Objectives: To examine disparities between transgender and gender-diverse (TGD) and cisgender (CG) people through analysis of attendance rates for cancer screening and compare differences between types of cancer screened. Design: Systematic review and meta-analysis. Data sources: PubMed, EMBASE [via Ovid], CINAHL Complete [via EBSCO], and Cochrane Library from inception to 30 September 2023. Methods: Studies for inclusion were case-control or cross-sectional studies with quantitative data investigating TGD adults attending any cancer screening services. Exclusion criteria were studies with participants ineligible for cancer screening or without samples from TGD individuals, qualitative data, and cancer diagnosis from symptomatic presentation or incidental findings. A modified Newcastle-Ottawa Scale was used to assess risk of bias and reports rated poor were excluded. Results were synthesised through random-effects meta-analysis and narrative synthesis. Results: Searches identified 25 eligible records, whereby 18 met risk of bias requirements. These were cross-sectional studies, including retrospective chart reviews and survey analyses, and encompassed over 14.8 million participants. The main outcomes measured were up-to-date (UTD) and lifetime (LT) attendance. Meta-analysis found differences for UTD cervical (OR=0.37, 95% CI [0.23, 0.60], p<0.0001) and mammography screening (OR=0.41, 95% CI [0.20, 0.87], p=0.02). There were no meaningful differences seen in LT results. Pooling total odds ratios for each synthesis (cervical, breast, prostate, and colorectal cancer) showed reduced attendance in TGD participants (OR=0.50, 95% CI [0.37, 0.68], p<0.0001). Narrative synthesis of seven remaining articles supported meta-analysis results, finding generally reduced screening rates in TGD versus CG participants. Conclusions: TGD individuals are overall less likely to utilise cancer screening compared to CG counterparts. The greatest disparity in attendance was seen specifically in UTD cervical screening. Limitations of this review included high risk of bias within studies, high heterogeneity, and a lack of resources for further statistical testing. Individual and structural factors such as psychological distress, socioeconomic status, and healthcare accessibility can prevent TGD people from accessing cancer screening. Bridging this gap will require consolidated efforts from healthcare systems including reviews of structural design, innovation of accessible and inclusive technology, education of HCPs, and reassessment of patient information resources. Joint production of future interventions with the TGD community is vital to improving both cancer screening experience and outcomes. Funding: This work was supported by the INSPIRE grant generously awarded to the Hull York Medical School by the Academy of Medical Sciences through the Wellcome Trust [Ref: IR5\1018]. Systematic review registration: PROSPERO CRD42022368911.

The authors have declared no competing interest.

This work was supported by the INSPIRE grant generously awarded to the Hull York Medical School by the Academy of Medical Sciences through the Wellcome Trust [Ref: IR5\1018].

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