosterone sensitive. So our traditional cutoff of PSA above four is abnormal. Probably doesn't apply, probably just be a lower threshold. But what is that threshold? We don't know. So again, like all great research answers, some questions raises awareness and just raises more questions that we need to delve into.

Alicia Morgans: Absolutely. Because if we are in a situation where a patient's gender affirming medical therapy is lowering testosterone of course or really changing that balance. Yeah. And these cancers may then develop within that different hormonal milieu they may be more aggressive. I mean, questions to answer.

Stephen Freedland: That's what we actually saw is we actually, it was interesting, we had three groups of women and the predominant, the most common group was actually transgender women who were not on any hormonal therapy. And it was very clear from the radical records that they identified as transgender women. Okay, but we did see women that were on gender affirming hormone therapy. Some had been on it and stopped, but if we look at the ones that were on it up until diagnosis, they actually had the highest rate of grade group five disease. And we looked at PSA density because you're changing hormones or changing prostate size, PSA, different things. So we looked at the highest PSA density numbers were pretty small in terms of we weren't able to do formal statistical analysis. But certainly suggesting exactly what you said, that those on hormones by the time they're diagnosed do seem to have a little bit more aggressive disease, which is concerning.

Alicia Morgans: Absolutely. And so how do you and the team think we should work as a community, which of course is gonna have to include our, our internal medicine colleagues Yeah. To raise awareness and then to kind of develop practices around how do we screen, how do we treat? And then, you know, of course on the backend after a diagnosis, I, I think that it's gonna be important for us to support the mental health of, of these women because they are really in a, in new territory in terms of trying to sort through some of the challenges that, that anyone with a diagnosis of prostate cancer may face.

Stephen Freedland: Yeah, it's great questions. And you know, I don't have all the answers at this point. I think that's the challenge. So I'm, I'm really excited director, Jennifer Anger, who's been a part of this research. She and I recently go, and some others got a DOD grant. And as part of that is actually plans to do focus groups with transgender women to providers that they typically see to understand what are the barriers to prostate cancer screening, how do they view this? And to really understand from their perspective, because we can sit in our offices and come up with ideas, but ultimately we need to engage with the patient advocates and understand from their perspective what are the issues so we can work collaboratively together to develop strategies to try and reduce this, you know, and make sure that we're, we're treating them appropriately.

Alicia Morgans: Wonderful. Well, and I do think that a Department of Defense grant, the DOD grant and working within a VA community is a great place to really potentially think through intervention screening and, and those kinds of algorithms in a way that you can implement and, and really have a closed system where you can, you can understand it. And I really commend you and your team for doing the preliminary work, of course, for getting the grant. And we'll have to check back and hear how things are going in the future. So what would your message be to those who are, who are listening and who are thinking about, you know, how do I, how do I think through this in my clinical practice?

Stephen Freedland: Yeah. I, I think it's, first off, it's, it's a sensitive subject and it's not you traditional cisgender male or it's like, all right, let's just check your PSA and you check a box that should be shared decision making. But often it's, it's not, it's a box that checked you don't think about it. It is a conversation. And I think asking the patient, you know how do you want to discuss these topics? I know they may well be sensitive, but you know, there's certain diseases that you may be at risk for based upon your sex assigned at birth and how do you want to have this conversation? So I think understanding and being sensitive, is number one. But then, you know, I guess number one would just be awareness. If you're not aware, you're not even gonna start that conversation. So once you're aware, then starting that conversation and it's not, it's gonna be a trickier conversation, you know, than your standard cisgender male patient. But you know, a very important conversation to have.

Alicia Morgans: Absolutely. Well, thank you again for the work that you're doing. Congratulations to you, your resident, the team on the recent publication, and we do look forward to future conversations.

Stephen Freedland: Thank you very much for having me.