2. UroToday Home
  3. Recent Abstracts
  4. Urologic Oncology
  5. Bladder Cancer

Multidisciplinary Management of Sexual and Gender Minorities with Bladder Cancer - Beyond the Abstract

Bladder cancer, a common urologic malignancy, has poor morbidity and mortality in sexual and gender minority (SGM) individuals, stemming from higher risk, poor access to care, and lack of quality cancer care. Individuals included in the SGM population include those who identify as gay, lesbian, bisexual, asexual, transgender (identify with a gender different than the sex assigned at birth), gender fluid (identify with more than one gender identity), and others not described here.1

Our recent review highlights key considerations for the evaluation, diagnosis, and treatment of SGM individuals with bladder cancer.2 Multidisciplinary management of SGM individuals provides the most holistic care to improve patient satisfaction and overall health outcomes and is more nuanced than currently available guidelines for the care of cisgender men and women.

Initial Evaluation
As with all patients, the initial evaluation of SGM individuals diagnosed with bladder cancer should include a discussion of medical and surgical history, which can be aided by an organ inventory (Figure 1) to guide screening and surgical planning. Additionally, this is relevant to establishing patient reproductive and sexual function goals. These discussions should refer to existing anatomy, regardless of gender presentation, and be conducted with sensitivity, without assumptions and mirroring language the patient uses to describe their genital organs.


Figure 1: Sexual Orientation and Gender Identity Form with Organ Inventory Adapted from LGBTQ Primary Care Toolkit16

Assessment of sexual function in cisgender, heterosexual individuals is assessed using established metrics like the Female Sexual Function Index (FSFI) or International Index of Erectile Functioning (IIEF).3 However, for gay and bisexual cis-men, differences in sexual activity and goals are not adequately captured by these scales. The Sexual Functioning Index for Men who have Sex with Men (SFI-MSM) has been validated for sexual minority cis-male populations, and similar efforts are underway to adapt the heteronormative language in the FSFI for sexual minority cis-females.4,5,6 Tools for evaluation of sexual function in transgender patients are also limited, however preliminary data has been established for scales such as the Transmasculine Sexual Function Index (TM-SFI) and Operated Male to Female Sexual Function Index (oMtFSFI) for transmasculine and transfeminine patients respectively.7,8

Diagnosis and Treatment
While the diagnostic evaluation of bladder cancer in sexual minority individuals can proceed in the traditional manner, diagnosis in gender minorities following genital gender-affirming surgery may pose challenges due to meatal stenosis (following vaginoplasty) or neourethral strictures (after phalloplasty or metoidioplasty). MRI of the pelvis can aid in diagnosis and surgical planning, such as providing the patient and surgeon with objective data about the possible dimensions of a neovagina, involvement of native or non-native pelvic organs, and potential preservation based on disease status. Smaller caliber ureteroscopes may be considered for endoscopic evaluation, with use of a laser for tissue resection or ablation.

Radiotherapy considerations relevant to SGM individuals should also be recognized. Radiation proctitis can lead to anodyspareunia, negatively impacting sexual function. Patients should be advised to avoid anal penetration for at least 6 weeks following pelvic radiation. In SGM women, radiotherapy may cause vaginal and neovaginal stenosis, which can make vaginal intercourse and/or dilation painful; placement of a vaginal dilator during radiotherapy may help limit the severity of vaginal stenosis.9,10 Surgically reconstructed tissues should be contoured when possible to limit radiation dose to these structures.9 Planning for surgical and radiotherapy interventions should include consideration of nerve preservation and patient sexual function goals, when oncologically possible.

Additional Considerations
The decision on whether to discontinue gender-affirming hormone therapy (GAHT) at the time of cancer diagnosis, or during the perioperative period, is complex and currently not well-defined due to a lack of comprehensive data.11 The benefit of discontinuing GAHT includes mitigating the theoretically increased risk of venous thromboembolism, which is increased in the setting of malignancy and surgery. However, it is also important to consider the detrimental effects of GAHT discontinuation, including worsening gender dysphoria and existing depression.12 At present, there is no data regarding the relationship between estrogen GAHT and urothelial cancer in TGD individuals.

Stress and anxiety associated with a bladder cancer diagnosis may compound existing mental health disorders more highly prevalent in the SGM population compared to the heterosexual cisgender population.13,14 Screening of mental health disorders, engagement of “chosen family,” support groups, and mental health specialists are important in navigating cancer diagnosis and related stress.15 Figure 2 offers a list of SGM-inclusive online resources for general mental health and cancer-specific support.


Figure 2: Mental Health and Cancer Support Resources for Sexual and Gender Minority Patients.

Though this review primarily focuses on objective tools and management strategies for SGM patients with bladder cancer, it is critical to acknowledge the systemic discrimination that these individuals may experience approach conversations with sensitivity and humility, and incorporate mental and social support as appropriate. Knowledge of best practices in care for SGM individuals with bladder cancer continues to evolve, and management recommendations should be monitored for updates.

Written by: Hannah Ahrendt,1 Helen Sun MD,2 Laura Bukavina MD MPH MSc2

  1. Case Western Reserve University, School of Medicine, Cleveland, OH.
  2. Case Western Reserve University, School of Medicine, Cleveland, OH; Urology Institute, University Hospitals of Cleveland, Cleveland, OH.

References

  1. Leone AG, Trapani D, Schabath MB, et al. Cancer in Transgender and Gender-Diverse Persons: A Review. JAMA Oncol. 2023;9(4):556-563.
  2. Ahrendt H, Sun H, Mishra K, Gupta S, Bukavina L. Multidisciplinary management of sexual and gender minorities with bladder cancer. Urologic Oncology: Seminars and Original Investigations. Published online June 2024:S1078143924004964. doi:10.1016/j.urolonc.2024.05.024
  3. Dickstein DR, Edwards CR, Lehrer EJ, et al. Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer. Nat Rev Urol. 2023;20(6):332-355.
  4. Clements MB, Walters CB, Lynch KA, et al. Patient-Reported Outcome Measures for Male Sexual Function Do Not Meet the Needs of Sexual Minority Men. Arch Sex Behav. 2023;52(8):3193-3200.
  5. Boehmer U, Timm A, Ozonoff A, Potter J. Applying the Female Sexual Functioning Index to Sexual Minority Women. Journal of Women’s Health. 2012;21(4):401-409.
  6. Austria MD, Lynch K, Le T, et al. Sexual and Gender Minority Persons’ Perception of the Female Sexual Function Index. The Journal of Sexual Medicine. 2021;18(12):2020-2027.
  7. Reisner SL, Pletta DR, Potter J, Deutsch MB. Initial Psychometric Evaluation of a Brief Sexual Functioning Screening Tool for Transmasculine Adults: Transmasculine Sexual Functioning Index. Sex Med. 2020;8(3):350-360.
  8. Vedovo F, Di Blas L, Perin C, et al. Operated Male-to-Female Sexual Function Index: Validity of the First Questionnaire Developed to Assess Sexual Function after Male-to-Female Gender Affirming Surgery. J Urol. 2020;204(1):115-120. doi:10.1097/JU.0000000000000791
  9. Smart AC, Liu KX, Domogauer JD, et al. Gender-Affirming Surgery and Cancer: Considerations for Radiation Oncologists for Pelvic Radiation in Transfeminine Patients. International Journal of Radiation Oncology, Biology, Physics. 2023;117(2):301-311.
  10. Briere TM, Crane CH, Beddar S, et al. Reproducibility and genital sparing with a vaginal dilator used for female anal cancer patients. Radiotherapy and Oncology. 2012;104(2):161-166.
  11. Braun H, Nash R, Tangpricha V, Brockman J, Ward K, Goodman M. Cancer in Transgender People: Evidence and Methodological Considerations. Epidemiol Rev. 2017;39(1):93-107.
  12. Goldstein Z, Khan M, Reisman T, Safer JD. Managing the risk of venous thromboembolism in transgender adults undergoing hormone therapy. J Blood Med. 2019;10:209-216.
  13. Hajek A, König HH, Buczak-Stec E, Blessmann M, Grupp K. Prevalence and Determinants of Depressive and Anxiety Symptoms among Transgender People: Results of a Survey. Healthcare (Basel). 2023;11(5).
  14. Rosser BRS, Rider GN, Kapoor A, et al. Every urologist and oncologist should know about treating sexual and gender minority prostate cancer patients: translating research findings into clinical practice. Transl Androl Urol. 2021;10(7):3208-3225.
  15. Vencill JA, Kacel EL, Avulova S, Ehlers SL. Barriers to sexual recovery in women with urologic cancers. Urologic Oncology: Seminars and Original Investigations. 2022;40(8):372-378.
  16. Willging C, Sturm R, Sklar M, Kano M, Davies S, Eckstrand K. LGBTQ primary care toolkit: A guide for primary care clinics to improve services for sexual and gender minority (SGM) patients. Albuquerque, NM: Pacific Institute for Research and Evaluation. Published 2021.
Read the Abstract