Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer

Challenges in the implementation of a high-resolution anoscopy clinic for people with HIV in an oncologic center in Mexico City

BACKGROUND

Anal cancer incidence is increased in people with HIV (PWH), up to 60 times higher in men who have sex with men, and almost 15 times higher among women with HIV. Screening and treating high-grade lesions (HSIL) have proven to reduce the incidence of invasive anal cancer. In 2020, we started implementing a high-resolution anoscopy (HRA) clinic at INCan, a tertiary care oncologic center, as part of a screening program for PWH from the HIV clinic.

OBJECTIVES

We describe the barriers and difficulties in implementing an HRA Clinic from January 2020 to April 2021, including physician training, the certification process, discrepancies between cytology and histopathologist results, and the lack of experience of gastrointestinal pathologists in HPV-related lesions.

RESULTS

During the first 18 months of the HRA clinic implementation, 124 studies were performed, and 85 biopsies were done. The prevalence of HSIL was 22%. Initially, when a gastrointestinal pathologist reviewed anal canal biopsies, a second opinion was requested from a genitourinary pathologist who examined 72 of the biopsies; there were discrepancies in the diagnosis in 61% of the cases, with more advanced intraepithelial lesions in 43% of cases. Specifically, gastrointestinal pathologists missed 68% of HSILs. The difficulties we faced were not having access to adequate anoscopes. Training and certification are a long way to go. Also, women's reachability was low.

CONCLUSIONS

Diagnosis and management of anal HSIL have become a standard of care in the prevention of Anal Carcinoma in PWIH, the population with the highest incidence of this neoplasia. Implementing HRA programs requires correct supplies and equipment, which are not always locally available; investing in physicians' training and an experienced pathologist in HPV-associated lesions interpretation is also imperative. More advocacy is needed for HIV programs to incorporate and invest in anal cancer screening.

Stratified Mucin-producing Lesions of the Anus: Insights into an Emerging Histologic Type of HPV-driven Anal Neoplasia

Primary anal cancers are rare and typically driven by high-risk human papillomavirus (HPV) infection. Though squamous cell carcinoma is most common, a spectrum of HPV-related nonsquamous anogenital neoplasms with similarities to cervical stratified mucin-producing carcinoma has been reported. In this study, we mined our institutional archives to characterize the clinicopathologic features of this emerging entity. Six cases were identified from the files at 2 institutions, including 4 cases of invasive stratified mucin-producing carcinoma and 2 stratified mucin-producing intraepithelial lesions (SMILE). Four patients were women, and the mean age was 70 years. Patients presented with rectal/anal mass or polyp, rectal bleeding or pain, weight loss, or at the time of screening colonoscopy. Tumors displayed histologic features as described in the gynecologic tract. Cases of invasive stratified mucinous carcinoma showed infiltrative tumor nests with variable intracytoplasmic mucin, peripheral palisading, prominent apoptosis, and neutrophilic infiltrate. One invasive stratified mucinous carcinoma associated with high grade glandular dysplasia, whereas 1 SMILE was next to conventional low-grade squamous intraepithelial lesion. All lesions stained with p16 showed block-like p16 expression. HPV in situ hybridization was performed in 5 cases, 4 of which were positive; one was interpreted as equivocal. Follow-up information, available in 4 patients, revealed 1 local recurrence followed by death due to unrelated causes in a patient with invasive stratified mucin-producing carcinoma. We report the first series of HPV-associated primary anal stratified mucin-producing neoplasms analogous to those seen in the gynecologic tract, further broadening the spectrum of HPV-related anal neoplasia.

Anal Cancer Screening Practices Among Higher-Risk Populations in an Academic Medical System

BACKGROUND

Although some experts recommend anal cancer screening for disproportionally affected populations including people living with HIV (PWH), condyloma acuminata, human papillomavirus-associated gynecologic dysplasia and cancers, and solid organ transplants, actual screening practices remain understudied. Our objective was to characterize anal cancer screening practices among higher-risk populations in an academic medical system with access to high-resolution anoscopy.

METHODS

We extracted outpatient clinical data for the aforementioned populations from January 1, 2015, to August 1, 2022, at 3 sites of an academic medical system. Data included patients' demographics, medical comorbidities, and anal cytology and human papillomavirus testing results. We used χ2 tests and logistic regression to assess for associations between patient characteristics and anal cancer screening.

RESULTS

Of 7654 patients, 6.3% received anal cytology screening at least once including 21.7% of PWH, 13.8% of people with condyloma acuminata, 1.1% of people with gynecologic cancers, and 0.5% of people with solid organ transplants. In multivariable analysis, Black patients were 46% less likely to receive screening than White patients (95% confidence interval [CI], 0.40-0.71), and cisgender women were 73% less likely to receive screening than cisgender men (95% confidence interval, 0.20-0.38). Of 485 individuals who received anal cytology screening, 37.5% were only screened once and 70.5% had abnormal cytology on one or more screenings.

CONCLUSION

Only one-fifth of PWH received anal cancer screening, and other higher-risk populations had even lower screening rates. Black patients and women were also less likely to be screened. Strategies to improve equitable screening practices for anal cancer are needed.

Does use of anal cytology as a triage test improve the performance of high-risk human papillomavirus screening in gay and bisexual men for anal cancer prevention?

Anal high-risk human papillomavirus (HRHPV) testing-based anal cancer screening gay and bisexual men (GBM) is associated with high sensitivity, but low specificity. We report the potential role of triage use of anal cytology with HRHPV testing in detecting 12-month persistent anal high-grade squamous epithelial lesions (HSIL) in a cohort of GBM in Sydney, Australia. Participants were GBM from the Study of the Prevention of Anal Cancer (SPANC) who underwent annual anal HPV testing, cytology, and high-resolution anoscopy (HRA)-guided histology. The sensitivity and specificity of five screening algorithms based on HRHPV test results with triage use of anal cytology (atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells, cannot exclude HSIL (ASC-H) used as referral thresholds) were compared to these of HRHPV testing and anal cytology alone. A total of 475 men who had valid HRHPV, cytological, and histological results at both baseline and first annual follow-up visits were included, median age 49 years (inter-quartile range: 43-56) and 173 (36.4%) GBM with human immunodeficiency virus. Of all triage algorithms assessed, two had comparable sensitivity with HRHPV testing alone in detecting persistent anal HSIL, but ~20% higher specificity and 20% lower HRA referral rates. These two algorithms involved the immediate referral of those with HPV16 and for those with non-16 HRHPV either immediate or delayed (for 12 months) referral, depending on cytology result at baseline. Triage use of anal cytology in GBM testing positive for anal HRHPV increases specificity and reduces referral rates while maintaining high sensitivity in detection of HSIL.

Real-time diagnosis of a lesion of the anal canal observed by endocytoscopy

Anal canal cancer (ACC) is a rare yet noteworthy malignancy that is strongly associated with high-risk human papillomaviruses (HPVs). This case report highlights the diagnostic utility of endocytoscopy (EC) in distinguishing high-grade squamous intraepithelial lesions (HSILs) from low-grade lesions (LSILs) in a 57-year-old male presenting with hematochezia. Traditional magnifying endoscopy was inconclusive; however, EC provided detailed visualization of cellular and vascular changes, facilitating a diagnosis of HPV-associated HSIL or carcinoma in situ. Subsequent en bloc resection by endoscopic submucosal dissection was performed successfully, with no recurrence at the 6-month follow-up. This case underscores the value of EC in enhancing diagnostic accuracy for anal lesions, suggesting potential benefits for broader diagnostic applications.

A Sequential Mixed-Methods Study of Factors Associated with Low High-Resolution Anoscopy Completion in Transgender Women with Abnormal Anal Cytology

In a cohort of transgender women (TGW) with abnormal anal cytology (AAC) in Washington, DC, we determined the rates of and factors associated with completion of high-resolution anoscopy (HRA). This mixed-methods study used a sequential study design. In an academic-community clinic, we recruited TGW who provided blood samples, anal swabs for anal cytology, and completed surveys. For the quantitative phase of this study, we used χ2 test to compare factors associated with HRA completion among TGW with AAC. From that cohort, we used purposive sampling to recruit 16 TGW for qualitative interviews, based on their HRA completion status. We used thematic analysis to analyze the qualitative data. Of 75 TGW, 36 (48%) had AAC, 32 (43%) were referred to HRA, and 15 (20%) completed HRA. HRA completion was associated with being employed (75% vs. 25%; p = 0.01) in the quantitative phase, and low socioeconomic status (SES) was considered a barrier to completing HRA in the qualitative phase. HRA completion was associated with suppressed HIV (67% vs. 18%; p = 0.01) in the quantitative phase. In the qualitative phase, trans-affirming care, receptive anal sex, and engaging in sex work were identified as motivators to completing HRA. In a population of TGW, we found high rates of AAC and low rates of HRA completion. Interventions targeting this gap should address barriers associated with low SES and HIV viremia in TGW. Trans-affirming care and the impact on anal sexual practices should be used as motivators to engage TGW in anal cancer screening.

Access to High-Resolution Anoscopy and Colorectal Surgery Support Identified as Important Facilitators to Successful Veterans Affairs Anal Cancer Screening Programs

BACKGROUND

Anal cancer disproportionately affects people living with HIV. The Department of Veterans Affairs is the largest single provider of health care to people living with HIV in the United States and recommends all veterans living with HIV be screened for anal cancer annually. There are barriers to developing successful anal cancer screening programs, and screenings within Veterans Affairs have been underused.

OBJECTIVE

This study aims to identify facilitators to anal cancer screening programs in Veterans Affairs.

DESIGN

This is a qualitative study involving semistructured virtual interviews. Thematic analysis was used to identify themes in the interview data.

SETTINGS

Study participants included Veterans Affairs infectious disease providers and colorectal surgeons who care for veterans living with HIV. Participants were asked to discuss factors that influence anal cancer screenings in Veterans Affairs.

MAIN OUTCOME MEASURES

Themes were mapped to theoretical constructs and domains related to behavioral change using the Theoretical Domains Framework.

RESULTS

A total of 23 Veterans Affairs providers from all major United States geographical regions were interviewed. Important facilitators identified included access to high-resolution anoscopy and colorectal surgery support. The themes for successful anal cancer screening programs were mapped to 15 behavior-influencing constructs and categorized into 6 domains: 1) knowledge, 2) skills, 3) professional role and identity, 4) goals, 5) environmental context and resources, and 6) social influences.

LIMITATIONS

This study involves health care providers who are invested in caring for veterans living with HIV, and their perspectives might not be representative of all Veterans Affairs providers.

CONCLUSIONS

Access to a clinician with high-resolution anoscopy training and colorectal surgery support were identified as integral components of a successful anal cancer screening program. This study provides a framework for improving anal cancer screenings in veterans living with HIV by use of evidence-based interventions that incorporate the identified facilitators. See Video Abstract .

Early detection of anal squamous cell carcinoma with the use of high-resolution anoscopy

In the UK, few (12%) anal squamous cell carcinomas (aSCCs) are diagnosed early at stage 1 (T1N0M0). The Homerton Anogenital Neoplasia Service (HANS) is a highly specialized tertiary centre where high-resolution anoscopy (HRA) is performed to diagnose and treat anal intraepithelial neoplasia (AIN), a precursor to cancer. In some cases, aSCC (here defined as anal canal cancers and perianal cancers up to 5 cm from the anal verge) is found on referral for AIN; in others, aSCC may develop during management of AIN. We reviewed aSCC diagnoses at our specialist unit to establish whether HRA offers added value in the early detection of aSCC in a high-risk cohort. A cross-sectional analysis was performed of all primary aSCC diagnoses at HANS between January 2016 and June 2021. Patient records and histopathology and radiology reports were reviewed to define anal cancer stage per TNM classification (AJCC version 8). The results were compared with national anal cancer data published by the Office for National Statistics (AJCC version 8). Fifty-three aSCC diagnoses were made at HANS; 35 (66%) were stage 1 (14 prevalent, 21 incident), 11 (21%) stage 2 (9 prevalent, 2 incident) and 6 (11%) stage 3 (5 prevalent, 1 incident). None were stage 4, and one cancer was unstageable due to further management at another unit. By comparison, 5836 aSCCs were diagnosed in the UK between 2013 and 2017. Of these, 12.0% were stage 1, 22.8% stage 2, 33.0% stage 3 and 8.5% stage 4; 23.8% were unknown or unstageable. There was a statistically significant difference in the proportion of early (i.e. stage 1) HRA-detected cancers between HANS and national statistics (P < 0.001). Our results suggest that surveillance and examination within an HRA programme may lead to the detection of aSCC at an earlier stage, allowing for less morbid treatment and potentially lower mortality.

Prevalence, Incidence and Predictors of Anal HPV Infection and HPV-Related Squamous Intraepithelial Lesions in a Cohort of People Living with HIV

Background: Anal HPV infection can cause squamous intraepithelial lesions (SILs), which are precursors of anal squamous cell carcinoma (SCC). The early detection of HPV infections and improvement of effective screening programmes are, therefore, essential to prevent progression from pre-cancerous lesions to SCC, especially in people living with HIV (PLWH), who represent a population at higher risk of HPV infection and associated lesions. Among prevention strategies, HPV vaccination is relevant too, but its efficacy in persons already infected by HPV is still debated. Methods: This is a retrospective single-center study on a cohort of PLWH who performed longitudinal screening for anal dysplasia and HPV infection. The screening included cytological and molecular analyses. Results: A total of 110 PLWH performed at least one anal HPV screening, with an overall prevalence of HPV infection of 86.4% [23.6% low risk (LR)-HPV and 62.7% high risk (HR)-HPV genotypes]. Abnormal cytology was demonstrated in 39.1% of subjects, of whom ASCUS 6.4%, LSIL 30.9% and HSIL 1.8%. In total, 80 patients (72.7%) had an available longitudinal screening. No patient developed SCC during follow-up. However, a high incidence of new cytological abnormalities and new HPV infections was observed. On the other side, clearance of some HPV genotypes was also frequent, confirming that HPV infection is a dynamic process. A CD4 cell count > 500/mmc was an independent predictor of HPV clearance. HPV vaccination was performed on 30.9% of patients. A trend toward an increased clearance of HPV genotypes included in 9-valent vaccine was observed in vaccinated patients (40.6% versus 30.8% in unvaccinated, p = 0.079). Conclusions: A high prevalence of HPV infection and SILs was observed in our cohort of PLWH. A high incidence of new HPV infections and HPV-associated lesions was also observed in the longitudinal cohort, highlighting the need of strengthening immunization programs and continuous screening for anal HPV infection. Whether HPV vaccination may be efficacious in patients already infected by HPV remains to be determined.

Self- versus clinician-collected swabs in anal cancer screening: A clinical trial

BACKGROUND

Risk of anal cancer is high in certain populations and screening involves collection of anal swabs for HPV DNA and/or cytology testing. However, barriers exist, such as the need for an intimate examination, and stigma around HIV status, sexual orientation, and sexual practices. Self-collected anal swabs (SCA) are a proposed alternative to clinician-collected swabs (CCA) to overcome these barriers.

METHODS

Participants were order-randomised to undergo SCA or CCA first, with a second swab taken immediately afterwards. Sample adequacy was assessed for HPV DNA and cytology testing. CCA was used as the gold standard to calculate sensitivity and specificity of SCA for cytology and HPV results. Acceptability of swab collection was assessed following the procedure.

RESULTS

There was no significant difference in sample validity for HPV DNA testing between SCA and CCA (p = 0.564). Concordance was >90% for detection of any HR-HPV and HPV16. There was no significant difference in cellular adequacy for cytological testing between SCA and CCA, (p = 0.162). Concordance for cytologic prediction was 88.2% for any cytologic abnormality. Almost half (48.5%) of participants expressed no preference for SCA versus CCA; 15.2% preferred SCA and 35.4% CCA.

CONCLUSIONS

SCA may be an acceptable and feasible alternative to CCA for detecting HPV and cytological abnormalities in a clinic population.

Utilization of Anal Cytology Screening among Sexual and Gender Minority Populations in Pennsylvania

BACKGROUND

Despite the risk of anal cancer in sexual and gender minority (SGM) populations, anal cancer screening remains infrequent and inconsistent in these populations. The objective of this analysis was to identify factors associated with anal cancer screenings among SGM populations using the Andersen's behavioral model of health services use.

METHODS

Secondary analyses of two cross-sectional surveys from the 2020 (N = 1,125) and 2022 (N = 630) Pennsylvania LGBTQ Health Needs Assessment. Multiple logistic regression analyses were used to identify correlates of anal cytology screening.

RESULTS

Average age was 37.7 (SD = 13.3) and 39.7 (SD = 13.6) in 2020 and 2022, respectively. Approximately 16% to 18% reported living with human immunodeficiency virus (HIV). A minority of respondents reported past year screening (14.0%, 2020 and 13.6%, 2022). Enabling and need-based factors consistently associated with screening included sexually transmitted infection treatment, living with HIV, preexposure prophylaxis use, and multiple sex partners. Robust factors associated with ever being screened were age and living with HIV.

CONCLUSIONS

Anal cytology screening is being done in Pennsylvania at a small but not insignificant rate. In accordance with existing guidelines, SGM populations living with HIV were most likely to be screened, but still at a low rate. Predictive factors associated with screening in this study can inform future interventions to implement guideline-specific anal cancer prevention.

IMPACT

Factors that reflect consistent connection to healthcare are associated with increased rates of screening via anal cytology testing, indicating there are opportunities to implement anal cancer screening as part of a larger, more comprehensive SGM-focused care pathway.

Electrocautery ablation therapy for anal intraepithelial carcinoma with high-resolution anoscopy

OBJECTIVE

This study investigated the efficacy and safety of electrocautery ablation for high-grade squamous intraepithelial lesions (HSILs) in men who have sex with men (MSM) including people with human immunodeficiency virus, using comprehensive biopsy with high-resolution anoscopy (HRA).

METHODS

This single-arm, open-label pilot study included 20 MSM with HSIL who were treated with electrocautery ablation. The participants were recruited from the National Center for Global Health and Medicine and followed up using HRA with a comprehensive biopsy approach at 3- and 6-months post-ablation. A comprehensive biopsy was defined as at least 1 biopsy taken from each of the 6 segments of the anal canal regardless of any abnormal findings. The primary endpoint was the local HSIL cure rate at 6 months. Secondary endpoints included the total cure rate, recurrence rates, and adverse events.

RESULTS

The median age of the 20 participants was 45 years, and 90 % were HIV-positive. The local cure rates were 40 % at 3 months and 50 % at 6 months. The total cure rates were 35 % and 40 % at 3 and 6 months, respectively. Ectopic recurrence occurred in 27.8 % of the participants. Most adverse events were mild and self-limiting.

CONCLUSION

Electrocautery ablation was a moderately effective and safe treatment for HSIL among MSM in Japan. However, the recurrence rates were high, indicating that conducting biopsies on normal-appearing lesions did not sufficiently prevent ectopic recurrence. Further research with larger sample sizes and longer follow-up periods is warranted to improve outcomes. This trial was registered in the Japan Registry of Clinical Trials: Clinical Trial Plan Number: jRCTs032210649.

[Translated article] Retrospective Study of Risk Markers for Developing High-Grade Anal Intraepithelial Neoplasm in Men Who Have Sex With Men Living With HIV

BACKGROUND

High-grade anal intraepithelial squamous lesion is significantly prevalent among men who have sex with men and are infected with the human immunodeficiency virus (HIV). This condition-the precursor to anal cancer-significantly increases the risk of developing it. Conversely, low-grade anal intraepithelial squamous typically follow a benign course and usually regress spontaneously.

MATERIALS AND METHODS

To describe a population of men who have sex with men living with HIV followed in a specialized anal cancer screening unit we conducted an observational, retrospective, and single-center study.

RESULTS

Ninety-four patients were analyzed, with a mean age of 39±9 years, and a 87% positivity rate for high-risk human papillomavirus (HR-HPV). At the initial visit, 47% presented with low-grade squamous intraepithelial lesions. The progression rate to high-grade squamous intraepithelial lesion was 37.2 per 100,000 patients/year. None of the patients developed anal cancer. Tobacco and alcohol consumption were associated with this progression.

DISCUSSION

In this series, longer duration of HIV infection, tobacco and alcohol use and the presence of HR-HPV were significantly associated with the occurrence of high-grade intraepithelial lesions. A lower risk of progression was seen in patients with higher education.

CONCLUSION

In men who have sex with men living with HIV, the association of factors such as smoking, alcohol, the presence of HR-HPV and an increased burden of human papillomavirus disease makes these patients more susceptible to develop high-grade anal squamous lesions.

Predictors of Resolution and Recurrence of Anal High-Grade Squamous Intraepithelial Lesions in People With HIV

OBJECTIVE

High-resolution anoscopy (HRA) with ablation of high-grade squamous intraepithelial lesions (HSIL) can prevent the development of anal cancer in people with HIV (PWH). The authors sought to characterize factors associated with successful HSIL resolution or local or metachronous recurrence.

METHODS

The authors conducted a retrospective study of 62 PWH who underwent HRAs from December 1, 2017, to July 1, 2022. Participants were ≥30 years old with ≥2 HRAs and ≥1 HSIL lesions. Poisson and logistic regressions were used to assess factors associated with HSIL resolution and local or metachronous recurrence of HSIL.

RESULTS

Of 62 PWH, 85.5% had resolution of at least 1 HSIL. Undergoing ≥5 HRAs with thermoablation was associated with HSIL resolution (adjusted rate ratio [aRR] = 2.82) (confidence interval [CI] = 1.55-5.15), p < .001). Tobacco use was negatively associated with resolution (aRR = 0.62 (CI = 0.43-0.90), p = .01). Of this cohort, 58.1% had HSIL recurrence. Having more HRAs (adjusted odds ratio [aOR] = 2.77 (CI = 1.27-6.06), p = .01) and female sex (aOR = 9.66 (CI = 1.14-81.85), p = .04) were associated with recurrence. Non-White race was negatively associated with recurrence (aOR = 0.12 (CI = 0.02-0.68), p = .04). This study was primarily limited by its retrospective nature and small sample size.

CONCLUSION

This study supports the utility of HRA/ablation for HSIL treatment with >85% of participants experiencing resolution of at least 1 HSIL. The authors found that having more HRAs was associated with a higher likelihood of resolution. However, the high rate of recurrence and progression to HSIL highlights the need for continued surveillance after treatment.

Trends in Cervical and Anal Cancer Incidence and Mortality in the United States

OBJECTIVES

This article describe trends in the incidence and mortality of cervical (CC) and anal (AC) cancers by race and neighborhood socioeconomic status.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to construct a cohort of CC and AC cases from 2006 to 2018. Incidence rates and survival were calculated by race and neighborhood socioeconomic status (nSES). Annual percent change (APC) in incidence was calculated using linear regression, and 5-year overall survival (OS) by the Kaplan-Meier method.

RESULTS

Of the cases, 33,487 CC and 16,018 AC cases were identified. Women of low nSES were nearly 4 times more likely to be diagnosed with cervical cancer than those of high nSES. Cervical cancer incidence declined marginally in all groups except for low nSES women who are White (APC 0.0). Women who are Black had lower 5-year OS than their nSES counterparts of other races (most notably for Black women of low nSES 53% vs White 63%). Similarly, the low nSES AC cohort contained nearly 3 times the number of diagnoses as the high nSES cohort. AC incidence increased most in women who are White (APC 1.8 and 2.2 for low and high nSES) and men who are Black and low nSES (APC 3.3). Five-year OS was lowest for men who are Asian American and Pacific Islander (40% and 50% for low and high nSES, respectively).

CONCLUSIONS

These data suggest a strong correlation between nSES, race, and their interaction on the incidence and survival trends of HPV-related disease and highlight inconsistent effects between cervical and anal cancers.

Health Disparities and Anal Cancer

Health disparities are preventable differences in health outcomes that are experienced by disadvantaged patient populations. Disparities in prevention, incidence, treatment, and mortality exist among patients with anal cancer. Factors contributing to these disparities are found at the patient, provider, health system, and public policy levels. Future multilevel interventions targeted at each of these levels will provide opportunities to reduce these disparity gaps and improve anal cancer care for all patient populations.

Anal cancer prevention: A field in need of scientific Advancement

Despite the availability of several human papillomavirus (HPV) vaccines, the incidence of HPV-associated anal cancer is growing at a rate of 2.2% each year. As shown in results from the recent Phase III ANCHOR study, the treatment of high-grade anal lesions in people living with HIV (PLWH) can significantly reduce rates of anal cancer development compared to active surveillance alone. As a result, screening programs to identify and treat patients with anal precancers are recommended by recent guidelines. Intense resources are needed to perform screening tests and follow-up abnormal results. The lack of effective and well-tolerated therapies, the lack of understanding regarding therapeutic targets, the paucity of preclinical models to test therapies, and the lack of biomarkers to determine which patients will develop cancer or respond to therapies are the issues that need to be addressed. We provide an overview of cutting-edge research and propose additional research that is needed to help move the field of anal cancer prevention forward. This review highlights the most significant current areas of research, as defined by the authors, and is by no means comprehensive of all anal dysplasia/cancer research.

Surgical protocols for oral leukoplakia and precancerous lesions across three different anatomic sites

OBJECTIVE

This systematic review and meta-analysis aimed to compare the risk of recurrence and cancer progression after surgical treatment for oral potentially malignant disorders (OPMD) and precancerous lesions in different anatomical sites.

MATERIALS AND METHODS

A comprehensive search was conducted in nine databases and grey literature. We included randomized controlled trials assessing surgical treatment efficacy for OPMD and precancerous lesions of cervical, vaginal, anal, and penile sites. Excision or ablation surgical treatments were considered.

RESULTS

Overall, 12 studies met the eligibility criteria for oral leukoplakia (OL), proliferative verrucous leukoplakia, cervical intraepithelial neoplasia (CIN), vaginal intraepithelial neoplasia, and anal intraepithelial neoplasia (AIN). In qualitative analysis of surgical protocols, the lack of margin description impacts the clinical outcomes of OL and AIN, and the ablative protocols were heterogeneous in both OPMD and precancerous lesions. No significant difference in OL (risk ratio 0.82 [95% CI: 0.59-1.15]) and CIN (risk ratio 0.31 [95% CI: 0.09-1.09]) for recurrence was observed when cold-knife was compared with ablative protocols. OL exhibited higher recurrence and cancer progression rates compared to CIN and AIN.

CONCLUSION

There is no difference in recurrence risk post-surgical treatment for OL and CIN. Surgical protocols for oral leukoplakia and CIN/AIN lack standardized approaches.

Future Research Directions in Anal Cancer

While anal cancer is somewhat rare, it is increasing in incidence despite improving screening and the human papillomavirus vaccine. Given this, there is growing research into the management of high-grade squamous intraepithelial lesion as well as how to optimize screening approaches. This includes increased study of biomarkers to improve screening sensitivity as well as strategies to improve access and reduce loss to follow-up. Additionally, there is an ongoing research into the role of the microbiome in oncogenesis and research to adapt other treatments to anal cancer.

Using Anal Cytology and Human Papillomavirus DNA and E6/E7 mRNA Detection to Optimize High-Resolution Anoscopy Referrals in Men Who Have Sex With Men With HIV

Background

This study was conducted to evaluate screening procedures for anal high-grade squamous intraepithelial lesions (HSILs) with anal liquid-based cytology (aLBC) and biomarkers to identify candidates for high-resolution anoscopy (HRA).

Methods

This cross-sectional study included men who have sex with men with HIV. Participants underwent HRA, aLBC, and biomarker testing. Three screening procedures were compared with aLBC: biomarker alone, cytology and biomarker in all, and cytology and reflex biomarkers (biomarkers applied if aLBC results were atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion). Biomarkers included Linear Array (LA), LA for 14 high-risk human papillomavirus (LA 14 HR-HPV) genotypes, LA HPV-16, Hybrid Capture 2 (HC2), E6/E7 mRNA, and E6/E7 mRNA HPV-16.

Results

Of 354 participants, 179 (50.6%) had atypical squamous cells of undetermined significance or worse, requiring HRA (sensitivity, 80%; specificity, 57.3%; area under the curve, 0.687; reference, biopsy-proven HSIL). Cytology and reflex biomarkers per E6/E7 mRNA, LA 14 HR-HPV, and HC2 and the biomarker-alone procedure with HC2 showed comparable accuracy (sensitivities: 71.6%, 78.8%, 73.1%, 75.7%; specificities: 73.5%, 67.9%, 76.1%, 65.5%; areas under the curve: 0.726, 0.734, 0.746, 0.706) with fewer HRA referrals (number needed to diagnose: 2.2, 2.1, 2, 2.4).

Conclusions

Our findings suggest that E6/E7 mRNA, LA 14 HR-HPV, and HC2 in the cytology and reflex biomarkers procedure, as well as HC2 in the biomarker-alone procedure, can improve anal HSIL screening effectiveness.

Considerations for the Treatment of Sexual and Gender Minority Individuals in Colon and Rectal Surgery

Sexual and gender minorities (SGMs) experience critical barriers to health care access and have unique health care needs that are often overlooked. Given the rise in individuals identifying as lesbian, gay, bisexual, transgender, and queer, colorectal surgeons are likely to care for increasing numbers of such individuals. Here, we discuss key barriers to health care access and research among SGM populations and outline approaches to address these barriers in clinical practice. We also highlight two specific topics relevant to SGM populations that colorectal surgeons should be familiar with: current approaches to anal cancer screening among men who have sex with men, and transgender individuals, as well as the management of recto-neovaginal fistula in transfeminine individuals.

Pathophysiology of Anal Cancer

The pathophysiology of the development of anal cancer is thought to be linked to chronic inflammation, a possible consequence of infections with human papillomavirus (HPV) or HIV, or inflammation from inflammatory bowel disease. Anal HPV-induced carcinogenesis bears similarities to its cervical counterpart via viral integration into the host genome and the development of precursor lesions termed anal intraepithelial neoplasia. HPV-16 and -18 are the most common HPV genotypes associated with anal cancer. Other risk factors for the development of anal cancer include chronic immunosuppression, sexual activity and sexually transmitted diseases, female gender, history of anogenital dysplasia, and smoking.

Prevention of Anal Cancer

Anal cancer, though rare, is witnessing an annual increase in incidence, predominantly of squamous cell carcinoma (SCC). Prevention strategies revolve around reducing risk factors such as human papillomavirus (HPV) infection, human immunodeficiency virus/acquired immunodeficiency syndrome, immunosuppression, smoking, and high-risk sexual practices, while advocating for HPV vaccination. The Anal Cancer-HSIL Outcomes Research trial validates treating anal high-grade squamous intraepithelial lesion to curb SCC development. Screening methods include digital anal rectal examination, anal Papanicolaou smear, HPV testing, and high-resolution anoscopy. However, standardized screening guidelines are lacking, necessitating future efforts to streamline protocols and enhance public awareness of anal cancer.

Retrospective Study of Risk Markers for Developing High-Grade Anal Intraepithelial Neoplasm in Men Who Have Sex With Men Living With HIV

BACKGROUND

High-grade anal intraepithelial squamous lesion is significantly prevalent among men who have sex with men and are infected with the human immunodeficiency virus (HIV). This condition-the precursor to anal cancer-significantly increases the risk of developing it. Conversely, low-grade anal intraepithelial squamous typically follow a benign course and usually regress spontaneously.

MATERIALS AND METHODS

To describe a population of men who have sex with men living with HIV followed in a specialized anal cancer screening unit we conducted an observational, retrospective, and single-center study.

RESULTS

Ninety-four patients were analyzed, with a mean age of 39±9 years, and a 87% positivity rate for high-risk human papillomavirus (HR-HPV). At the initial visit, 47% presented with low-grade squamous intraepithelial lesions. The progression rate to high-grade squamous intraepithelial lesion was 37.2 per 100,000 patients/year. None of the patients developed anal cancer. Tobacco and alcohol consumption were associated with this progression.

DISCUSSION

In this series, longer duration of HIV infection, tobacco and alcohol use and the presence of HR-HPV were significantly associated with the occurrence of high-grade intraepithelial lesions. A lower risk of progression was seen in patients with higher education.

CONCLUSION

In men who have sex with men living with HIV, the association of factors such as smoking, alcohol, the presence of HR-HPV and an increased burden of human papillomavirus disease makes these patients more susceptible to develop high-grade anal squamous lesions.

'Does human papillomavirus (HPV) cause cancer?' - A cross-sectional study of HPV awareness among sexual minority men in Nigeria

Background Human papillomavirus (HPV)-associated cancers are a global concern, particularly for sexual minority men (SMM). Understanding awareness and the determinants of these beliefs is crucial for developing educational programs to reduce HPV-associated cancers. This study explored awareness and determinants of beliefs about HPV's carcinogenicity among SMM living with and without HIV in Nigeria. Methods Participants were recruited through secure social media platforms in Abuja, Nigeria. REDCap surveys captured demographics, sexual practices and participants' beliefs regarding HPV's role in cancer. Multivariable logistic regression modeling was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the relationships between individual characteristics and belief levels stratified by those living with and without HIV. Results Of 982 participants, the median age was 29years (interquartile range: 26-34); 64.1% were living with HIV, and 9.7% believed HPV causes cancer. Awareness was highest for anal (82.1%) and penile cancers (15.8%) and less so for oropharyngeal and female HPV-associated cancers (range: 3-7%). Anogenital warts increased the odds of awareness for SMM living with HIV (aOR: 6.4, CI: 3.0-13.6) and for individuals without HIV (aOR: 4.8, CI: 1.6-14.2). Living with HIV for over 6years was independently associated with a two-fold increased knowledge about HPV's carcinogenicity (aOR: 2.1, CI: 1.1-4.1). Conclusions Awareness of HPV's carcinogenicity was low; however, those who were aware were more likely to identify male HPV-associated cancers relevant to their own cancer risk. Formalizing targeted education in HIV care settings may promote knowledge and advocacy for prevention strategies.

Diagnosis of Anal Cancer: Symptoms, Imaging, and Endoscopy

Anal cancer is an uncommon disease in a sensitive region of the body that benefits from early and systematic workup and treatment. Main modalities for workup include history, physical examination, and MRI. PET scan and computed tomography scan are helpful in assessing spread of disease. High-resolution anoscopy may be useful in identifying precancerous lesions but come with a high-learning curve.

Epidemiology of Anal Cancer

Anal cancer is a rare disease, accounting for only 2% of all gastrointestinal tract malignancies. While individuals with advanced age (>50 years) and female sex have an increased risk of anal cancer, there has been a trend toward diagnosis at a younger age particularly among men who have sex with men, irrespective of their human immunodeficiency virus status. Histologically, approximately 85% of anal cancers are squamous cell carcinomas (ASCC). However, while more than 90% of ASCC is associated with oncogenic human papillomavirus, the temporal trends of anal cancer incidence modeled on national databases represent an unmet need for primary prevention.

Self-collected versus clinician-collected anal swabs for anal cancer screening: A systematic review and meta-analysis

Anal squamous cell carcinoma (ASCC) incidence is increasing globally. International consensus guidelines published in 2024 include HPV and/or cytology testing of anal swabs in those at greatest risk of ASCC. Self-collected anal swabs may be important for increasing screening uptake, but evidence is needed as to their equivalence to clinician-collected swabs. We searched Medline, Embase, Cochrane Library, and CINAHL databases for publications to 13 June 2023. Studies were included if reporting data on HPV testing, cytology testing, or acceptability, for both self- and clinician-collected anal swabs. Risk of bias was assessed using the QUADAS-2 assessment tool. The primary outcome was HPV and cytology sampling adequacy. Secondary outcomes were HPV and cytology results, and acceptability of collection methods. Thirteen papers describing 10 studies were eligible. Sample adequacy was comparable between self- and clinician-collected swabs for HPV testing (meta-adequacy ratio: 1.01 [95% CI 0.97-1.05]) but slightly lower for cytology by self-collection (meta-adequacy ratio: 0.91 [95% CI 0.88-0.95]). There was no significant difference in prevalence (meta-prevalence ratio: 0.83 (95% CI 0.65-1.07) for any HR-HPV, 0.98 (95% CI 0.84-1.14) for any HPV, and 0.68 (95% CI 0.33-1.37) for HPV16), or any cytological abnormality (meta-prevalence ratio 1.01 [95% CI 0.86-1.18]). Only three papers reported acceptability results. Findings indicate self-collection gives equivalent sample adequacy for HPV testing and ~ 10% inferior adequacy for cytological testing. Meta-prevalence was similar for HPV and cytology, but confidence intervals were wide. Larger studies are required to definitively assess use of self-collected swabs in anal cancer screening programs, including acceptability.

Hospitalization burden associated with anus and penis neoplasm in Spain (2016-2020)

In 2020, there were approximately 50,865 anal cancer cases and 36,068 penile cancer cases worldwide. HPV is considered the main causal agent for the development of anal cancer and one of the causal agents responsible for the development of penile cancer. The aim of this epidemiological, descriptive, retrospective study was to describe the burden of hospitalization associated with anal neoplasms in men and women and with penis neoplasms in men in Spain from 2016 to 2020. The National Hospital Data Surveillance System of the Ministry of Health, Conjunto Mínimo Básico de Datos, provided the discharge information used in this observational retrospective analysis. A total of 3,542 hospitalizations due to anal cancer and 4,270 hospitalizations due to penile cancer were found; For anal cancer, 57.4% of the hospitalizations occurred in men, and these hospitalizations were also associated with significantly younger mean age, longer hospital stays and greater costs than those in women. HIV was diagnosed in 11.19% of the patients with anal cancer and 1.74% of the patients with penile cancer. The hospitalization rate was 2.07 for men and 1.45 for women per 100,000 in anal cancer and of 4.38 per 100,000 men in penile cancer. The mortality rate was 0.21 for men and 0.12 for women per 100,000 in anal cancer and 0.31 per 100.000 men in penile cancer and the case-fatality rate was 10.07% in men and 8,26% in women for anal cancer and 7.04% in penile cancer. HIV diagnosis significantly increased the cost of hospitalization. For all the studied diagnoses, the median length of hospital stays and hospitalization cost increased with age. Our study offers relevant data on the burden of hospitalization for anal and penile cancer in Spain. This information can be useful for future assessment on the impact of preventive measures, such as screening or vaccination in Spain.

Acceptance of human papillomavirus vaccine among boys in Asia: A narrative review

Human papillomavirus (HPV) is a prevalent sexually transmitted infection globally, linked to genital warts and various cancers. The burden of HPV-related diseases in males is rising significantly. We reviewed studies published until September 2024 from databases like PubMed, Embase®, and Web of Science, summarizing HPV vaccination acceptance among boys and parents in Asia and exploring influencing factors. Acceptance rates for HPV vaccination among boys ranged from 48.4% to 69.9%, while parental acceptance varied from 10.0% to 91.0%. Recent years have shown a positive trend in acceptance, influenced by perceived risk and benefits, barriers, sociodemographic characteristics, knowledge and awareness of HPV and its vaccine, and social support factors. Targeted educational interventions are crucial for increasing awareness of male-associated HPV diseases and for dispelling misconceptions. The future implementation of gender-neutral vaccination policies may facilitate broader acceptance. Future studies should focus on developing interventions to promote pan-gender HPV vaccination.

WITHDRAWN: Intravaginal artesunate pessaries for treatment of cervical intraepithelial neoplasia 2/3 among HIV-positive and HIV-negative women in Kenya: Study protocol for a pilot trial

The authors have withdrawn this manuscript because the article was posted prior to consultation from all relevant collaborators. If you have any questions, please contact the corresponding author.

High Prevalence of High-Risk HPV Among People with and Without HIV: Insights into Risk Factors for Tailored Screening Approaches

Men who have sex with men (MSM) and people with HIV are at increased risk of anal HPV infection and cancer. This study aimed to assess the prevalence of anal HPV among MSM with HIV (MWH) and without HIV (MWoH), as well as among MSM under and over 35 years. Factors associated with infection from high-risk (HR) HPV were investigated. This retrospective cohort analysis included MSM receiving care at IRCCS San Raffaele, Milan, Italy, with at least one HPV test collected from 2014 to 2023. Among 1577 MSM, 1427 (90%) were MWH. At first screening, 87.6% were had HR-HPV and MWoH were significantly younger, as compared to MWH. Cytological abnormalities were more frequent among younger MSM, while high-grade lesions were more frequent among those over 35 years of age. In multivariate regressions, the risk of ≥1 HR-HPV genotype at first and last screening was associated with younger age (adjusted odds ratio, aOR (95% confidence interval): 0.33 (0.18, 0.59); 0.34 (0.18, 0.58), p < 0.001) and concomitant STI (aOR 2.74 (1.59, 5.08), p < 0.001; 1.68 (1.09, 2.67), p: 0.023). A discrepancy between the recommend and actual age for screening was found. As a younger age and concomitant STIs were associated with infection by ≥1 HR-HPV, we promote a more tailored screening approach for both MWH and MWoH.

Piloting of a Screen‑Triage‑Treat Surgical Approach Model for Management of Anal Cancer in Liberia

Background: While cancer is a leading cause of death worldwide, significant disparities exist in care access in low‑ and middle‑income countries (LMICs). In Liberia, screening and treatment for anal cancers remain limited, and are exacerbated among vulnerable groups, including men who have sex with men (MSM). Screen‑triage‑treat models for cancerous lesions have been successful in reducing cervical cancer mortality, but the feasibility of this approach has not been studied for anal cancers in a low‑resource context. Objective: The aim of this study is to determine the feasibility of implementing a screen‑triage‑treat model for anal high‑grade squamous intraepithelial lesions (aHSIL) among MSM in Liberia. Methods: This descriptive study represented a collaboration between Stop AIDS in Liberia (SAIL) and health institutions in Liberia and the USA. MSM and transgender participants were recruited through convenience sampling with SAIL peer‑educators. A survey validated by SAIL experts assessed demographics and sexual risk factors. Participants underwent anal self‑swabbing for high‑risk human papillomavirus (HPV) and offered human immunodeficiency virus (HIV) testing. Those with positive results were offered a screen‑triage‑treat model through high‑resolution anoscopy (HRA) and infrared coagulation (IRC). Data were cleaned and analyzed in SPSS. Findings: Among 110 participants, most were single (n = 94, 88%) and without formal employment (n = 21, 75%). Participants engaged in regular anal (n = 64, 60%), oral (n = 62, 58%), and receptive sex (n = 58, 54%), and sex with women (n = 51, 48%). Nearly 20% of participants reported being HIV positive (n = 21). In all, 50 participants (45%) tested positive for anal high‑risk HPV, 34 (68%) elected to undergo HRA, and 10 (84%) were treated with IRC. Of those who underwent HRA, 75% tested HIV positive. Conclusions: Our findings suggest that a screen‑triage‑treat model presents a feasible option to identify and reduce the incidence of anal cancer among MSM in Liberia. The screen‑triage‑treat model, with proven success in management of cervical dysplasia, may be a viable option to treat aHSIL for anal cancer prevention in LMICs.

Anal high-grade intraepithelial neoplasia and cancer in women with HIV and women without HIV with other risk factors

OBJECTIVE

To determine the prevalence and the risk factors for anal high-grade intraepithelial neoplasia and anal cancer (HSIL+) in women with HIV (WWH), and to compare them to women without HIV with other risk factors.

DESIGN

Prospective cohort study.

METHODS

WWH and women without HIV with other risk factors were included. Screening for anal HSIL+ using anal cytology and HPV testing was performed. A high-resolution anoscopy with directed biopsy was also performed in patients with an abnormal cytology result or a positive HPV testing for high-risk (HR) genotypes, and in those with anal symptoms.

RESULTS

The period prevalence of anal HR-HPV infection and histological HSIL was 57.9% and 10.9% among WWH, and 60.8% and 9.2% among women without HIV. The prevalence of anal HPV 18 infection was higher in WWH. The risk factors for anal HSIL+ in WWH included anal HPV 16, other HR genotypes and low-risk genotypes infection, as well as a history of vulvar HSIL+. In women without HIV, the risk factors included anal HPV 16 infection, history of anogenital warts and of vulvar HSIL+, and immunosuppressive treatment.

CONCLUSIONS

A high prevalence of anal HPV infection and HSIL was observed in WWH and women without HIV with other risk factors. Both groups share anal HPV 16 infection and history of vulvar HSIL+ as risk factors for the development of anal HSIL+. Genotyping for anal HPV 16 may help identify women at higher risk of anal cancer.

Cancer screening in people with HIV: Implementation in clinical practice and barriers perceived by medical specialists in Spain

OBJECTIVE

To assess the degree of implementation of cancer screening recommendations in people living with HIV (PLHIV) in Spain.

METHODS

A self-administered questionnaire was designed on the strategies used for early detection of the main types of cancer in PLHIV. The survey was distributed electronically to HIV physicians participating in the Spanish CoRIS cohort.

RESULTS

106 questionnaires were received from 12 different Spanish Autonomous Communities, with an overall response rate among those who accessed the questionnaire of 60.2%. The majority responded that they followed the CPGs recommendations for the early detection of liver (94.3%), cervical (93.2%) and breast (85.8%) cancers. In colorectal and anal cancer, the proportion was 68.9% and 63.2%, and in prostate and lung cancer of 46.2% and 19.8%, respectively. In hospitals with a greater number of beds, a tendency to perform more cancer screening and greater participation of the Infectious Diseases/HIV Services in the screening programmes was observed. Significant differences were observed in the frequency of colorectal and anal cancer screening among the different Autonomous Communities. The most frequent reasons for not performing screening were the scarcity of material and/or human resources and not being aware of what is recommended in the CPGs.

CONCLUSIONS

There are barriers and opportunities to expand cancer screening programmes in PLHIV, especially in colorectal, anal and lung cancers. It is necessary to allocate resources for the early detection of cancer in PLHIV, but also to disseminate CPGs screening recommendations among medical specialists.

International consensus to define outcomes for trials of chemoradiotherapy for anal cancer (CORMAC-2): defining the outcomes from the CORMAC core outcome set

Variation in outcomes definitions and reporting limit the utility of clinical trial results. The Core Outcome Research Measures in Anal Cancer (CORMAC) project developed a core outcome set (COS) for chemoradiotherapy trials for anal squamous cell carcinoma (ASCC) through an international healthcare professional and patient consensus process. The CORMAC-COS comprises 19 outcomes across 4 domains (disease activity, survival, toxicity, life impact). In CORMAC-2 we have established standardised definitions for the 11 disease activity and survival outcomes in the CORMAC COS. Definitions were agreed through a 3 step process, initially identifying existing definitions through systematic review (registered with PROSPERO, CRD42016036540), using these to populate a two-round Delphi questionnaire completed by 51 experts from 13 countries, and finally ratification through an online consensus meeting. Standardising the definitions for these core outcomes facilitates real world utilisation of the CORMAC-COS, thereby increasing the quality of data available for clinical decision-making and ultimately enhancing patient care.

High Rates of High-risk HPV Anal Infection and Abnormal Cytology in a Cohort of Transgender People Assigned Male at Birth

Background

Transgender people assigned male at birth (TG-AMAB) have higher rates of anal human papillomavirus (HPV) infection and anal cancer compared with cisgender populations. In a cohort of TG-AMAB in Washington DC, we determined the prevalence and epidemiological factors associated with anal high-risk HPV (HR-HPV) infection and cytological abnormalities.

Methods

In an urban academic-community clinic, we recruited adults identifying as a gender different than their sex assigned at birth. Participants provided blood samples, anal swabs for HR-HPV and cytology, and completed surveys on sexual behaviors and use of gender-affirming hormones. Logistic regression was used to identify predictors of HR-HPV and abnormal cytology.

Results

Of 97 TG, 80 were AMAB, of whom 66% were people with HIV (PWH); 73% tested positive for any anal HR-HPV, and 48% had abnormal cytology. Only 24% recalled HPV immunization. While TG-AMAB PWH had increased risk of HPV16 infection (37% vs 8%; P = .014), the prevalence rates of any HR-HPV (80% vs 62%; P = .097) and abnormal cytology (56% vs 32%; P = .085) were similarly elevated regardless of HIV status. Among TG-AMAB, estradiol use was not associated with increased odds of any HR-HPV or abnormal cytology (all P > .05); however, higher testosterone levels were associated with any HR-HPV (P = .014). Age ≥35 years was associated with abnormal cytology in TG-AMAB (59% vs 34%; P = .035).

Conclusions

TG-AMAB have a high prevalence of any HR-HPV and abnormal cytology, regardless of age, HIV status, or hormone use. Given high risk for anal cancer and low rates of HPV vaccination, there is a pressing need for primary and secondary anal cancer prevention strategies targeting this population.

Prevention of Anal Cancer in High-Risk Individuals

This JAMA Insights examines the treatment and rising prevalence of anal cancer in the US in high-risk groups, including people with HIV and immunosuppression associated with solid organ transplant.

Implementation of a Screening Program for High-Grade Anal Dysplasia in High-Risk Patients in a Tertiary Cancer Center

INTRODUCTION

The incidence of anal squamous cell carcinoma (SCC) has been increasing over the last decades. Human papillomavirus (HPV) infection accounts for more than 90% of anal cancers, and HIV co-infection increases the risk of invasive cancer. Men who have sex with men (MSM) with HIV are the highest risk group for developing anal high-grade squamous intraepithelial lesions (aHSILs), which can be found in 45%-50% of these patients and are precursor lesions for invasive cancer. Anal cytology is an effective screening tool, but it lacks sensitivity. High-resolution anoscopy (HRA) is the gold standard procedure for diagnosis and treatment of aHSILs. Recent data suggest that early detection and treatment of aHSILs could prevent the development of invasive cancer in this population.

OBJECTIVE

The objective of the study was to describe the implementation of an office-based screening program for anal cancer prevention in a Comprehensive Cancer Center in Brazil.

METHODS

Training included participation in the International Anal Neoplasia Society (IANS) HRA course at UCSF Medical Center Mount Zion in San Francisco, CA, USA, by three colorectal cancer surgeons. In-person and hands-on training was provided by a specialist through the AIDS Malignancy Consortium (AMC) of the US NIH. Equipment purchased and provided by the AMC included a colposcope with a digital camera, a hands-free mouse pedal, and a photo documentation imaging software program that allows images to be recorded for documentation and training purposes.

RESULTS

The program was implemented in 2022 after a delay of more than two years due to the COVID-19 pandemic. An average of 24 exams are performed monthly. Patients with HIV aged 35 years or older who are undergoing antiretroviral therapy were recruited from the metropolitan area of Rio de Janeiro and referred by primary care providers for screening. Patients diagnosed with aHSILs are scheduled for in-office ablative treatment in the clinic. From March 2022 to June 2024, 324 exams were performed, and aHSIL was found in 38.2% of 220 high-risk patients, including 45 of 129 MSMs (34.9%), 6 of 19 transgender women (31.6%), and 33 of 72 women living with HIV (45.8%). A total of 69 treatments for aHSIL were performed in 62 patients. Patients are followed on a regular basis and long-term results are awaited, including the effectiveness of local therapy for aHSIL.

CONCLUSIONS

The screening and treatment program was successfully implemented in a tertiary comprehensive Cancer Center. Team training and external proctorship were decisive for the achievement of benchmark standards. The program aims to permanently provide screening for the prevention of anal cancer through the detection and treatment of aHSIL within the National Cancer Institute of Brazil for populations considered at-risk for anal cancer.

Identifying Motivators, Facilitators, and Barriers to Engagement and Retention in Anal Cancer Screening Among Men and Women with HIV in One Ryan White HIV/AIDS Clinic

Anal squamous cell carcinoma disproportionally affects people with HIV (PWH); however, engagement in anal cancer screening is low in many settings. This study was conducted to assess knowledge and perceptions of anal cancer screening to identify factors in the engagement and retention in prevention services among PWH. Semistructured interviews were conducted among adult PWH eligible for anal cancer screening in our Ryan White HIV/AIDS Program clinic. Descriptive statistics were tabulated; thematic analyses were performed to identify emerging motivators, facilitators, and barriers. Among 26 PWH, 9 had not been screened, 8 had undergone Papanicolaou (Pap) testing alone, and 9 had undergone anoscopy. The median age of the cohort was 55.2 years; 54% identified as men who have sex with men, and 54% identified as Black. In the unscreened cohort, participants were motivated by investing in their health and positive attitudes toward cancer prevention however were deterred by a lack of referral and low awareness about screening. Among those who had Pap testing, trust in healthcare providers and abnormal testing results were motivators to engagement, whereas lack of perceived risk of anal cancer and worry about pain of an anoscopy were prominent barriers. Among those who had anoscopy, perceived risk, positive experience with the procedure, and use of anxiolytics prior to anoscopy were motivators, whereas anxiety around a new cancer diagnosis and negative experience with anoscopy were barriers. Clinics seeking to build or strengthen their anal cancer screening programs can address the barriers described in this study to promote access to anal cancer screening among PWH.

Males Have Lower Anal Pap Smear Screening in a Miami Safety-Net HIV Clinic

BACKGROUND

Although people with HIV have a markedly higher risk of anal squamous cell carcinoma (ASCC), there are few evaluations of anal Pap screening determinants within safety-net HIV clinics.

METHOD

We conducted an evaluation of anal Pap screening correlates within a safety-net HIV clinic in Miami. Medical records were reviewed for 298 people ages 45 and older receiving HIV primary care. Demographic information and the prevalence of anal Pap screening over 1 year (i.e., 2018-2019) were extracted.

RESULTS

Between 2018 and 2019, approximately half (46%) of patients completed anal Pap screening although this varied by sex assigned at birth. More than three-fourths of females (77%) compared to one-fourth (23%) of males were screened between 2018 and 2019 (p < 0.0001).

CONCLUSION

Findings underscore the need for multi-level intervention approaches to optimize anal Pap screening among males with HIV within the Miami-based safety-net clinic.

HPV Vaccination Status in HIV-Negative MSM and Its Association with High-Risk HPV Detection Using HPV Serology and Anorectal Swabs

Background/Objective: The aim of this study was to determine the prevalence of high-risk (HR) human papillomavirus (HPV) types by HPV vaccination status and the feasibility of using HPV L1 serology to identify HIV-negative men who have sex with men (MSM) who may be at risk for anal cancer. Methods: This cross-sectional study recruited HIV-negative MSM from a US metropolitan area. The prevalence of HR, quadrivalent, and nonavalent anorectal HPV DNA and HPV L1 serum antibodies was estimated. McNemar's chi-square and kappa statistics were used to determine significant differences in HPV detection between anorectal DNA swabs and HPV L1 serology. Results: Eighty-two men had adequate anorectal swabs and serology samples for analysis. Men who self-reported receipt of the HPV vaccine (35.6%) had detectable L1 HPV antibodies (93.1%) and a lower prevalence of active anal HPV infections (20.7%) compared to those who reported none. Conclusions: If confirmed in larger prospective studies, a combination of HPV vaccination status or HPV L1 serology and anorectal swabs for HR HPV types could identify HIV-negative MSM who do not need to undergo follow-up anal testing.

To Improve Motivational Barriers to Retention in High Resolution Anoscopy, Patients and Providers Recommend Social and Environmental Changes: A Sequential Explanatory Mixed-Methods Pilot Study in a Federally Qualified Health Center

Loss to follow-up (LTFU) in high-resolution anoscopy (HRA) programs jeopardizes the procedure's potential to help prevent anal cancer. We explored quality improvement factors to understand how to address this LTFU. Using the transtheoretical COM-B Model (Capability, Opportunity, Motivation, and Behavior) and a sequential explanatory mixed-methods design, we surveyed and interviewed 13 patients who remained engaged in HIV care but who delayed their HRA monitoring or treatment visits in the same community clinic, and 6 HRA clinicians and medical assistants. Analyses involved descriptive statistics and rapid qualitative analysis. Patients were racially, ethnically, and economically representative of the LTFU population, and were generally experienced with HRA (Mean HRA visits = 4.6, SD = 2.8, mdn = 3). Providers were experienced clinicians and medical assistants (Mean years providing HRA = 6.0, SD = 2.2). Analyses revealed two primary, related barriers: (A) motivational barriers such as physical pain, discomfort, embarrassment, and anxiety; which were largely borne from (B) opportunity barriers such as difficulties with scheduling, inconsistent after-care (particularly for pain and discomfort), anxiety-inducing exam rooms and equipment, and internalized and anticipated stigma. Capability barriers, such as limited health literacy about HRA, were less common and, like motivational barriers, linked to opportunity barriers. Participants recommended potential facilitators, including easier scheduling, standardization of pain management and after-care services, and examination room modifications to reduce anxiety. To retain HRA patients in community settings, interventions should address social and physical opportunity barriers that strongly determine motivational and capability barriers. Improving convenience, standardizing pain management, and introducing stigma interventions specific to HRA, could alleviate both motivational and capability barriers.

Demographic, clinical, and social characteristics of anal cancer among patients stratified by age (<50 and ≥50 years) in Alabama between 2012 and 2018

BACKGROUND

Anal cancer is increasing globally, with a high number of new cases occurring in highly developed countries, including the U.S. The incidence of anal cancer is higher among people living with HIV (PLHIV), and the U.S. South continues to see higher HIV incidence rates and lagging HPV vaccination rates. We aimed to identify factors associated with early onset anal cancer in Alabama which may help explain cancer disparities in the South.

METHODS

Using a cross-sectional study design, we examined demographic, clinical, and social characteristics among anal cancer patients stratified by diagnosis age (<50 and ≥50 years) in the Alabama cancer registry between 2012 and 2018. We used Wilcoxon rank sums and Pearson chi-square tests to assess associations between age at diagnosis, demographic (i.e., sex, race, marital status), clinical (i.e., BMI, HIV infection, site, stage, and histological type), and social (i.e. social vulnerability) characteristics, and multivariable logistic regression to estimate the odds of early onset cancer.

RESULTS

Among 519 patients with anal cancer in Alabama, 92 (17.7 %) were diagnosed at <50 years. The majority of patients were female (66.5 %) and White (83.4 %). Male sex, Black race, and HIV infection were associated with younger age at diagnosis. Black patients had a 4-fold increased odds of early onset anal cancer compared to White patients (AOR=4.39, CI=1.54-12.49). Black patients disproportionately lived in areas with higher social vulnerability. About 42 % of patients in areas with the highest social vulnerability were diagnosed with stage 3 or 4 cancer. About 8 % of cases were among people aged 35-44 years, which is close to double the proportion of anal cancer cases in this age group in the U.S. (4.7 %).

CONCLUSIONS

Patients who are Black, male, and PLHIV may be at higher risk of early onset anal cancer compared to other populations in the South.