- Email: [email protected]
Cancer in the transgender community
Correspondence
Cancer in the transgender community The Lancet Oncology editorial “Cancer risk in the transgender community”1 provides a timely and important insight into a patient population that has long been neglected. Prostate cancer in transgender women deserves special emphasis. Although only four cases of prostate cancer have been reported in this group, the reported incidence is very likely to be a gross underestimate for several reasons.2–5 First, many patients, and some physicians, do not realise that the prostate is not removed during sex reassignment surgery. Second, some patients and caregivers erroneously assume that the oestrogen replacement that is routinely given to these patients protects them from prostate cancer. In all reported cases of prostate cancer in transgender women, the patients started hormone therapy aged 45 years or older, and one developed metastatic disease 31 years after starting hormone ablation. 5 No published guidelines exist to recommend how frequently, how long, or in what manner transgender women should be followed up after surgery. I am not aware of any study that is designed to examine these issues; such a study is overdue, and these important questions need to be addressed. What is the proper monitoring of transgender women in terms of frequency of prostatespecific antigen (PSA) testing and digital rectal examination? Is earlieronset oestrogen therapy (for example, in patients aged 20–29 years) more protective against cancer development than when oestrogen therapy is commenced later, in middle-aged patients, when subclinical prostate cancer might already be present? Regular PSA testing and rectal exams in this group of patients would seem advisable until an analysis of larger cohorts followed for longer periods provide data for evidence-based recommendations.
I declare no competing interests.
Kevin R Loughlin [email protected] Division of Urology, Brigham and Women’s Hospital, Boston, MA 02115, USA 1
2 3
4
5
The Lancet Oncology. Cancer risk in the transgender community. Lancet Oncol 2015; 16: 999. Thurston AV. Carcinoma of the prostate in a transexual. Br J Urol 1994; 73: 217. Van Haarst EP, Newling DW, Gooren LJ, et al. Metastatic prostatic carcinoma in a male to female transsexual. Br J Urol 1998; 81: 776. Dorff TB, Shazer RL, Nepomuceno EM, et al. Successful treatment of metastatic adrogen-independent prostate carcinoma in a transsexual patient. Clin Genitourin Cancer 2007; 5: 344–46. Turo R, Jallad, S, Prescott S, Cross W. Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy. Can Urol Assoc J 2013; 7: E544–46
TRIBE study: are all three cytotoxic drugs crucial? In the updated analysis of the TRIBE study, Chiara Cremolini and colleagues 1 reported that patients treated with FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan) plus bevacizumab (the experimental group) had significantly better overall survival in patients with metastatic colorectal cancer compared with FOLFIRI (fluorouracil, leucovorin, and irinotecan) plus bevacizumab (the control group). In accordance with a general consensus that administration of all three cytotoxic drugs (ie, fluorouracil, oxaliplatin, and irinotecan) can maximise overall survival in advanced colorectal cancer, 2 the patients in the control group were supposed to receive oxaliplatin-based chemotherapy at the initial diagnosis of disease progression. 81% of the control group received oxaliplatin as either second-line treatment (121 [67%] of 180 patients) or third-line treatment (25 [14%] of 180 patients). This difference in exposure to oxaliplatin between the experimental group and control group may have, at least partly, contributed to the 4-month prolongation of
www.thelancet.com/oncology Vol 16 December 2015
overall survival in the experimental group. Although the proportion of patients who received all three cytotoxic drugs in the control group compares favourably with the results of previous trials, 3,4 the smooth, seamless induction of oxaliplatin is crucial to the outcomes of any patient with metastatic colorectal cancer. Therefore, the baseline characteristics of the 19% of patients in the control group, who did not receive oxalipatin, as well as the reasons why they did not receive the drug as subsequent chemotherapy are of great interest. YA reports grants from Sanofi, Torii Pharmaceutical, Mitsubishi Tanabe Pharma, and Mochida Pharmaceutical; grants and personal fees from Chugai Pharmaceutical, Takeda Pharmaceutical, Daiichi Sankyo, Kyowa Hakko Kirin, Eisai, Taiho Pharmaceutical, Nippon Kayaku, YakultHonsya, and Merck Serono; personal fees from Ono Pharmaceutical, Eli Lilly Japan KK, Pfizer Inc, Novartis Pharma KK, and Janssen Pharmaceutical KK, grants and personal fees from Hisamitsu Pharmaceutical, AstraZenaca KK, GlaxoSmithKline, ASKA Pharmaceutical, Terumo Corporation, Bayel Holding, Meiji Seika Pharma, Arkray Marketing, CBC Radio, Igaku-shoin, Vigorous-Med, Nakayama Shoten, Nanzando, Benesse Style Care, Tokyo Kagaku Dojin, Kowa Pharmaceutical, Boehringer Ingelheim, and Bristol-Myers Squibb outside of the submitted work. AM and OM declare no competing interests.
*Ayumu Matsuoka, Osamu Maeda, Yuichi Ando [email protected] Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya 466-8550, Japan 1
2
3
4
Cremolini C, Loupakis F, Antoniotti C, et al. FOLFOXIRI plus bevacizumab versus FOLFIRI plus bevacizumab as first-line treatment of patients with metastatic colorectal cancer: updated overall survival and molecular subgroup analyses of the open-label, phase 3 TRIBE study. Lancet Oncol 2015; 16: 1306–15. Grothey A, Sargent D, Goldberg RM, et al. Survival of patients with advanced colorectal cancer improves with the availability of fluorouracil-leucovorin, irinotecan, and oxaliplatin in the course of treatment. J Clin Oncol 2004; 22: 1209–14. Tournigand C, André T, Achille E, et al. FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: a randomized GERCOR study. J Clin Oncol 2004; 22: 229–37. Heinemann V, von Weikersthal LF, Decker T, et al. FOLFIRI plus cetuximab versus FOLFIRI plus bevacizumab as first-line treatment for patients with metastatic colorectal cancer (FIRE-3): a randomised, open-label, phase 3 trial. Lancet Oncol 2014; 15: 1065–75.
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Cancer in the transgender community The Lancet Oncology editorial “Cancer risk in the transgender community”1 provides a timely and important insight into a patient population that has long been neglected. Prostate cancer in transgender women deserves special emphasis. Although only four cases of prostate cancer have been reported in this group, the reported incidence is very likely to be a gross underestimate for several reasons.2–5 First, many patients, and some physicians, do not realise that the prostate is not removed during sex reassignment surgery. Second, some patients and caregivers erroneously assume that the oestrogen replacement that is routinely given to these patients protects them from prostate cancer. In all reported cases of prostate cancer in transgender women, the patients started hormone therapy aged 45 years or older, and one developed metastatic disease 31 years after starting hormone ablation. 5 No published guidelines exist to recommend how frequently, how long, or in what manner transgender women should be followed up after surgery. I am not aware of any study that is designed to examine these issues; such a study is overdue, and these important questions need to be addressed. What is the proper monitoring of transgender women in terms of frequency of prostatespecific antigen (PSA) testing and digital rectal examination? Is earlieronset oestrogen therapy (for example, in patients aged 20–29 years) more protective against cancer development than when oestrogen therapy is commenced later, in middle-aged patients, when subclinical prostate cancer might already be present? Regular PSA testing and rectal exams in this group of patients would seem advisable until an analysis of larger cohorts followed for longer periods provide data for evidence-based recommendations.
I declare no competing interests.
Kevin R Loughlin [email protected] Division of Urology, Brigham and Women’s Hospital, Boston, MA 02115, USA 1
2 3
4
5
The Lancet Oncology. Cancer risk in the transgender community. Lancet Oncol 2015; 16: 999. Thurston AV. Carcinoma of the prostate in a transexual. Br J Urol 1994; 73: 217. Van Haarst EP, Newling DW, Gooren LJ, et al. Metastatic prostatic carcinoma in a male to female transsexual. Br J Urol 1998; 81: 776. Dorff TB, Shazer RL, Nepomuceno EM, et al. Successful treatment of metastatic adrogen-independent prostate carcinoma in a transsexual patient. Clin Genitourin Cancer 2007; 5: 344–46. Turo R, Jallad, S, Prescott S, Cross W. Metastatic prostate cancer in transsexual diagnosed after three decades of estrogen therapy. Can Urol Assoc J 2013; 7: E544–46
TRIBE study: are all three cytotoxic drugs crucial? In the updated analysis of the TRIBE study, Chiara Cremolini and colleagues 1 reported that patients treated with FOLFOXIRI (fluorouracil, leucovorin, oxaliplatin, and irinotecan) plus bevacizumab (the experimental group) had significantly better overall survival in patients with metastatic colorectal cancer compared with FOLFIRI (fluorouracil, leucovorin, and irinotecan) plus bevacizumab (the control group). In accordance with a general consensus that administration of all three cytotoxic drugs (ie, fluorouracil, oxaliplatin, and irinotecan) can maximise overall survival in advanced colorectal cancer, 2 the patients in the control group were supposed to receive oxaliplatin-based chemotherapy at the initial diagnosis of disease progression. 81% of the control group received oxaliplatin as either second-line treatment (121 [67%] of 180 patients) or third-line treatment (25 [14%] of 180 patients). This difference in exposure to oxaliplatin between the experimental group and control group may have, at least partly, contributed to the 4-month prolongation of
www.thelancet.com/oncology Vol 16 December 2015
overall survival in the experimental group. Although the proportion of patients who received all three cytotoxic drugs in the control group compares favourably with the results of previous trials, 3,4 the smooth, seamless induction of oxaliplatin is crucial to the outcomes of any patient with metastatic colorectal cancer. Therefore, the baseline characteristics of the 19% of patients in the control group, who did not receive oxalipatin, as well as the reasons why they did not receive the drug as subsequent chemotherapy are of great interest. YA reports grants from Sanofi, Torii Pharmaceutical, Mitsubishi Tanabe Pharma, and Mochida Pharmaceutical; grants and personal fees from Chugai Pharmaceutical, Takeda Pharmaceutical, Daiichi Sankyo, Kyowa Hakko Kirin, Eisai, Taiho Pharmaceutical, Nippon Kayaku, YakultHonsya, and Merck Serono; personal fees from Ono Pharmaceutical, Eli Lilly Japan KK, Pfizer Inc, Novartis Pharma KK, and Janssen Pharmaceutical KK, grants and personal fees from Hisamitsu Pharmaceutical, AstraZenaca KK, GlaxoSmithKline, ASKA Pharmaceutical, Terumo Corporation, Bayel Holding, Meiji Seika Pharma, Arkray Marketing, CBC Radio, Igaku-shoin, Vigorous-Med, Nakayama Shoten, Nanzando, Benesse Style Care, Tokyo Kagaku Dojin, Kowa Pharmaceutical, Boehringer Ingelheim, and Bristol-Myers Squibb outside of the submitted work. AM and OM declare no competing interests.
*Ayumu Matsuoka, Osamu Maeda, Yuichi Ando [email protected] Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya 466-8550, Japan 1
2
3
4
Cremolini C, Loupakis F, Antoniotti C, et al. FOLFOXIRI plus bevacizumab versus FOLFIRI plus bevacizumab as first-line treatment of patients with metastatic colorectal cancer: updated overall survival and molecular subgroup analyses of the open-label, phase 3 TRIBE study. Lancet Oncol 2015; 16: 1306–15. Grothey A, Sargent D, Goldberg RM, et al. Survival of patients with advanced colorectal cancer improves with the availability of fluorouracil-leucovorin, irinotecan, and oxaliplatin in the course of treatment. J Clin Oncol 2004; 22: 1209–14. Tournigand C, André T, Achille E, et al. FOLFIRI followed by FOLFOX6 or the reverse sequence in advanced colorectal cancer: a randomized GERCOR study. J Clin Oncol 2004; 22: 229–37. Heinemann V, von Weikersthal LF, Decker T, et al. FOLFIRI plus cetuximab versus FOLFIRI plus bevacizumab as first-line treatment for patients with metastatic colorectal cancer (FIRE-3): a randomised, open-label, phase 3 trial. Lancet Oncol 2014; 15: 1065–75.
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