Cancer in the LGBTQ Community. Katie Imborek, MD Clinical Assistant Professor University of Iowa Department of Family Medicine

Transcription

1 + Cancer in the LGBTQ Community Katie Imborek, MD Clinical Assistant Professor University of Iowa Department of Family Medicine

2 + Objectives Discuss the possible reasons that LGBTQ people have a disproportionate amount of cancer prevalence Recall the cancer risk factors affecting lesbians more than their heterosexual counterparts Compare the correlation between anal and cervical dysplasia Explore the potential benefits and unknowns regarding anal pap smears Construct a plan for cancer screening in trans* persons

3 + Barriers to Healthcare Insurance Same sex partners Transgender people Less likely to access preventive care services Discrimination and lack of medical knowledge National LGBT Cancer Network. The LGBT Community s Disproportionate Cancer Burden. ortionate_cancer_burden.php

4 + Lesbians and Breast Cancer Increased rates of smoking Increased alcohol consumption Decreased parity Higher obesity rates and diets higher in fat Healthy People 2020 Lesbian Fact Sheet.

5 + Lesbians and Ovarian Cancer Less likely to have used birth control pills Lower parity and breastfeeding rates Higher BMI Higher rates of tobacco abuse National LGBT Cancer Network. Ovarian Cancer in Lesbians.

6 + Screening for Cancer in Lesbians Identical guidelines as for heterosexual women Breast: Mammograms every 1-2 years starting at age Ovarian: Screening not recommended Cervical: Pap smears every 3 starting at age 21, every 5 years at age 30

7 + Anal Cancer- Symptoms 45% - Rectal bleeding 30% - Sensation or pain associated with a rectal mass During defecation or with receptive anal intercourse 25% - Pruritus or anal discharge 56% - Asymptomatic US Department of Veterans Affairs. National HIV/AIDS Website. Anal Dysplasia. Accessed 5/28/13.

8 The anal canal is approximately 4 cm long from the anal verge (margin) to the transitional zone. Ortoski R A, and Kell C S J Am Osteopath Assoc 2011;111:S35-S43 Published by American Osteopathic Association

9 + MSM and Anal Cancer HIV negative MSM Rates of anal HPV is 60% (compared to 36% in heterosexual men) 20x as likely than heterosexual men to be diagnosed with anal cancer Rates of anal cancer similar to that of cervical cancer in women prior to pap smears (37/100,000) Increasing age does not decrease rates of anal HPV Palefsky J. The Path To Anal Cancer Prevention: Where We Are and Where We re Going. PRN Notebook

10 + MSM and Anal Cancer HIV positive MSM Rates of anal HPV is 90% 40x more likely as heterosexual men to be diagnosed with anal cancer Rates of anal cancer higher than the highest incidence of cervical cancer anywhere around the world (75-137/100,000) Anti-retroviral therapy does not seem to decrease rates of anal cancer Increasing age does not decrease rates of anal HPV

11 + Guidelines for Screening for Anal Dysplasia No national or international guidelines NY State Department of Public Health AIDS Institute Baseline anal cytology for patients infected with HIV AND: MSM History of anogenital condylomas Women with abnormal cervical and/or vulvar histology University of California San Francisco HIV positive patients High Risk HIV negative patients NYS Guidelines recommendations on anal pap smears. July

12 + The Anal Pap Smear HIV negative with risk factors: MSM > age of 40, perianal condylomas, solid organ transplant recipients, women with a history of vulvar or cervical cancer Every 2-3 years HIV positive Men and women regardless of sexual activity Annually Palefsky J. The Path To Anal Cancer Prevention: Where We Are and Where We re Going. PRN Notebook

13 + Evaluation for Anal Dysplasia/Cancer in HIV + MSM At baseline and annually Ask about symptoms Examine perianal skin and inguinal lymph nodes Screen for dysplasia Anal Pap test if referral process is in place Screen for anal cancer: Digital Rectal Exam (DRE) US Department of Veterans Affairs. National HIV/AIDS Website. Anal Dysplasia. Accessed 5/28/13.

14 + Anal Pap Preparation and Materials Cytology obtained prior to using lubrication No receptive anal intercourse or enema treatment within 24 hours of sampling Dacron Swab Thin Prep pap smear medium Patient side-lying NYS Guidelines recommendations on anal pap smears. July

15 + Anal Pap Technique Moisten Dacron swab with sterile or non-sterile water Spread anus with non-dominant hand Gently insert swab until it hits the wall of the rectum Must be inserted above the squamocolumnar transition zone, approximately 2 cm from anal verge Move swab slowly in and out without withdrawing it Rotate in a spiral motion applying pressure on anal wall Withdraw and immediately place into Thin Prep medium Leave swab in container, cap container, shake vigorously for 10 seconds NYS Guidelines recommendations on anal pap smears. July

16 + Abnormal Anal Pap Results analogous to cervical pap smear If ASCUS or LSIL or more Refer for High Resolution Anoscopy with biopsy if available Refer to Colorectal Surgery for surveillance with anoscopy and early treatment (resection) of cancer Treatment of AIN 2/3 Not proven to prevent anal cancer = Lack of studies Infra-red coagulation 85% trichloracetic acid Topical 1% cidofovir for peri-anal disease Palefsky J. The Path To Anal Cancer Prevention: Where We Are and Where We re Going. PRN Notebook

17 + High Resolution Anoscopy Course offered through the American Society of Colposcopy and Cervical Pathology (ASCP) Providers Chicago, IL Howard Brown Health Center Anal Dysplasia Clinic Midwest Minneapolis, MN U of Minnesota Hennepin Co Medical Center University of California, San Francisco, Anal Cancer Info.

18 + HPV Vaccination Effectiveness among MSM 78% reduction in any grade anal intraepithelia neoplasia HPV4- Gardasil- available for males FDA approved for prevention of genital warts and anal cancer in males CDC recommendations for males Vaccination series can be started at 9 years of age Males ages may be vaccinated MSM specific recommendation through age 26 CDC. Morbidity and Mortality Weekly Report. Recommendations on the Use of Quadrivalent Human Papillomavirus Vaccine in Males- Advisory Committee on Immunizations Practices. December 23,

19 + Transgender Women Breast Cancer screening with mammography Over the age of 50 with additional risk factors: Estrogen/progestin use >5 years Positive family history BMI > 35 Prostate cancer screening PSA test is usually falsely low with androgen blockade May multiply PSA x and interpret with caution Consider in high risk patients Perform a DRE to evaluate the prostate in all transwomen Pap smears in neovaginas are not indicated Center of Excellence for Transgender Health. General Prevention and Screening.

20 + Transgender Men Breast cancer screening Prior male chest reconstruction Annual chest wall/axillary exam Mammograms not indicated Breast reduction only or no history of top surgery Clinical breast exams and mammograms as for assigned sex at birth females Center of Excellence for Transgender Health. General Prevention and Screening.

21 + Transgender Men Cervical Cancer screening As per guidelines for assigned sex at birth females Inform pathologist of current or prior testosterone use Endometrial Cancer evaluation Spontaneous vaginal bleeding with identifiable cause evaluated as for post-menopausal bleeding Consider hysterectomy if >40 years

22 + Take Home Points Lesbians should be screened per guidelines for heterosexual women Counsel lesbians regarding weight loss and smoking cessation to decrease cancer risk Discuss a plan with your organization and patients regarding anal pap smears and determine appropriate follow up of positive results Use the vaccine to prevent HPV infection and anal dysplasia Transwomen need DREs and likely need mammograms Transmen with an intact cervix need pap smears but do not need mammograms if s/p male chest reconstruction

23 + Questions???