September is Prostate Cancer Awareness Month. Many people don’t know that prostate cancer is the second-leading cause of cancer deaths in men, causing more than 300,000 deaths each year (only lung cancer claims more lives). Approximately one in six men will develop invasive prostate cancer in his lifetime. Men (and transwomen) who have anal sex have a greater likelihood of encountering prostate problems — whether theirs, their partner’s or both — at some point. But until very recently, the issue of prostate cancer and gay/bisexual men or transwomen has not received much attention from medical researchers.
One of the key reasons for this is the historical lack of research and data collection on gay/bisexual men and transgender women. Another major barrier is the difficulty many people have in discussing sexual orientation or behavior with their health providers. Gay and bisexual men are often not out to their primary-care providers — and when you look at the statistics on men of color, or men in older age brackets, the likelihood of being closeted is dramatically higher. In the case of prostate cancer we’re often dealing with two stigmas: the historical discomfort in talking about this form of cancer, and the stigma that continues to surround homosexuality/bisexuality and gender identity.
As with most health concerns, doctor-patient communication is critical when it comes to preventing and dealing with prostate cancer. Among the most common, life-altering effects of treating prostate cancer are changes in sexual functioning — which could impact gay or bisexual and heterosexual men in very different ways. Yet too few health-care providers ask about their patients’ sexual practices, or have the answers when asked about the effect of prostate cancer on gay men’s sexuality, for example. For many gay/bisexual men and particularly transwomen, finding culturally competent support on issues of sex, intimacy and relationships is difficult.
Risk and detection
Age is the main risk factor for prostate cancer. The chance of getting prostate cancer increases as you get older. Most prostate cancer occurs in patients older than 50. (In the United States, most patients with prostate cancer are over 65). This disease is rare in patients under 45. Race seems to play a role, as African Americans are more likely than white patients to develop prostate cancer. Having one or more close relatives (father, brother or son) with prostate cancer also increases one’s risk, as does eating a lot of red meat or high-fat dairy products.
Your health-care provider can check for prostate cancer before you have any symptoms. During an office visit, you’ll be asked about your personal and family medical history, and you’ll undergo a physical exam, which may include a digital rectal exam in which your physician or provider inserts a lubricated, gloved finger into the rectum and feels your prostate through the rectal wall, checking for hard or lumpy areas and assessing the size of the prostate.
You may also get a blood test for what’s called prostate specific antigen (PSA). This is a protein made by the prostate gland and found in the blood. PSA blood levels may be higher than normal in patients who have prostate cancer, but can also be seen in other non-cancer diagnoses like benign prostatic hyperplasia (BPH) or infection or inflammation of the prostate gland. It’s important to note that while the digital rectal exam and PSA test can detect a problem in the prostate, they can’t show whether the problem is cancer or a less serious condition. So if you have abnormal test results, your doctor may suggest further tests to determine the cause.
Treatment
There are a variety of treatment options available for prostate cancer, ranging from active surveillance (also known as “watchful waiting”) to surgery, radiation therapy, hormone therapy and/or chemotherapy. What works for one person may not be best for another, and in some cases providers will recommend a combination of treatments. The treatment (or combination of treatments) that’s right for you will depend on your age, the grade of the tumor, the number of biopsy tissue samples that contain cancer cells, the stage of the cancer, your symptoms and your general health. Your provider can explain your treatment options and the expected results of each, as well as any possible side effects. Together with your provider, you can work to develop a treatment plan that fits your medical and personal needs.
The good news
Prostate cancer survivors maintain high health-related quality of life, with a return to baseline and comparability to national norms of non-cancer comparison groups within six months to a year after treatment. The only exceptions to high quality of life are related to sexual dysfunction and, to a lesser degree, urinary incontinence and bowel problems caused by treatment; percentages of long-term effects vary by major treatment choices. It’s important to ask your provider about how your treatment may affect anal sex, both in the short and long term. Thankfully, most men live cancer free after primary treatment or, if not, live for long periods of survivorship with the disease.
The best defense with prostate cancer, as with most forms of cancer, is early detection. Your doctor should talk to you about the PSA blood test and rectal exam every year starting when you are 50. Talk about the benefits and limitations of testing so that you can make an informed decision. If you are African American or have close relatives who have had prostate cancer, you should begin having these discussions when you are 40.
Clearly, more research specific to the GBT community is needed to better understand how prostate cancer impacts our communities. In the meantime, the best thing you can do is talk candidly with your provider. Be aware of your risks and be sure you get screened on time and with the appropriate fre
Further resources: American Cancer Society (www.cancer.org ); Centers for Disease Control and Prevention (www.cdc.gov ); Gay and Lesbian Medical Association (www.glma.org ); National LGBT Cancer Network (www.cancer-network.org).
Robert Winn is medical director at Mazzoni Center, the region’s only LGBT-specific health center.