The UroOnc Minute: Prostate Cancer Screening in the Transgender Population, with Farnoosh Nik-Ahd, MD

In this episode of The UroOnc Minute, host Adam Weiner, MD, speaks with Farnoosh Nik-Ahd, MD, an assistant professor of urology at the University of California, San Francisco, whose research has helped shape emerging guidance on prostate cancer screening in transgender women. Their discussion centers on a critical but historically understudied question in urologic oncology: how to appropriately assess prostate cancer risk and interpret prostate-specific antigen (PSA) values in transgender women receiving gender-affirming care.

Nik-Ahd explains that despite gender-affirming surgeries, transgender women retain their prostate and remain at risk for prostate cancer—a point that many clinicians, and even patients, may not fully appreciate. Early findings from her team indicate that transgender women on estrogen therapy are often diagnosed with more aggressive disease, likely reflecting delayed detection. One key driver, she notes, is that commonly used PSA cutoffs are not calibrated for this population. In their research, median PSA levels among transgender women on estrogen for at least 6 months were just 0.02 ng/mL, far below the traditional 4.0 ng/mL threshold, underscoring the need for far lower trigger points for evaluation.

The conversation also explores how these insights should guide clinical practice. Nik-Ahd emphasizes the importance of ongoing PSA screening discussions with transgender women, thoughtful interpretation of results in the context of hormone therapy or prior orchiectomy, and early referral to urology when values deviate from expected baselines. As diagnostic pathways evolve, she continues to approach imaging, biomarkers, and biopsy decisions similarly to cisgender men, while also advocating for research to define population-specific cut points and screening intervals.

Looking ahead, Nik-Ahd highlights the landmark inclusion of transgender-specific PSA guidance in the NCCN guidelines, as well as the need to partner directly with transgender patients to ensure screening strategies are clinically sound, affirming, and free from unintentional stigma. Her message is clear: improving prostate cancer detection in transgender women will require better evidence, greater awareness, and patient-centered communication that reflects the needs of this vulnerable and underserved population.