Scott Webb (Host): Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting all of us. We think you'll enjoy our fresh take. I'm Scott Webb.

Today, we have with us physician assistant David Miller. He's here to discuss prostate cancer in the LGBTQ+ community. David, it's nice to have you here today. Why is it so important that we talk about prostate health in the LGBTQ+ community specifically?

David Miller: The LGBTQ+ community historically has been kind of like a hidden population in prostate cancer research. Cancer registries, they don't routinely collect sexual orientation or gender identity data. So, there's a lot of gaps that have been left on how we look at prostate cancer and how prostate cancer actually affects these communities.

Interestingly, one in six gay and bisexual men will be diagnosed with prostate cancer in their lifetime. And sexual minorities actually experience poor health-related quality of life after prostate cancer treatment. They've got increased psychological distress from sexual dysfunction, which is a big thing in the LGBTQ+ community. They've got a lot more dissatisfaction with treatment compared to heterosexual men.

And the interesting thing about this topic, when I'm talking about it today is that there's another exceptionally hidden population of transgender women who actually retain their prostates regardless of their gender affirmation surgery. So, they are significantly less likely to undergo PSA screening or receive any kind of clinical recommendations for screening.

Host: Right. Yeah

David Miller: That's pretty huge. And because we're talking about the LGBTQ+ population, we also have to know that there is a higher prevalence of cancer risk factors, which include smoking, obesity, alcohol consumption compared to heterosexual or cisgender populations.

Host: Yeah. Yeah. So, you give us a sense there why it's so important to have this conversation, and good to have you here and have this conversation. So, what are some of the misconceptions about who needs to think about prostate health?

David Miller: I'm going to say that the key misconception is that transgender women do not need prostate cancer screening. So, the cancer guidelines specifically state that transgender women and other gender-diverse individuals who are assigned male at birth, they retain their prostates regardless of the gender affirmation surgery, and they need to be screened for prostate cancer.

Another misconception is that prostate cancer is only relevant to heterosexual men. in reality, any person with a prostate, regardless of sexual orientation or gender identity, is at risk. And the third major misconception, I think, is that PSA interpretation, because gender hormones like estrogen can drastically suppress the PSA levels. So, transgender women may have an underlying disease, and they will have delayed diagnosis because their PSA will be so low that you wouldn't actually know that they possibly might have prostate cancer.

Host: That's interesting, yeah. Yeah. It makes me wonder then what are maybe some of the differences in prostate cancer risk among gay, bisexual, and transgender individuals?

David Miller: First of all, currently, there is no evidence that demonstrates that sexual minorities are inherently more or less likely to develop prostate cancer than heterosexual men. There are some nuances. So when you talk about gay and bisexual men, there was a study in the UK that showed that the distribution of cancer sites does not vary substantially by sexual orientation, with the exception of HPV and HIV-associated cancers.

So, that's something that's pretty specific. But gay men were 1.7 times more likely to report any cancer diagnosis after adjusting for sociodemographic factors. So if they're HIV positive, they may actually have a decreased incidence of prostate cancer, though with poorer cancer-specific mortality.

Transgender women, it's associated with lower prostate cancer incidence. But for those transgender women who are diagnosed, it's associated with higher rates of what we call biochemical recurrence and bone mets or metastases. So, the PSA that's being suppressed from the estrogen therapy can mask disease, which leads to later stage diagnoses of this cancer.

Scott Webb: Right.

David Miller: Again, risk factors, LGBTQ plus adults, they have higher rates of smoking, obesity, and alcohol use, and also they say physical inactivity. So, these can also contribute to elevated overall cancer burden.

Host: Right. Yeah, and you had mentioned those before, the unique sort of risk factors. Wondering how can prostate issues impact sexual health, and do they, and specifically for gay or bisexual men?

David Miller: Absolutely. Prostate cancer treatment has a couple of very unique and often under-recognized effects on the sexual health in the gay male and bisexual population. So, the first thing is painful receptive anal intercourse, which is something that people in, you know, heterosexual population don't really consider. But after men who've had prostate treatment, prostate cancer treatment, either with radiation or with a radical prostatectomy, they can have painful receptive anal intercourse.

And that can also lead to another thing, which is also interesting, the changes in the role in sex. So, there are men who might shift from being a top to them being a bottom, which is a receptive role in a relationship, and that can actually affect the relationship for gay men or bisexual men.

And interestingly also, after radical prostatectomy, a lot of men have reported urine leakage when they orgasm. So, urine leakage at orgasm is something that's not pleasant during a sexual encounter. And also after prostatectomy, I would say about almost 70% of men have reported decreased penile length and even girth. And it's the way that we do the prostatectomy. We're actually taking the entire prostate out and then sewing that back together. So, it could lead to decreased penile length.

The other most common thing is orgasm dysfunction. So after you have radiation therapy, especially after you've had prostatectomy, the orgasm is not the same. You know, it doesn't feel the same. And after you've had a prostatectomy, there is no more ejaculate. So, that's pretty exceptional.

Host: Yeah. And as you say, it obviously really does impact sexual health, maybe not for everybody, but for a good number of folks. So then, maybe broadly speaking, what are the screening guidelines for prostate health?

David Miller: All right. Now, I work specifically in urology. So, I will say that the screening guidelines for us in urology are maybe a little bit more stringent than internal medicine doctors and primary care providers. The American Urological Association, their guidelines are that we screen people with prostates between the ages of 55 and 69 years old with a screening every two to four years. That's your basic population. We're just looking at their PSAs. And for those who are under 40, it's not recommended at all unless these patients are higher risk. So if they're high risk from age 40 to 54, you should screen these patients, and I'm talking patients who have a very strong family history of prostate cancer. And it's interesting because we've come so far in the way that we can detect and treat prostate cancer that to not screen a patient that is higher risk does a disservice to a lot of these patients who have prostates.

Host: Of course, yeah.

David Miller: A lot of patients will say, "Oh, my dad had prostate cancer when he was 55, and it was advanced prostate cancer." For those patients, I'm going to say, "You know what? I think that it's a good idea to get a baseline PSA even though you're only 42 years old. Just get a baseline. Because we don't know how old your father was when he had prostate cancer, even though it was high-grade prostate cancer at 55. Could he have been treated much, much sooner?" So, you know, I think it's really important to look at the other risk factors.

And we look at the PSA as well. You know, if your PSA is less than 1, then you can repeat it every two years, three years if you want. But if your PSA is between one and three, then you want to repeat the PSA every one to two years. And if it's over three, then there's consideration of needing to not just repeat the PSA, keep a close eye on it, and possibly evaluate it with a prostate MRI.

Now interestingly, the screening health is different for transgender women, and that's one of the other things I want to focus on. So, because the PSA will be so low for a transgender woman because they're on the gender-affirming hormones, clinicians have to really, really look closely at the PSA for this population. You're looking at a PSA that could be 0.7, 0.4. And in a normal population of men, you would say, "Well, that's low."

Scott Webb: That's really low, right. Yeah.

David Miller: It looks like the PSA of somebody who was already treated for prostate cancer. So, it's important that we do digital rectal exam on transgender women, and you have to also get a PSA. And we're actually looking not just at the PSA itself, but we're looking at the acceleration rate of the PSA. So, if you're looking at a PSA on a transgender woman and it's a 0.2. And then, the next year the PSA is 0.9. That's something to look at pretty closely. You know, we look at that and we go, "Hmm, I really think that we should take a close look at this patient because it shouldn't jump up that quickly. It shouldn't jump up that high in somebody who is on hormone suppressive therapy."

Host: Right. In the span of just a year.

David Miller: Right. And a lot of this stuff, we always use the term shared decision-making. So, it's important that the provider use shared decision-making with their transgender women patients about how they want to manage, you know, their PSA and the things that they want to do to continue to look forward.

Of the things I also want to talk about is there are some newer tests on the market that are helping us prevent doing unnecessary prostate biopsies on patients with prostates. In the olden days, I'm going to say—when I say the olden days, I mean, like, literally five years ago.

Host: Okay. The good old days of 2021, right? Yeah, of course.

David Miller: Yeah, that's it. You do a digital rectal exam. And after the digital rectal exam, you know, you've got your PSA. You go, "Oh, you have a high PSA. Let's do a biopsy." And all the biopsies were done, you know, in the office or in the OR with a mild anesthesia. They were all done through the rectum. And you basically put a rectal probe in. And transrectally, you're going to look at the prostate. You're going to take random samples in the regular template, so you can try to get as many quadrants as possible, and you send that out for pathology.

Now, we have MRI. MRI has become much better than it was five years ago because the Tesla magnets have improved., The radiologists that are reading the MRIs of the prostate, they become better at reading them because they've seen more and more over the last several years. So, they're all getting better at seeing if there is an area of interest, something that they need to shoot for. So, that's all fantastic.

But still, if people don't want to undergo a biopsy, we have new tests now that are using something called exosomes. And an exosome is basically a small little packet of RNA that is released from the prostate into the urine, and now we can collect a urine test and send this out for a special test that's going to look at the exosomes, which are basically the outside of the packet of RNA, and it can give a risk stratification of whether or not this patient has high-grade prostate cancer with 96% sensitivity. And i I think it's about 92% sensitivity for patients to tell whether or not they actually have significant prostate cancer. And then, for that, I'm talking about the Gleason score, but that's a different podcast.

Host: Yeah, that would be a separate podcast.

David Miller: I was just thinking though that this new test that we're using may also be something that we can use in the transgender community, because with a urine test, you can actually tell even with a very low PSA if this patient has the high probability of having aggressive prostate cancer or high-grade prostate cancer just from the DNA and the RNA.

Host: Yeah. Yeah. I was just thinking what you said, you know, the good old days five years ago, and here we are things have changed so much. New guidelines, new tools in the tool belt, so to speak. I want to get a sense from you, David, like, what does inclusive prostate care look like in a clinical setting?

David Miller: That's a challenge for medical providers across the entire country, even across the entire world. First, it has to be systemic. It has to be part of your entire culture for your medical care system. Intake forms should include something that indicates sexual orientation or gender identity. And most importantly, providers need to be asking every one of their patients about their sexual orientation and gender identity if necessary, if it's not already stated, you know, on the patient's intake form. We have to really use organ-based language.

So like I said before, people with a prostate rather than saying men. Even here in my office, I had a transgender woman who came in and this was pre-transgender affirmation care in large medical systems. You know, I had my nurse literally come out of the room and say, "David, that woman has a prostate."

Host: Right.

David Miller: "And she's gorgeous." I'm like, "Yeah, that doesn't change the fact that she has a prostate," you know? And we still have to take care of that. So, organ-based language is good.

We have to kind of avoid things like what we call heteronormative assumptions. There's a large group of urologists that were surveyed that actually disagreed that knowing sexual orientation was necessary for optimal care. And evidence shows that it affects treatment decisions tremendously, especially with quality of life for these patients.

And I think it's important that there's some kind of visible inclusivity in offices. So, some kind of inclusive signage, LGBTQ+ friendly provider listings. We need staff training. We need staff to understand that the LGBTQ+ population is a population that also needs inclusive medical care, and they need to be treated that way. And we really need a little bit more tailored counseling. You know, we have to be able to feel free and open to discuss things like receptive anal intercourse, the role in sex changes, and be able to provide specific LGBTQ+ support group referrals. There are a lot out there and the Valley Health System is very inclusive when we talk about how we treat our LGBTQ+ community, but every health system can do better.

Host: Right. Yeah, that's well said. And you're talking there about just having conversations, open conversations, real conversations. So, what would you tell a patient who's maybe kind of unsure of how to start a conversation about their prostate health?

David Miller: I think that the first thing you do is you normalize the discussion, okay? I always frame prostate health as routine for anybody who has a prostate, regardless of their identity. We always use open-end questioning. And in our initial intake forms, you know, it says on the top if your relationship status, you know, married, and if you have any kids. And even if it says married and two kids, you cannot assume that this patient is heterosexual. And I will always say, "Are you married to a man, a woman, or somebody who is trans?" I will quickly just say it as a throw-off comment. You know, I'm not going to dwell on this, but it has to be something that is easily rolled off your tongue. That is what makes patients feel most comfortable. And most of my heterosexual patients, they don't have any issues that I'm asking them, "Oh, you know, are you sexually active with women, men, or both?" A lot of them will say, "Oh." Like, they'll laugh and they'll say, "Oh, yeah, I guess you do have to ask me that question," you know? Of course you do.

Host: Of course, yeah.

David Miller: So, that's another thing, the open-ended question. And I always try to stress shared decision-making with all of our guidelines. You know, the American Urological Association has guidelines for all of this stuff. And it's important that, you know, you're not directing care and saying, "You need to have this done," and "We need to do this for you."

I always reassure my patients that disclosure of their sexual orientation or gender identity actually helps me tailor their care. And most people in the LGBTQ+ community understand that, and they're usually really comfortable about talking with me about all of these things. I would also say that for transgender patients, I like to acknowledge to them that prostate cancer screening, while it may feel strange with their gender identity, I always explain the medical importance of it.

Host: Yeah. A high medical importance as we've established here today, thanks to your expertise. And David, I know that some risk factors are modifiable, let's say, right? Smoking, losing some weight, all that kind of stuff, right? But in general, like, what can we do to support our prostate health?

David Miller: I think, you know, other than what you just mentioned, the avoid smoking, limit, alcohol intake because, you know, alcohol consumption can raise the risk for lots of cancers out there. You need to maintain a healthy lifestyle, make sure that, you know, you're trying to a healthy body weight, and make sure that you understand, as a patient, you understand your personal risk factors, which include your age, your race and ethnicity, your family history, and your genetic predisposition, which also includes, you know, from your mother's side, whether or not they were BRCA positive on your mother or your father's side, whether or not there were any first or second-degree relatives that had prostate cancer and whether or not it was aggressive prostate cancer. You need to engage in decision-making about PSA screening.

You know, there are patients who say, "You know what? I'm a little uncomfortable. I really would like to start it at 45 instead of 55 or 50." I would like to start at 40 if they're high risk. If you are African American and your father had prostate cancer, then I want to screen you earlier.

I mean, I don't want to wait until you're 55. But most importantly, you have to really just communicate openly with your healthcare provider about your sexual orientation, your gender identity, and your sexual behaviors. When we look at, you know, getting a PSA, I always tell my patients if they have an elevated PSA, that there are things that can increase a PSA.

Are you an avid bicyclist? Do you like to bike a couple of times a week, 20 miles, 20 miles a stretch? Because, you know, a bicycle seat is pressing up against the prostate. Ejaculating before you get your PSA drawn is another reason to increase the PSA. And if you have receptive anal intercourse and you have it the night before, that is another reason to increase your PSA.

So, patients have to just understand so that they know, you know, certain things that they need to do to take care of themselves, especially even before they get their lab work drawn for their PSA.

Host: I certainly appreciate your time and your expertise today. We've established along the way here we could be doing other podcasts about some of the subtopics and, you know, I feel like we're just kind of scratching the surface. But good stuff. And I wanted to give you a chance here at the end just briefly tell folks if they enjoyed listening to you today, where can they or how can they listen to your personal podcast?

David Miller: Ah. So, I do have a personal podcast. And you can listen to it anywhere. You can listen to it anywhere that podcasts stream. It is called Urine Luck, spelled like urine, Now Streaming. And I think that anybody would enjoy these podcasts. There's a couple of podcasts that are straight interviews with one of my colleagues, which is a three-part series on prostate cancer.

But the majority of my podcasts are me interviewing another patient that I take care of, and I play myself as well as the patient. So, you will meet all different characters that I play from little old ladies in New Jersey to lawyers who work in New York City who are very anxious people. I've got patients from middle America to the deep South. So, I think anybody who wants to listen to these short podcasts, Urine Luck: Now Streaming.

Host: That's great. That's perfect. As I told you earlier, I love a good pun. And it's really good stuff and it's great to have you here, and I appreciate your time. Thanks so much.

David Miller: I appreciate it. Thanks for having me, Scott.

Host: And for more information, go to valleyhealth.com/urology. And if you found this podcast helpful, please share on your socials and check out our entire podcast library for topics of interest to you. And thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey. For more information on today's topic or to be connected with today's guest, please call 201-689-3646 or email valleypodcast@valleyhealth.com. I'm Scott Webb. Stay well.