In This Article
- Gender-affirming surgery is becoming more common, and healthcare providers in all settings are likely to encounter transgender patients
- Transgender patients often have unique needs, goals, and potential complications when they are treated for cancer
- The literature contains limited information about the effects of radiation on the genitopelvic region in patients who have had gender-affirming surgery
- A new article offers a unique review of special considerations in this population, which may lead to development of formal recommendations
Radiation oncologists at Mass General Cancer Center, Andrea Russo, MD, and Alicia "Lish" Smart, MD, led one of the first publications to focus on radiation treatment planning in transfeminine people receiving pelvic radiation for cancer.
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"Unfortunately, most transgender patients have had negative experiences with the healthcare system. As physicians, we need to acknowledge that and do everything we can to make sure that our patients know—despite the limited knowledge and research we have so far—we're going to do the best we can to try to figure out how to treat them, understand their anatomy as much as we can, and do our best to predict what the side effects of radiation are going to be," says Dr. Smart, a resident radiation oncologist at Mass General Cancer Center. "We don't have as much data as we would like to be able to say how radiation and other cancer treatments will affect transgender patients, but perhaps this article is one of the first steps to get there."
The paper entitled "Gender-Affirming Surgery and Cancer: Considerations for Radiation Oncologists for Pelvic Radiation in Transfeminine Patients" was published in the International Journal of Radiation Oncology–Biology–Physics. It is one step in a multi-institutional collaboration to develop detailed recommendations to help radiation oncologists understand unique anatomical considerations and likely side effects in this patient population.
Gender-affirming Surgery Becoming More Common
According to the American Society for Plastic Surgeons, the number of gender-affirming surgeries in the United States is increasing. There were 2,700 such surgeries in 2015—and 16,400 in 2020. Therefore, Dr. Smart says, healthcare providers in all settings are likely to interact with patients who have had gender-affirming surgery.
Specifically, radiation oncologists must consider whether a patient has had surgery in a planned treatment field, which could influence radiation side effects or complications. However, these topics are poorly understood or covered in medical school and residency training programs, and no guidelines are currently available to guide radiation treatment planning in patients who have had these surgeries.
Dr. Smart and colleagues are beginning to fill the gap with their research. Their literature review explains the most common types of genitopelvic gender-affirming surgeries in transfeminine people:
- Vaginoplasty: This surgery creates a neovagina and vulva from existing tissue, usually from the penis and scrotum
- Vulvoplasty, labiaplasty, and minimal-depth vaginoplasty: These surgeries generally remove the penis and testicles, form a neoclitoris, shorten the urethra, and create an inner and outer labia and a neovaginal introitus—but they do not create a neovaginal canal
- Orchiectomy: This surgical procedure removes the testicles
The authors also reviewed the literature for any information about cancers that affected the genitopelvic area in transfeminine patients. Specifically, the article reviews neovaginal and neovulvar cancer, anal cancer, rectal cancer, prostate cancer, bladder cancer, and other primary cancers that have spread to the pelvis.
"Unfortunately, those data are very limited. There are only a few case reports, which we summarize and extrapolate from, combined with our experiences at Mass General Cancer Center," Dr. Smart says.
Considerations When Planning Radiation Therapy for Transgender Cancer Patients
Based on the findings of their review and their clinical experience, Dr. Smart and colleagues developed recommendations for a systematic approach to radiation treatment in this patient population. They offer in-depth suggestions for each step along the way—from consultation to consent to counseling and treatment planning.
"We cover how radiation oncologists can have conversations with patients to understand what kinds of surgery they've had or hope to have, as well as understand the patient's unique anatomy. That way, they are better equipped to see what they're looking at on the patient's radiation planning scan, understand where tissue may have come from, determine what structures they're seeing, and plan for radiation," Dr. Smart says. "This article provides understanding about the principles that you should be thinking about to give radiation in the best and safest way possible and how you should counsel patients about what to expect and how radiation might impact the outcome of the surgery they've had."
These conversations also can help determine which other specialists should be on the multidisciplinary team. This may include a medical oncologist, radiation oncologist, surgical oncologist, urologist, plastic surgeon, primary care provider or endocrinologist who manages hormone therapy, mental health clinician, sexual health specialist, and pelvic floor physical therapist, Dr. Smart says.
Transfeminine patients who have had gender-affirming surgery are likely to experience similar toxicities and side effects with radiation treatment as cisgender patients do. These include decreased sensation, difficulty with sexual functioning, and bowel or urinary side effects.
"One of the main ones we worry about is vaginal stenosis, which is a narrowing or tightening of the vagina. Radiation oncologists may choose to use tighter dose constraints on the neovagina because the tissue flaps used to construct it may be more sensitive to radiation than native tissue, making it particularly prone to fibrosis, scarring, and stenosis," Dr. Smart says.
The cancer treatment team should counsel patients early that they may need to use a vaginal dilator as often as daily and participate in pelvic physical therapy.
Expanding Recommendations and Education for Radiation Oncologists
Dr. Smart emphasizes that Mass General's multidisciplinary approach to care has facilitated this research. The team at Mass General Cancer Center works closely with Anton Wintner, MD, a Mass General urologist who performs gender-affirming surgeries, as well as the Transgender Health Program.
"Mass General is a great place to be able to learn about the nuances of both gender-affirming surgery and hormone therapies, the psychosocial aspects of care, and how it all impacts cancer treatment," Dr. Smart says.
The team's next step, in collaboration with colleagues at Mount Sinai Health System, NYU Langone Health, and Dana-Farber Brigham Cancer Center, is to develop more formal recommendations on how to care for transgender patients with cancer, including transfeminine and transmasculine people. One goal is to create a "radiation contouring atlas" with detailed recommendations for radiation oncologists regarding anatomical considerations in transgender patients.
"We're also working to ensure that national professional organizations present educational content on sexual and gender minority patients with cancer," Dr. Smart explains.
Learn more about the Mass General Transgender Health Program
Learn more about the Mass General Cancer Center