By Harry Jones
Studies have brought to life the cancer concerns afflicting the lesbian, gay, bisexual, and transgender (LGBT) community. There is adequate research showing the community to have a number of unique risk factors leading to both a greater cancer risk and later stage diagnosis.
But we’re all the same, aren’t we?
Rather than any biological or physiological differences, this higher incidence level is believed to stem from socioeconomic factors and behaviours, which lead to many overlooking preventative testing that would make all the difference. Examples of such behaviours include higher rates of smoking, drug abuse, poor diet and avoidance of healthcare. These lifestyle choices paired with general misinformation have led to the development of many cases that should have been caught sooner or prevented from ever occurring.
There are seven cancers which present a particularly high risk to the LGBT community1. It is important that these cancers are well-known amongst both the community itself and healthcare professionals to both prevent and diagnose them as early as possible.
Lesbians are 3.2 times more likely to develop fatal breast cancer than heterosexual women as they are less likely to visit a healthcare professional for a mammogram to detect breast cancer2,3 . As well as mammogram avoidance, other risk factors include alcohol-use, smoking, obesity and nulliparity (never bearing a child) 4. Mammogram testing is effective in recognising breast cancer in early stages, but it is a concern that lesbians and bisexual women may avoid because of concerns about discrimination from their healthcare providers5.
It is estimated that lesbian and bisexual women have a significantly higher prevalence of cervical cancer. The most common risk factor for cervical cancer is Human papillomavirus (HPV)6. In fact, nearly all cervical cancers are caused by HPV infections. Research has shown that sexually transmitted diseases are common amongst lesbians and can be passed easily through sexual contact7,8,9 and misinformation that sexually transmitted diseases are rarely transmitted between lesbians has led many to contract the virus. Additionally, lesbians may have higher rates of other cervical cancer risk factors, including obesity and smoking history10.
The Papanicolaou test (also known as Pap test or smear test) is the most important screening used to detect cervical abnormalities. However, Pap testing is significantly lower in lesbian women, largely because of lower utilisation of sexual and reproductive health services among these patients11.
Colorectal cancers (commonly referred to as colon cancer) generally affects older generations. Family history, polyps in the colon or rectum and inflammatory bowel disease are also risk factors. An ecological analysis of sexual minority density showed that counties with greater sexual minority density tend to have a higher incidence of colorectal cancer for both men and women12, this is thought to be due to lifestyle factors such as obesity, smoking and alcohol consumption.
Colorectal cancer screening is important regardless of sexual orientation or gender identity. Health professionals should educate their patients on lifestyle changes that lower colorectal cancer risk – for example, eating a high-fibre diet that includes plenty of fruits, vegetables and whole grains, and limits red or processed meat.
Endometrial cancer begins in the lining of the uterus. It is more common amongst women who have taken estrogen therapy without progesterone, have never been pregnant, have never taken oral contraceptives, have polycystic ovarian syndrome (PCOS), or have a family history of hereditary non-polyposis colon cancer (HNPCC)13 . Endometrial cancer can be higher among lesbians due to their significantly higher prevalence of nulliparity, higher body mass index, and lower use of the contraceptive pill.
Smoking and second-hand smoke is responsible for 87% of all lung cancer deaths14. A study looking at associations between lung cancer and geographic areas with greater sexual minority density found higher incidence and mortality rates in geographic areas with a greater density of sexual minority males15. Smoking among the LGBT population is higher compared with that in heterosexual populations, and evidence suggests that gay and bisexual men are more likely to smoke than heterosexual men14. Lung cancer is one of the few cancers that can often be prevented simply by avoiding both smoking and second-hand smoke.
Studies have shown a higher risk of anal cancer among gay men. Gay and bisexual men are at increased risk for sexually transmitted diseases, and two such diseases – HPV and HIV – have both been shown to increase the risk of anal cancer16. Smoking and poor diet are also likely to put gay and bisexual men at increased risk. Other factors associated with increased risk of anal cancer include a high number of lifetime sexual partners, multiple and concurrent sexual partnerships, coexistence of other sexually transmitted infections and smoking.
Prostate cancer is most common in men older than 50 years. A family history of the condition along with a poor diet high in red meat and dairy products increase a patient’s disposition. For male-to-female transgender individuals, removal of the prostate is not typical. Although androgen-deprivation treatment reduces the size of the prostate, the potential to develop prostate cancer remains, especially among those beginning hormonal treatment after the age of 5017. However, it often goes untested after sex-reassignment. The benefits of prostate cancer screening, therefore, should be discussed with male-to-female transgender individuals.
Where do we go from here?
More focus need to be put into primary cancer prevention and early cancer detection within the LGBT community. Whilst patients and healthcare professionals may feel that a patient’s sexual orientation and/or gender identity may be irrelevant to caring for a patient’s well-being, as biologically as we are all equal, for truly preventative and successful healthcare this information needs to be established. This knowledge can then be positively used to asses a patient’s cancer risk and to successfully decide upon potentially life-saving recommendations.
- http://www.ncbi.nlm.nih.gov/pubmed/20088668 5,62.
- Boehmer U, Ozonoff A, Miao X. An ecological analysis of colorectal cancer incidence and mortality: differences by sexual orientation [serial online]. BMC Cancer. 2011;11:400.
- Zaritsky E, Dibble SL. Risk factors for reproductive and breast cancers among older lesbians. J Womens Health (Larchmt).2010;19:125-131.
- Boehmer U, Ozonoff A, Miao X. An ecological approach to examine lung cancer disparities due to sexual orientation. Public Health. 2012;126:605-612.
- Chin-Hong PV, Vittinghoff E, Cranston RD, et al. Age-specific prevalence of anal human papillomavirus infection in HIV-negative sexually active men who have sex with men: the EXPLORE study. J Infect Dis. 2004;190:2070-2076.
- Sattari M. Breast cancer in male-to-female transgender patients: a case for caution. Clin Breast Cancer. 2015;15:e67-e69.