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Prostate cancer in sexual minorities and the influence of HIV status

Abstract

Prostate cancer is the second most common cause of cancer-related death in men in the USA, but the effect of prostate cancer diagnosis and treatment on men in a sexual minority group, including men who have sex with men and transgender women, is poorly understood. Efforts to study this population are complicated, as cancer registries do not routinely collect information on sexual orientation. As a result, epidemiological data regarding this population have come from small studies that have included disparate rates of prostate cancer screening, diagnosis and treatment. Qualitative studies indicate that prostate cancer is experienced differently by sexual minorities, with distinct health-care needs that arise owing to differences in sexual practices, social support systems and relationships with the medical community. Notably, sexual minorities have been reported to experience poorer health-related quality of life outcomes than heterosexual men, and tend to have less robust social support systems, experience increased psychological distress caused by sexual dysfunction (areas of which are unmeasured after treatment), experience isolation within the health-care system and express increased levels of dissatisfaction with treatment. The incidence of prostate cancer actually seems to be decreased in men from sexual minorities living with HIV, despite there being no differences in screening and treatment, with poor cancer-specific mortality. Although the literature on patients with prostate cancer in men from sexual minority groups has historically been sparse, peer-reviewed research in this area has grown considerably during the past decade and has become an important field of study.

Key points

  • Men from sexual minorities who are diagnosed with prostate cancer can have different experiences from heterosexual men and rely on different support networks to navigate their illness.

  • No clear evidence exists to suggest that screening practices and rates of diagnosis of prostate cancer vary in men from sexual minorities compared with heterosexual men.

  • Men from sexual minorities with prostate cancer have poorer health-related quality of life and show a small but significant increase in psychological distress associated with the sexual adverse effects of treatment than their heterosexual counterparts.

  • Health-care providers are often underprepared to address the unique needs of these men; moreover, few validated questionnaires are able to assess sexual function in men who participate in both penetrative and receptive anal intercourse.

  • The intersecting diagnoses of prostate cancer and HIV in men from sexual minorities can lead to further disparities in care, with reduced cancer-specific survival in HIV-positive men.

  • Transgender women should be screened for prostate cancer as they seem to remain at risk of the disease after transition; a serum PSA concentration of 1 ng/ml should be used as the upper limit of normal in these patients, as gender-affirming hormone therapy can artificially lower PSA levels.

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Fig. 1: Postimplantation precautions to protect the partner after brachytherapy.

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Reviewer information

Nature Reviews Urology thanks R. Wassersug, S. Rosser and D. Mitteldorf for their contribution to the peer review of this work.

Review criteria

A literature search was performed using MEDLINE via PubMed, EMBASE via Ovid, PsycINFO and Web of Science. Search terms included “gay”, “bisexual”, “sexual minorities”, “homosexual”, “LGBT”, “MSM”, “GBM”, “men who have sex with men”, “HIV”, “human immunodeficiency virus”, “AIDS”, “prostate cancer”, “transgender”, “transsexual” and “prostate neoplasm”. We restricted our search to studies published in English.

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C.A., V.W., E.Y. and A.M. researched data for the article. C.A., V.W. and E.S. made a substantial contribution to discussions of content. C.A., V.W., E.Y. and A.M. wrote the manuscript. C.A., E.S. and S.K. reviewed and edited the manuscript before submission.

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Correspondence to Channa Amarasekera.

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Related links

Malecare: https://malecare.org

Prostate Cancer UK LGBT group: https://prostatecanceruk.org/get-support/support-groups/lgbt-group

Glossary

Gay

Used to describe people who have physical, romantic and/or emotional attractions to people of the same sex as them. Can encompass men and women, but often the term ‘lesbian’ is used to identify gay women.

Queer

An umbrella term with different interpretations; often used by people whose sexual orientation is not solely heterosexual.

Bisexual

Used to describe people who can develop physical, romantic and/or emotional attractions to either gender.

Transgender

A term for people whose gender that they identify with or externally manifest (for example, through clothes, name or behaviour) differs from their biological sex.

Men who have sex with men

(MSM). Men who engage in sexual activity with other men. Includes those who do not self-identify as gay or bisexual.

Homosexual

An outdated term with the same meaning as ‘gay’ that is sometimes regarded as offensive in the lesbian, gay, bisexual and transgender community.

Masculine self-esteem

How masculine one feels or, in other words, how whole of a man they feel.

PSA concern

The degree of concern or anxiety that the patient feels with monitoring and how comfortable they feel knowing their serum PSA value.

Outlook

How much the patient feels that dealing with cancer has contributed to making them stronger or giving them a better outlook on life.

Sexual confidence

Confidence regarding one’s own sexuality, sexual orientation and sexual capability.

Disease-specific support

Support of specific behaviours that improve the disease and supportive attitudes towards the disease.

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Amarasekera, C., Wong, V., Yura, E. et al. Prostate cancer in sexual minorities and the influence of HIV status. Nat Rev Urol 16, 404–421 (2019). https://doi.org/10.1038/s41585-019-0194-2

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