Cover StoryPerspective

‘Negative experiences,’ lack of research impede cancer care in LGBTQ community

Upon receipt of a cancer diagnosis, bias and judgement from medical providers should not be a concern for patients.

However, research has shown that patients who identify as lesbian, gay, bisexual, transgender or queer (LGBTQ) regularly experience increased anxiety and fear discrimination in medical situations. LGBTQ cancer survivors consistently report lower satisfaction with medical care, and gay, bisexual and transgender men who survive cancer appear more likely to experience depression or relationship difficulties.

Barriers to care exist in these communities, as well.

Despite enactment of the Affordable Care Act and nationwide recognition of marriage equality, those who identify as LGBTQ are more likely than heterosexuals to lack health insurance, according to the American Cancer Society.

This may be of particular concern for cancer care. Although no specific data exist about the number of patients with cancer who identify as LGBTQ, studies suggest this population may be at increased risk for malignancy. A study published in Cancer showed gay men appeared more likely than heterosexual men to receive a cancer diagnosis (8.25% vs. 5.04%; P < .0001).

Further, data show gays and lesbians are more likely to report cancer-associated behaviors, such as smoking cigarettes, tanning, and consuming excessive alcohol and high-fat diets.

“We live in a fairly hetero-centric world,” Allison L. Diamant, MD, associate professor of general internal medicine and health services research at David Geffen School of Medicine at University of California, Los Angeles, told HemOnc Today. “The assumption by most providers — and not necessarily in a pejorative way — is that their patients are heterosexual. Educating doctors and trainees on the importance of asking questions about a patient’s sexual orientation, gender identity or sexual behavior should be key components of the patient interview when establishing care.”

HemOnc Today spoke with clinicians and researchers about the factors that influence cancer risk in the LGBTQ community, the importance of open communication about sexuality and gender identity between patients and their physicians, the issues faced by transgender patients seeking cancer care, and the need for improved and expanded cancer research in this patient population.

Risk assessment

Although research that focuses on cancer in the LGBTQ community is limited, data suggest certain cancers may be more prevalent in these individuals.

Ulrike Boehmer, PhD, associate professor of community health sciences at Boston University’s School of Public Health, and colleagues conducted an ecological study — published in 2014 in BMJ Open — that used sexual orientation population data aggregated at the county level to determine its association with cancer incidence.

Among men, greater bisexual population density appeared linked to lower incidence of lung cancer and higher incidence of colorectal cancer. Among women, greater lesbian population density appeared associated with lower incidence of lung and colorectal cancers and higher incidence of breast cancer, whereas greater bisexual population density was linked to higher incidence of lung and colorectal cancers and lower incidence of breast cancer.

However, because SEER data and cancer registries do not collect information about sexual orientation, researchers concluded “it cannot be readily determined ... whether cancer is more prevalent among individuals with a sexual minority orientation.”

Any excess risk in the LGBTQ community may be driven by potentially actionable factors.

“Most cancers are linked to behavioral risks, such as smoking, obesity, alcohol consumption, poor diet or nutrition, and physical inactivity,” Boehmer told HemOnc Today. “From available population surveillance, we know that lesbians have a higher rate of obesity than straight women. We know that LGBTQ individuals smoke at much higher rates than straight counterparts. These are relevant to breast and lung cancers, so we can say that, at a population level, LGBTQ individuals carry a higher cancer risk.”

Gwendolyn P. Quinn, PhD, MS, and Matthew B. Schabath, PhD, MS senior members at Moffitt Cancer Center and senior professors at Morsani College of Medicine at University of South Florida who have focused their research on cancer incidence in the LGBTQ community — agreed specific, alterable risk factors are common.

Perspective
  • Researchers have hypothesized that lesbians are at increased risk for breast cancer due to known risk factors within the lesbian community. Data have shown that lesbians are more likely than their heterosexual peers to be nulliparous, obese and consume alcohol in excess. A 2013 review of incidence, prevalence and risk studies assessing breast cancer among lesbians revealed mixed evidence supporting an increased risk for breast cancer among lesbians. The researchers concluded that the balance of evidence suggests a higher incidence of breast cancer among lesbians, but more data are needed. The data did not provide conclusive evidence that young lesbians have higher rates of breast cancer than their heterosexual peers. Based on current evidence, there is no recommendation by the U.S. Preventive Services Task Force, the American Cancer Society or the National Comprehensive Cancer Network for lesbians to initiate mammography at an earlier age than heterosexual women. Early mammography should be discussed with a patient’s physician, and it should be based on such risk factors as family history of breast cancer or a known underlying genetic mutation (such as BRCA1 or BRCA2 gene mutation).
    Currently, there is no national collection of sexual orientation data among patients with cancer. The Institute of Medicine has recommended the collection of sexual orientation data in federally funded surveys and electronic health records. It has also called for NIH support for lesbian health research. Some clinics and hospitals have begun to collect sexual orientation data among their patients, but coordinated national initiatives are lacking.
    Research has shown that lesbians are at increased risk for delayed cancer diagnosis and advanced disease upon diagnosis due to poor health care access. Lesbians are up to four times less likely to get mammograms than their heterosexual peers. This is due to lack of insurance and avoidance of health care providers, due to real or perceived bias. Efforts must be made to mitigate these known health disparities. Recommendations include — and are not limited to — health workforce cultural competency training, cancer screening advertising aimed at sexual minority communities and health maintenance initiatives targeting sexual minority communities.
    References:
    Blosnich JR, et al. Am J Prev Med. 2014;doi:10.1016/j.amepre.2013.11.010.
    Fredriksen-Goldsen KI, et al. Am J Public Health. 2013;doi:10.2105/AJPH.2012.301110.
    Kerker BD, et al. J Urban Health. 2006;83(5):970-9.
    Meads C and Moore D. BMC Public Health. 2013;doi:10.1186/1471-2458-13-1127.
    • Nelson Sanchez, MD
    • Chairperson, Weill Cornell Medical College LGBT Steering Committee
      Memorial Sloan Kettering Cancer Center
  • Disclosures: Sanchez reports no relevant financial disclosures.