The epidemiology of anal cancer

Anal carcinoma - exploring the epidemiology, risk factors, pathophysiology, diagnosis, and treatment

Anal carcinoma is a relatively rare tumor that accounts for approximately 2% of gastrointestinal malignancies and less than 7% of anorectal cancers. Most anal tumors originate between the anorectal junction and the anal verge. Risk factors for the disease include human papillomavirus infection, human immunodeficiency virus, tobacco use, immunosuppression, female sex, and older age. The pathogenesis of anal carcinoma is believed to be linked to human papillomavirus-related inflammation, leading to dysplasia and progression to cancer. Squamous cell carcinoma is the most common type of anal tumor, with an annual incidence of approximately 1 to 2 per 100000 persons. Treatment regarding anal cancer has emerged over time. However, chemoradiation therapy remains the mainstay approach for early localized disease. Patients with metastatic disease are treated with systemic therapy, and salvage surgery is reserved for disease recurrence following chemoradiation. This article aims to provide background information on the epidemiology, risk factors, pathology, diagnosis, and current trends in the management of anal cancer. Future directions are briefly discussed.

Emerging trends and demographic disparities in anal cancer mortality across the United States census regions: An analysis of National Center for Health Statistics mortality data

AIMS

Anal cancer, despite its rarity, is a matter of serious concern in the United States, with an uptrend in recent years and marked racial disparities in mortality rates. The aim of this work was to investigate anal cancer mortality trends and sex race disparities in the United States from 1999 to 2020.

METHOD

This is a retrospective study using data from the CDC WONDER database (1999-2020). We investigated deaths attributed to anal cancer, identified by the ICD-10 code C21.1, and excluded individuals aged 14 years and under. The Mann-Kendall trend test was used to investigate temporal trends and a t-test was used to compare continuous variables.

RESULTS

Both male and female age-adjusted mortality attributed to anal cancer increased significantly during the study period across all subgroups, including race (Black and White), US Census region (Northeast, Midwest, South and West) and age (15-64 and ≥65 years) (p < 0.001 for all comparisons). For each subgroup, women demonstrated significantly higher rates of mortality than men, except in the Black population, where Black men had higher rates than Black women (0.40 vs. 0.29, p < 0.001). Additionally, Black men had significantly higher mean mortality rates than White men (0.40 vs. 0.27, p < 0.001). The highest rates of anal cancer mortality were among geriatric individuals, especially women aged ≥65 years, at 1.18 per 100 000.

CONCLUSION

The rise in anal cancer mortality and racial and sex disparities present a significant challenge for healthcare providers and policy makers. Further studies are required to devise evidence-based strategies to effectively tackle this challenge.

Overall Satisfaction with Cancer Care Among Sexual and Gender Minority People and Their Utilization of Identity-Tailored Health Education Materials

Purpose: This study was conducted to understand whether health education materials made specifically for members of sexual and gender minority (SGM) groups play a pivotal role in SGM cancer survivors' care satisfaction and experiences. Methods: We identified 2250 SGM cancer survivors who completed the "OUT: National Cancer Survey," conducted by the National LGBT Cancer Network in 2020-2021, and classified participants by their self-reported satisfaction with overall cancer care. We examined care satisfaction in relation to use of SGM-tailored health education resources and factors surrounding their SGM identities, which may influence their satisfaction, including feelings of safety with care teams. Results: Regardless of satisfaction with overall care, substantial proportions of survivors reported lacking vital health education resources specific to their SGM identities in areas of mental health (69%), physical activity (91%), tobacco use cessation (89%), and alcohol consumption (86%), despite attributing value to these materials. Contextualizing SGM survivor satisfaction with care, it was notable that among SGM survivors who felt safe with members of their care team knowing their SGM identity, only 3% were less than satisfied with their overall cancer care, compared to 38% who felt unsafe. Conclusion: SGM survivors value tailored information and health education resources that incorporate their intersectional identities. More research must be done to elucidate why SGM survivors do not receive these materials, while creating spaces where they feel safe receiving care. Increased delivery of SGM-tailored materials and prioritization of SGM safety in health care may have implications for overall cancer care satisfaction among SGM survivors.

Short- and long-term outcomes of surgical treatment for inguinal lymph node metastasis in rectal and anal canal adenocarcinoma

AIM

The significance of lymphadenectomy and its indications in patients with inguinal lymph node metastasis (ILNM) of anorectal adenocarcinoma is unclear. This study aimed to clarify the surgical outcomes and prognostic factors of inguinal lymphadenectomy for ILNM.

METHOD

This study included patients who underwent surgical resection for ILNM of rectal or anal canal adenocarcinoma with pathologically positive metastases between 1997 and 2011 at 20 participating centres in the Study Group for Inguinal Lymph Node Metastasis from Colorectal Cancer organized by the Japanese Society for Cancer of the Colon and Rectum. Clinicopathological characteristics and short- and long-term postoperative outcomes were retrospectively analysed.

RESULTS

In total, 107 patients were included. The primary tumour was in the rectum in 57 patients (53.3%) and in the anal canal in 50 (46.7%). The median number of ILNMs was 2.34. Postoperative complications of Clavien-Dindo Grade III or higher were observed in five patients. The 5-year overall survival rate was 38.8%. Multivariate analysis identified undifferentiated histological type (P < 0.001), pathological venous invasion (P = 0.01) and pathological primary tumour depth T0-2 (P = 0.01) as independent prognostic factors for poor overall survival.

CONCLUSION

The 5-year overall survival after inguinal lymph node dissection was acceptable, and it warrants consideration in more patients. Further larger-scale studies are needed in order to clarify the surgical indications.

A Population-Based and Propensity Score-Matched Investigation of the Occurrence, Management, and Prognosis of Anal Mucinous Adenocarcinoma Patients

INTRODUCTION

Anal mucinous adenocarcinoma (AMAC) is an extremely rare form of anal cancer. Our objective was to examine the incidence, management, and prognostic factors of AMAC.

METHODS

We analyzed age-adjusted incidence (AAI) rates over time and compared the prognosis of AMAC with anal squamous cell carcinoma (ASCC) and adenocarcinoma (AAC) using propensity score matching and Kaplan-Meier analysis. Patients were classified based on summary stage and treatments to determine cancer-specific survival.

RESULTS

AAI of AMAC fluctuated within a narrow range (0.082-0.237 per million person-years) from 2000 to 2018. AMAC had a slight non-significant trend of worse prognosis than ASCC (p = 0.348) and a better prognosis than AAC (p < 0.01). Females made up a larger proportion of patients diagnosed with the distant disease (p < 0.05) and unmarried (p < 0.05) and somewhat less probably to need surgical removal (p < 0.01) and radiotherapy (p < 0.01). Elderly patients have lower rates of survival (p < 0.05). Localized stage was associated with better prognosis (p < 0.05). Surgery was associated with a tendency toward better survival (p = 0.095).

CONCLUSIONS

AMAC exhibits a low incidence yet favorable prognosis compared to typical AAC and slightly worse compared to ASCC. Elderly age is associated with poorer prognosis, while localized stage indicates better prognosis. Surgery demonstrates a trend toward improved survival.

Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

Psychometric Validation of the Patient Anal Cancer Knowledge Scale (PACKS) in a Cohort of Black and Hispanic/Latino Sexual and Gender Diverse Young Adults

Lack of anal cancer information in priority populations is a major barrier to the uptake and utilization of prevention services. A validated measure of anal cancer knowledge is needed to inform patient education and shared clinical decision-making for anal cancer prevention. The purpose of this study was to validate the Patient Anal Cancer Knowledge Scale (PACKS) in a sample of GBM, namely Black and Hispanic gay, bisexual, and other men who have sex with men (GBM) and gender expansive young adults (aged 18-30 years) living in the USA (N=188). Anal cancer knowledge was hypothesized as a 3-factor scale representing (1) risk and primary prevention (9 items), (2) symptoms (5 items), and (3) screening (3 items). Confirmatory factor analysis, internal consistency, and criterion validity were assessed. The 3-factor model demonstrated adequate fit (RMSEA=0.02; CFI=0.99). All items loaded on their respective factors (p<0.01). Scale scores indicated low to moderate anal cancer knowledge and acceptable reliability: factor 1 (M=3.5; SD=2.3; range: 0-9; α=.71), factor 2 (M=2.9; SD=1.9; range: 0-5; α=.85), and factor 3 (M=2.0; SD=1.2; range: 0-3; α=.79). History of HPV vaccination (51.3%) was positively correlated with factors 1 and 2. The PACKS demonstrated good construct validity related to knowledge of anal cancer risk, prevention, symptoms, and screening. Limited anal cancer knowledge among Black and Hispanic GBM is a potential barrier to the uptake and utilization of prevention recommendations.

Propensity-score matched analysis of the pathologic outcomes and survival benefits of neoadjuvant therapy in stage II-III anal adenocarcinoma

BACKGROUND

Anal adenocarcinomas are a rare condition which account for less than 10% of anal cancers. The present study aimed to assess the impact of neoadjuvant therapy on the clinical and pathologic outcomes and overall survival (OS) of patients with stage II-III anal adenocarcinomas after abdominoperineal resection (APR).

METHODS

A retrospective cohort study of patients with anal adenocarcinoma in the US National Cancer Database (NCDB) (2010-2020) was conducted. Propensity-score matching was used to compare patients who received neoadjuvant therapy (neoadjuvant therapy group) to the no-neoadjuvant group. The primary outcome was 5-year OS whereas secondary outcomes included conversion to open surgery, hospital stay, surgical margins, 30-day mortality, 90-day mortality, and 30-day readmission.

RESULTS

A total of 742 patients (56% male) with a mean age of 63.6 ± 12.4 years were included. A total of 214 patients in the neoadjuvant group were matched with 107 in the no-neoadjuvant group. The mean OS was similar between the two groups (47.5 vs. 44.8 months, p = 0.253). Patients who received neoadjuvant therapy had a longer median time between diagnosis and surgery (151 vs. 54 days, p < 0.001), lower 90-day mortality (1.9% vs. 6.7%, p = 0.046), more pT0 tumors (15.7% vs. 0%), less pT3-4 tumors (28.4% vs. 36.4%, p = 0.001), less pN1-2 tumors (22.9% vs. 34.7%, p < 0.001), and less lymphovascular invasion (16.2% vs. 40%, p < 0.001) than the no-neoadjuvant group. Both groups had similar conversion rates, hospital stay, 30-day mortality, 30-day readmission, and positive surgical margins.

CONCLUSIONS

Neoadjuvant therapy before APR was associated with significant downstaging of anal adenocarcinomas and lower 90-day mortality, yet similar OS to patients who were surgically treated without neoadjuvant treatment.

Integrating HPV Vaccination Within PrEP care Delivery for Underserved Populations: A Mixed Methods Feasibility Study

Human Papillomavirus (HPV) vaccination is effective at preventing anal cancer, which disproportionally impacts gay/bisexual men (GBM) and transgender women (TGW). Vaccine coverage among GBM/TGW is insufficient to reduce anal cancer disparities. Federally qualified health centers (FQHCs) can increase reach and uptake of HPV vaccination by integrating and promoting HPV vaccination in ongoing HIV preventive care (e.g., Pre-exposure Prophylaxis [PrEP]). The purpose of the current study was to assess the feasibility and potential impact of integrating HPV vaccination with PrEP care. We conducted a mixed methods study of PrEP providers and staff (qualitative interviews, N = 9) and PrEP patients (quantitative survey, N = 88) at an FQHC in Philadelphia, Pennsylvania. Qualitative thematic analysis of PrEP provider/staff interviews was informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify and describe barriers and facilitators to HPV vaccination implementation. Quantitative analysis of PrEP patient survey was informed by the Information-Motivation-Behavioral Skills Model. Quantitative interviews resulted in 16 themes related to characteristics of the inner and outer clinic context. Barriers among providers included lack of focus on HPV in PrEP management guidelines, in metrics mandated by funding agencies, and in electronic medical record templates. Lack of anal cancer specific knowledge and motivation was identified in both PrEP patients and providers/staff. Providing HPV vaccination during routine PrEP visits was highly acceptable to both patients and providers. Based on these findings, we recommend several multi-level strategies to increase HPV vaccine uptake among PrEP patients.

Prevalence and incidence of anal cancer in HIV-positive men: a systematic review protocol

OBJECTIVE

The objective of this review is to synthesize the best evidence available to determine the prevalence and incidence of anal cancer in HIV-positive men.

INTRODUCTION

Worldwide, an estimated 50,685 people were diagnosed with anal cancer in 2020 and an estimated 19,293 people died from the disease during the same year. From 2001 to 2015, the overall incidence of anal cancer increased by 2.7% per year, while mortality jumped by 3.1% each year. Evidence has shown that anal intraepithelial neoplasia can progress to cancer over time, particularly within the immunocompromised population.

INCLUSION CRITERIA

This review will consider studies conducted in any setting, in any geographical location that report on the prevalence and incidence of adult males aged 18 years or older from any racial or ethnic background who are HIV positive and diagnosed with any type of anal cancer. Participants will be included regardless of stage of anal cancer, type of cancer treatment used, or length of time diagnosed.

METHODS

CINAHL, MEDLINE, Embase, LBGTQ+ Source (EBSCO), Web of Science Core Collection, MedNar, WorldWideScience, and ProQuest Dissertations and Theses databases will be searched from 1990 till the present. Analytical and descriptive observational studies will be included and critically appraised by 2 independent reviewers. Data will be extracted using JBI standardized data extraction tools. If sufficient data are available, a meta-analysis will be conducted; otherwise, the findings will be presented in narrative format, including tables and figures to aid in data presentation.

REVIEW REGISTRATION

PROSPERO CRD42022327933.

Immunotherapies in non-metastatic gastrointestinal cancers

PURPOSE

Over the last decade, immune checkpoint inhibitors (ICI) have emerged as cornerstone in the treatment of many metastatic tumour types, including gastrointestinal cancers. In many solid tumours, the effective therapies in the metastatic field are progressively brought into the curative setting. Consequently, earlier tumoural settings have become a field of experiment for immunotherapies. In melanoma, lung, and bladder cancers, excellent results were recorded, possibly explained by differences in the tumour microenvironment between metastatic and non-metastatic settings. In gastrointestinal (GI) Oncology, nivolumab is the first immune checkpoint inhibitor to become a standard-of-care adjuvant treatment after curative surgery for oesophagal or gastroesophageal junction cancer.

RECENT FINDINGS

We herein discuss the results of a selection of the most relevant studies presented/published over the last 18 months testing immunotherapies in non-metastatic GI cancers. Among immunotherapies, ICI have been investigated in pre-, peri- and postoperative setting across tumour types, alone or in combination with chemo- and/or radiotherapy. Vaccines are also a new field of investigation.

SUMMARY

Promising results from two studies (NCT04165772 and NICHE-2 study) demonstrating never-seen-before responses to neoadjuvant immunotherapy in MMR deficient (dMMR) colorectal cancers raise hope for improving the patients' outcome and developing organ-sparing strategies in this situation.

Anal Cancer and Anal Intraepithelial Neoplasia Risk among Patients Treated for HPV-Related Gynecological Diseases-A Systematic Review

BACKGROUND

The most important causative agent of neoplasms in the anogenital area is the human papillomavirus (HPV). Due to the anatomical proximity of the genital and anus area and the ease with which HPV infection is transmitted, it seems that patients after the treatment of HPV-related gynecological diseases may have an increased risk of developing a second HPV-related neoplasm anal cancer. The aim of this study was to determine the risk of anal intraepithelial neoplasia (AIN) and anal cancer (AC) among patients after the treatment of HPV-related gynecological diseases.

METHODS

We conducted a comprehensive review of the available literature from multiple databases. The study was performed following Cochrane Reviewers' Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Moreover, we assessed the quality of each study using QUADAS-2.

RESULTS

Twenty-five studies were included in the final analysis. Patients after the treatment of HPV-related gynecological diseases have a significantly higher risk of AC (mean standardized incidence ratio (SIR) = 5.387, mean incidence risk (IR) = 0.096%, mean IR per 100,000 person-years = 10.37) and AIN (mean IR = 23.683%) compared to the population risk.

CONCLUSIONS

patients with HPV-related gynecological diseases should constitute a group for which an appropriate primary and secondary screening for AC should be introduced.

How can we improve the acceptability of vaccination against Human Papillomavirus (HPV) in France? An original qualitative study with focus groups comprising parents and school staff, interviewed separately

BACKGROUND

It has been proven that vaccination is effective against Human Papillomavirus (HPV) infections, genital warts, and pre-cancerous and cancerous cervical lesions. Nevertheless, the HPV vaccine coverage of 37.4 % in 2021 in France is one of the lowest in Europe. To explore and understand the reason why French population is so late compared to its neighbours, we carried out focus groups with mothers and with National Education school staff. We aimed to identify knowledge and perceptions of HPV in both study populations, as well as factors influencing HPV vaccination.

METHODS

Between January 2020 and March 2021, we performed a qualitative study using an inductive approach with a thematic content analysis (TCA). We conducted semi-structured focus groups with 29 people including 15 mothers of adolescents in middle schools and 14 school staff from the national education system.

RESULTS

Different factors influenced the decision-making process of parents and school staff: knowledge and perceptions of HPV and its vaccine, sources of information about HPV and vaccination. Mothers' discourses differed from those of school staff. They mentioned the importance of gynaecological monitoring and the negative image of pharmaceutical companies, and questioned internet as a reliable source of information. For their part, school staff mentioned cultural and/or religious affiliation, municipalities' role to inform the population, and ethical dilemma or logistical challenges regarding HPV vaccination in schools.

CONCLUSION

The results of these focus groups provided information on which elements may harm or help HPV vaccination. Identified perceptions, beliefs, knowledge, barriers, and facilitators will help us to build an intervention program focus on general practitioners (GP), school staff, parents, and adolescents.

The Immune Response Generated against HPV Infection in Men and Its Implications in the Diagnosis of Cancer

Human papillomavirus (HPV) infection is associated with precancerous lesions and cancer of the genital tract both in women and men. The high incidence of cervical cancer worldwide focused the research on this infection mainly in women and to a lesser extent in men. In this review, we summarized epidemiological, immunological, and diagnostic data associated with HPV and cancer in men. We presented an overview of the main characteristics of HPV and infection in men that are associated with different types of cancer but also associated with male infertility. Men are considered important vectors of HPV transmission to women; therefore, identifying the sexual and social behavioral risk factors associated with HPV infection in men is critical to understand the etiology of the disease. It is also essential to describe how the immune response develops in men during HPV infection or when vaccinated, since this knowledge could help to control the viral transmission to women, decreasing the incidence of cervical cancer, but also could reduce other HPV-associated cancers among men who have sex with men (MSM). Finally, we summarized the methods used over time to detect and genotype HPV genomes, as well as some diagnostic tests that use cellular and viral biomarkers that were identified in HPV-related cancers.

Synchronous Squamous Cell Carcinoma of Rectum and Anal Canal Detected by FDG PET/CT-A Rare Entity

ABSTRACT

Squamous cell carcinoma is the most common malignancy of the anal canal, and FDG PET/CT is recommended in its nodal staging, radiotherapy planning, and response assessment. We share an interesting case of dual primary malignancy of the anal canal and rectum, which was detected by 18 F-FDG PET/CT and confirmed on histopathology as synchronous squamous cell carcinoma.

Case report: a precancerous lesion associated with HPV in the anal canal diagnosed by magnifying endoscopy with narrow-band imaging and resected by endoscopic submucosal dissection

Although anal cancer remains rarely diagnosed in the world, its frequency is rising, especially in high-risk groups. The prognosis of advanced anal cancer is poor. However, there are still few reports on the endoscopic diagnosis and treatment of early anal cancer and its precancerous lesions. A 60-year-old woman was referred to our hospital for endoscopic treatment of a flat precancerous lesion in the anal canal, which was identified by narrow-band imaging (NBI) and confirmed by pathological examination in another hospital. The pathological results showed a high-grade squamous intraepithelial lesion (HSIL) in the biopsy specimen, and immunochemistry staining showed P16 positive, suggesting HPV infection. We performed pre-resection endoscopic examination for the patient. A lesion with a clear margin and tortuous dilated vessels was revealed under magnifying endoscopy with NBI (ME-NBI), which stayed unstained after iodine spraying. The lesion was successfully removed en bloc using ESD without complications, and the resected specimen was a low-grade squamous intraepithelial lesion (LSIL) with positive immunochemistry staining of P16. The patient underwent follow-up coloscopy a year after ESD, and the anal canal healed well with no suspicious lesions found. From this case, we can learn that ESD is safe and effective for curative resection of precancerous lesions of the anal canal.

Human papillomavirus in the setting of immunodeficiency: Pathogenesis and the emergence of next-generation therapies to reduce the high associated cancer risk

Human papillomavirus (HPV), a common sexually transmitted virus infecting mucosal or cutaneous stratified epithelia, is implicated in the rising of associated cancers worldwide. While HPV infection can be cleared by an adequate immune response, immunocompromised individuals can develop persistent, treatment-refractory, and progressive disease. Primary immunodeficiencies (PIDs) associated with HPV-related disease include inborn errors of GATA, EVER1/2, and CXCR4 mutations, resulting in defective cellular function. People living with secondary immunodeficiency (e.g. solid-organ transplants recipients of immunosuppression) and acquired immunodeficiency (e.g. concurrent human immunodeficiency virus (HIV) infection) are also at significant risk of HPV-related disease. Immunocompromised people are highly susceptible to the development of cutaneous and mucosal warts, and cervical, anogenital and oropharyngeal carcinomas. The specific mechanisms underlying high-risk HPV-driven cancer development in immunocompromised hosts are not well understood. Current treatments for HPV-related cancers include surgery with adjuvant chemotherapy and/or radiotherapy, with clinical trials underway to investigate the use of anti-PD-1 therapy. In the setting of HIV co-infection, persistent high-grade anal intraepithelial neoplasia can occur despite suppressive antiretroviral therapy, resulting in an ongoing risk for transformation to overt malignancy. Although therapeutic vaccines against HPV are under development, the efficacy of these in the setting of PID, secondary- or acquired- immunodeficiencies remains unclear. RNA-based therapeutic targeting of the HPV genome or mRNA transcript has become a promising next-generation therapeutic avenue. In this review, we summarise the current understanding of HPV pathogenesis, immune evasion, and malignant transformation, with a focus on key PIDs, secondary immunodeficiencies, and HIV infection. Current management and vaccine regimes are outlined in relation to HPV-driven cancer, and specifically, the need for more effective therapeutic strategies for immunocompromised hosts. The recent advances in RNA-based gene targeting including CRISPR and short interfering RNA (siRNA), and the potential application to HPV infection are of great interest. An increased understanding of both the dysregulated immune responses in immunocompromised hosts and of viral persistence is essential for the design of next-generation therapies to eliminate HPV persistence and cancer development in the most at-risk populations.

Population-Based Analysis of National Comprehensive Cancer Network (NCCN) Guideline Adherence for Patients with Anal Squamous Cell Carcinoma in California

PURPOSE

We analyzed adherence to the National Comprehensive Cancer Network treatment guidelines for anal squamous cell carcinoma in California and the associated impacts on survival.

METHODS

This was a retrospective study of patients in the California Cancer Registry aged 18 to 79 years with recent diagnoses of anal squamous cell carcinoma. Predefined criteria were used to determine adherence. Adjusted odds ratios and 95% confidence intervals were estimated for those receiving adherent care. Disease-specific survival (DSS) and overall survival (OS) were examined with a Cox proportional hazards model.

RESULTS

4740 patients were analyzed. Female sex was positively associated with adherent care. Medicaid status and low socioeconomic status were negatively associated with adherent care. Non-adherent care was associated with worse OS (Adjusted HR 1.87, 95% CI = 1.66, 2.12, p < 0.0001). DSS was worse in patients receiving non-adherent care (Adjusted HR 1.96, 95% CI = 1.56, 2.46, p < 0.0001). Female sex was associated with improved DSS and OS. Black race, Medicare/Medicaid, and low socioeconomic status were associated with worse OS.

CONCLUSIONS

Male patients, those with Medicaid insurance, or those with low socioeconomic status are less likely to receive adherent care. Adherent care was associated with improved DSS and OS in anal carcinoma patients.

Predisposing, Enabling, and Need-Related Factors Associated with Human Papillomavirus Vaccination Intentions and Uptake Among Black and Hispanic Sexual and Gender Diverse Adults in the USA

The purpose of the current study was to identify predisposing, enabling, and need-based factors associated with human papillomavirus (HPV) or HPV vaccination intentions among ethnoracial minority men who have sex with men (MSM) and gender expansive natal males. This was a secondary analysis of survey data from 299 Black and Hispanic MSM and gender expansive young (aged 18-30 years) adults living in the USA. Variable selection was informed by Anderson's model of healthcare utilization. Outcomes were self-reported HPV vaccination and vaccine intentions. Less than half of the sample (45.5%) reported initiating (i.e., receiving at least 1 dose) HPV vaccination. Hierarchical multiple regression was used to identify relevant theoretical predictors. Among those who were unvaccinated, 14.2% were unlikely, 56.3% were undecided, and 29.4% likely to initiate HPV vaccination within the next 12 months. More favorable vaccine attitudes (adjusted prevalence ratio [aPR] = 1.55; 95% CI: 1.12-2.15), past year routine check-up (aPR = 1.50; 95% CI: 1.14-1.97), and ever being diagnosed with anogenital warts (aPR = 1.55; 95% CI: 1.12-2.15) were independently associated with the probability of HPV vaccination. Several enabling factors (e.g., testing for sexually transmitted infections) were not associated with HPV vaccination, suggesting routine missed opportunities. There were no associations between predictor variables and HPV vaccine intentions. Targeted efforts are needed to decrease anal cancer disparities experienced by ethnoracial minority MSM. Leveraging enabling factors already present this population (e.g., STI testing and pre-exposure prophylaxis use) are potential targets for interventions to increase the reach of HPV vaccination.

The emerging role of immunotherapy in the treatment of anal cancer

For decades, chemoradiotherapy for early-stage disease and systemic chemotherapy for advanced disease have represented the mainstay of treatment for anal cancer. Over the last few years, however, the advent of immunotherapy has opened interesting therapeutic perspectives, with the establishment of new standards of care, and the development of clinical trials that may further shape the treatment algorithm for this tumour. In this review article, we discuss the rationale behind the use of immunotherapy for anal cancer and provide an overview of the available clinical data and ongoing efforts to build on these.

HPV vaccination and HIV preexposure prophylaxis (PrEP): Missed opportunities for anal cancer prevention among at risk populations

Gay, bisexual, and other men who have sex with men (GBM), in addition to transgender women who have sex with men (TW), are at disproportionate risk for anal cancer. Anal cancer can be prevented with HPV vaccination, but uptake among adult GBM/TW is low. Targeted HPV vaccination during the clinical management of pre-exposure prophylaxis (PrEP) is an unexplored strategy relevant to these populations. The purpose of this study was (1) to determine the need for HPV vaccination among GBM and transgender women PrEP users and (2) to identify correlates of HPV vaccination among PrEP users. Secondary analysis of the 2020 Pennsylvania LGBT Health Needs Assessment was conducted to estimate prevalence ratios of HPV vaccination among PrEP users. Overall, 43.8% of the sample had initiated HPV vaccination. Vaccine initiation was significantly lower among respondents 27 to 35 (PR = 0.64; 95% CI: 0.49-0.83) and 36 to 45 (PR = 0.38; 95% CI: 0.25-0.58). Respondents who had received Hepatitis A vaccination were significantly more likely to have had initiated HPV vaccination after adjusting for age (aPR = 2.60; 95% CI: 1.75-3.84). Overall, more than half of eligible GBM and TW engaged in PrEP care have not initiated HPV vaccination and represent potential missed opportunities for anal cancer prevention.

The prognostic impact of PD-L1 and CD8 expression in anal cancer patients treated with chemoradiotherapy

Background

Programmed death-ligand 1 (PD-L1) expression has been shown to be prognostic in many cancer types and used in consideration of checkpoint inhibitor immunotherapy. However, there are very limited and conflicting data on the prognostic impact of PD-L1 in patients with anal squamous cell carcinoma (ASCC). The objectives of this study were to measure the expression of PD-L1 and CD8 in patients with ASCC treated with radical chemoradiotherapy (CRT) and to correlate tumor expression with progression-free survival (PFS) and overall survival (OS).

Methods

Ninety-nine patients with ASCC treated with primary CRT at two tertiary care cancer centers between 2000 and 2013, with available pre-treatment tumors, were included. Tissue microarrays (TMAs) from pre-treatment tumor specimens were stained for PD-L1 and CD8. PD-L1 expression in the tumor and stroma was quantified using HALO image analysis software, and results were interpreted using quantitative methods. The density of CD8 cells within the tumor was interpreted by a trained pathologist semi-quantitatively, using a 0-4 scoring system. Kaplan-Meier analysis with log-rank was used to determine the significance in the association of tumor markers with PFS and OS. Cox multivariate analysis was used to explore independent predictors of PFS and OS.

Results

Of the 99 patients, 63 (64%) had sufficient tumor samples available for full analysis. CD8 high status was documented in 32 of 63 (50.8%) % of cases. PD-L1 expression was positive in 88.9% of cases. Approximately half the patients had tumor PD-L1 ≥ 5%. Patients with tumor PD-L1 ≥ 5% had better OS vs those with lower expression, HR=0.32 (95% CI 0.11-0.87), p=0.027; 10 years OS: 84% for tumor PD-L1 ≥ 5% vs 49% for PD-L1 < 5%. PD-L1 expression was not associated with PFS. On multivariate analysis, tumor PD-L1 ≥ 5% showed a trend to statistical significance for better OS, HR=0.55 (95% CI 0.12- 1.00), p=0.052.

Conclusions

Tumor PD-L1≥5% is associated with OS in patients with ASCC treated with CRT. PD-L1 expression status using this unique cut-point warrants further validation for prognostication in patients with this disease. Future studies are required to determine the benefit of alternative treatment strategies based on PD-L1 status.

Promoting vaccination during rapid HIV testing: Recommendations from men who have sex with men in California

Community-based rapid HIV testing is effective for reaching racial-ethnically diverse men who have sex with men (MSM), offering an opportunity for bundled health promotion interventions. Given MSM experience a heightened prevalence of human papillomavirus (HPV) and meningococcal disease, we examined their preferences for bundling rapid HIV testing with an intervention to promote vaccination against these infections. In 2020, we conducted five virtual focus groups (N = 25 participants) in English and Spanish with MSM in Southern California's Inland Empire. Participants discussed their knowledge about HPV and meningitis vaccination and attitudes toward receiving vaccination information and referrals during rapid HIV tests. We used the rigorous and accelerated data reduction technique to systematically analyse the data. Participants had a mean age of 30, were socioeconomically diverse, and predominantly (68%) Hispanic. 96% had ever been tested for HIV, while only 28% were vaccinated against HPV and/or meningitis. Most participants were unaware of MSM's elevated risk for HPV and meningitis and were eager to receive vaccination information from LGBTQ+-friendly providers. However, many participants emphasised rapid HIV testing was stressful and anticipated feeling overwhelmed if presented with vaccination information in this setting. Preferred formats for vaccine promotion included pamphlets and resources that could be discretely accessed online, supported by broader advertising featuring diverse MSM on social media, dating apps, and posters in the community. Overall, our findings suggest that bundling health promotion messages with rapid HIV testing may be ineffective, as the anxiety associated with taking an HIV test may interfere with such messages and their impact.

Immune Checkpoint Inhibitors for Gastrointestinal Malignancies: An Update

Simple Summary

Immune checkpoint inhibitors are a class of anti-cancer therapy that work by harnessing the body’s immune system to promote cancer cell death. These drugs have become standard of care for many types of cancer, including melanoma and lung cancer, after clinical trials showed they work better than traditional chemotherapy. The role of immune checkpoint inhibitors is still evolving in the treatment of cancers of the gastrointestinal tract. This article examines the literature to support the use of immune checkpoint inhibitors to treat cancers of each part of the gastrointestinal system.

Abstract

Gastrointestinal (GI) malignancies are a heterogenous group of cancers with varying epidemiology, histology, disease course, prognosis and treatment options. Immune checkpoint inhibitors (ICIs) have changed the landscape of modern cancer treatment, though they have demonstrated survival benefit in other solid tumors more readily than in GI malignancies. This review article presents an overview of the landscape of ICI use in GI malignancies and highlights recent updates in this rapidly evolving field.

Combined PET-CT and MRI for response evaluation in patients with squamous cell anal carcinoma treated with curative-intent chemoradiotherapy

OBJECTIVES

To assess the effectiveness of fluorine-18 fluorodeoxyglucose (FDG) positron-emission tomography-computed tomography (PET-CT) and magnetic resonance imaging (MRI) for response assessment post curative-intent chemoradiotherapy (CRT) in anal squamous cell carcinoma (ASCC).

METHODS

Consecutive ASCC patients treated with curative-intent CRT at a single centre between January 2018 and April 2020 were retrospectively identified. Clinical meta-data including progression-free survival (PFS) and overall survival (OS) outcomes were collated. Three radiologists evaluated PET-CT and MRI using qualitative response assessment criteria and agreed in consensus. Two-proportion z test was used to compare diagnostic performance metrics (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy). Kaplan-Meier analysis (Mantel-Cox log-rank) was performed.

RESULTS

MRI (accuracy 76%, PPV 44.8%, NPV 95.7%) and PET-CT (accuracy 69.3%, PPV 36.7%, NPV 91.1%) performance metrics were similar; when combined, there were statistically significant improvements (accuracy 94.7%, PPV 78.9%, NPV 100%). Kaplan-Meier analysis demonstrated significant differences in PFS between responders and non-responders at PET-CT (p = 0.007), MRI (p = 0.005), and consensus evaluation (p < 0.001). Cox regression analysis of PFS demonstrated a lower hazard ratio (HR) and narrower 95% confidence intervals for consensus findings (HR = 0.093, p < 0.001). Seventy-five patients, of which 52 (69.3%) were females, with median follow-up of 17.8 months (range 5-32.6) were included. Fifteen of the 75 (20%) had persistent anorectal and/or nodal disease after CRT. Three patients died, median time to death 6.2 months (range 5-18.3).

CONCLUSION

Combined PET-CT and MRI response assessment post-CRT better predicts subsequent outcome than either modality alone. This could have valuable clinical benefits by guiding personalised risk-adapted patient follow-up.

KEY POINTS

• MRI and PET-CT performance metrics for assessing response following chemoradiotherapy (CRT) in patients with anal squamous cell carcinoma (ASCC) were similar. • Combined MRI and PET-CT treatment response assessment 3 months after CRT in patients with ASCC was demonstrated to be superior to either modality alone. • A combined MRI and PET-CT assessment 3 months after CRT in patients with ASCC has the potential to improve accuracy and guide optimal patient management with a greater ability to predict outcome than either modality alone.

Reinfection of Nine-Valent Human Papillomavirus Vaccine Types Among HIV-Negative Men Who Have Sex With Men: A Prospective Cohort Study

Objectives

Reinfection of human papillomavirus (HPV) among men who have sex with men (MSM) after clearing the infection of HPV has not been well characterized. To understand the reinfection of HPV among human immunodeficiency virus (HIV) negative MSM without HPV vaccine, we analyzed the reinfection of nine-valent HPV vaccine (9v-HPV) types.

Methods

Data were acquired from a prospective cohort study among HIV-negative MSM in Urumqi of Xinjiang from 1 April 2016 to 14 July 2020. Participants were recruited through a local non-government organization using a website advertisement. Self-administered questionnaires and self-collected anal swabs were collected at baseline and every 6 months. The incidence rates of reinfection was calculated based on the number of events divided by person-months of observation of event risk. 95% confidence intervals (CIs) were calculated based on the Poisson distribution.

Results

A total of 515 HIV-negative unvaccinated MSM were included with a mean age of 30.93 years (SD 7.85), and 27.68% were reinfected with any 9v-HPV type after clearance. The reinfection incidence rate of any 9v-HPV was 14.47 per 1000 person-months (95% CI: 11.52–17.87). HPV52 was the most common type of reinfection, with a reinfection rate of 17.96 per 1,000 person months (95% CI: 11.58–26.33). Univariate analysis showed that MSM over the age of 30 had a slightly higher risk of reinfection with any 9v-HPV (Hazard ratio (HR): 1.57; 95% CI: 1.01–2.45), but no significant association was observed in multivariate analysis.

Conclusions

Our study showed MSM without HPV vaccine will become reinfected following the natural clearance of specific HPV types. It is also suggested that HPV vaccination is recommended not only prior to sexual debut but also after viral clearance for MSM to reduce HPV prevalence.

LGBTQ+ health and anaesthesia for obstetric and gynaecological procedures

PURPOSE OF REVIEW

People who self-identify as lesbian, gay, bisexual, transgender, queer, two-spirited and intersex (LGBTQ2SI) make up approximately 10% of the US population. Black, Native American and Latino/a/x communities are known to have a higher percentage of people who self-identify as LGBTQ2SI than white communities. Despite growing acceptance of LGBTQ2SI communities in the USA, these populations continue to experience health inequities. This review article will provide a narrative review of recent publications that discuss topics of LGBTQ2SI health and anaesthetic care during obstetric and gynaecological procedures.

RECENT FINDINGS

Of the articles reviewed for this study, there were four main themes that emerged: inclusion of LGBTQ2SI health topics in curriculum and provider training materials; social determinants of LGBTQ2SI reproductive and overall health; improving the quality and safety of perioperative care for LGBTQ2SI communities; and disparities in perinatal anaesthetic care for LGTBQ2SI communities.

SUMMARY

There are unique considerations when providing anaesthetic care for obstetric and gynaecological procedures to LGBTQ2SI communities. There is a limited, yet growing, body of literature exploring this aspect of perioperative and perinatal care. Researchers and clinicians must continue to pursue clinical research which seeks to improve the quality of care we provide all patients.

Beta HPV Deregulates Double-Strand Break Repair

Beta human papillomavirus (beta HPV) infections are common in adults. Certain types of beta HPVs are associated with nonmelanoma skin cancer (NMSC) in immunocompromised individuals. However, whether beta HPV infections promote NMSC in the immunocompetent population is unclear. They have been hypothesized to increase genomic instability stemming from ultraviolet light exposure by disrupting DNA damage responses. Implicit in this hypothesis is that the virus encodes one or more proteins that impair DNA repair signaling. Fluorescence-based reporters, next-generation sequencing, and animal models have been used to test this primarily in cells expressing beta HPV E6/E7. Of the two, beta HPV E6 appears to have the greatest ability to increase UV mutagenesis, by attenuating two major double-strand break (DSB) repair pathways, homologous recombination, and non-homologous end-joining. Here, we review this dysregulation of DSB repair and emerging approaches that can be used to further these efforts.

Anal Cancer Screening and Prevention: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infection Guidelines

In June 2019 the Centers for Disease Control and Prevention (CDC) convened an advisory group to assist in development of the 2021 CDC sexually transmitted infections (STI) guidelines. The advisory group on anal cancer screening and prevention met to formulate key questions in this field. The group examined published literature and abstracts to assess evidence and give recommendations for development of the CDC guidelines. This article summarizes key questions, evidence, recommendations, and areas for further research for the screening, diagnosis, and prevention of anal cancer.

Factors Associated with Human Papillomavirus Vaccine Initiation and Compliance Among U.S. Military Service Members

INTRODUCTION

The primary objective of the current study was to assess factors associated with Human Papillomavirus (HPV) vaccine initiation and compliance in a cohort of active duty US military service members (SM).

MATERIALS AND METHODS

We included active-duty participants aged 18-26 years from the Millennium Cohort Study, a longitudinal cohort study of over 200,000 military SMs. The eligible study population included 22,387 female SMs and 31,705 male SMs. Vaccination was assessed over the period 2006-2017. Logistic regression was used to estimate the odds of vaccine initiation and compliance (3 doses within a 1-year period) in relation to demographic, military, health, and behavioral characteristics.

RESULTS

Among female SMs, 37.8% initiated the vaccine and 40.2% of initiators completed the series within a year. Among male SMs, 3.9% initiated the vaccine and 22.1% of initiators completed the series within a year. Differences by sociodemographic factors, deployment status, branch of service, occupation, and smoking status-but not by selected mental health conditions-were observed.

CONCLUSION

HPV vaccination uptake is subpar across all military service branches. Certain subgroups of SMs could be targeted to increase overall HPV vaccine coverage in the US military population.

Long-term Patterns of Failure and the Value of Blood Prognostic Markers in Anal Cancers Treated With Intensity-Modulated Radiation Therapy

BACKGROUND

To analyze the long-term outcomes and prognostic value of hematological parameters in anal cancer patients receiving intensity-modulated radiation therapy (IMRT).

MATERIALS

Hospital records of consecutive patients with anal squamous cell carcinoma who received curative-intent IMRT according to a standardized contouring protocol between 2010 and 2020 were reviewed. Locoregional failure-free survival (LRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) were estimated using the Kaplan-Meier method. Coverage of locoregional recurrences by the initial IMRT volumes were assessed. The prognostic value of pretreatment blood counts for PFS and OS were determined using Cox regression analysis.

RESULTS

A total of 166 patients were analyzed with a median follow-up of 3.3 years. Forty-six percent and 54% of patients had Stage I-II and IIIA-B cancers, respectively. The 5-year LRFS, DMFS, PFS and OS were 81%, 89%, 65% and 76% respectively. Grade ≥ 3 toxicity occurred in 5% of patients. Of all patients who relapsed, 70% had only locoregional recurrence as first site of failure. Ninety percent of locoregional recurrences were in-field. Hemoglobin, neutrophil and platelet counts were associated with PFS on univariable analysis, but only cancer stage and p16 status remained prognostic on multivariable analysis. Patients with more advanced cancer stages also had higher baseline neutrophil counts. Performance status and neutrophil counts were prognostic for OS on multivariable analysis.

CONCLUSION

This study affirms the long-term efficacy and safety of IMRT. Treatment resistance, rather than radiation geographic miss, is a major issue underpinning locoregional recurrences. Pretreatment blood counts were not validated to be independently prognostic for disease recurrence.

Multi-institutional Comparison of Intensity Modulated Photon Versus Proton Radiation Therapy in the Management of Squamous Cell Carcinoma of the Anus

Purpose

Concurrent chemoradiation therapy is a curative treatment for squamous cell carcinoma of the anus, but patients can suffer from significant treatment-related toxicities. This study was undertaken to determine whether intensity modulated proton therapy (IMPT) is associated with less acute toxicity than intensity modulated radiation therapy (IMRT) using photons.

Materials and Methods

We performed a multi-institutional retrospective study comparing toxicity and oncologic outcomes of IMRT versus IMPT. Patients with stage I-IV (for positive infrarenal para-aortic or common iliac nodes only) squamous cell carcinoma of the anus, as defined by the American Joint Committee on Cancer's AJCC Staging Manual, eighth edition, were included. Patients with nonsquamous histology or mixed IMPT and IMRT treatment courses were excluded. Acute nonhematologic toxicities, per the National Cancer Institute's Common Terminology Criteria for Adverse Events (CTCAE), version 4, were recorded prospectively at all sites. Acute and late toxicities, dose metrics, and oncologic outcomes were compared between IMRT and IMPT using univariable and multivariable statistical methods. To improve the robustness of our analysis, we also analyzed the data using propensity score weighting methods.

Results

A total of 208 patients were treated with either IMPT (58 patients) or IMRT (150 patients). Of the 208 total patients, 13% had stage I disease, 36% stage II, 50% stage III, and 1% stage IV. IMPT reduced the volume of normal tissue receiving low-dose radiation but not high-dose radiation to bladder and bowel. There was no significant difference between treatment groups in overall grade 3 or greater acute toxicity (IMRT, 68%; IMPT, 67%; P = .96) or 2-year overall grade 3 or greater late toxicity (IMRT, 3.5%; IMPT, 1.8%; P = .88). There was no significant difference in 2-year progression-free survival (hazard ratio, 0.8; 95% CI, 0.3-2.0).

Conclusions

Despite reducing the volume of normal tissue receiving low-dose radiation, IMPT was not associated with decreased grade 3 or greater acute toxicity as measured by CTCAE. Additional follow-up is needed to assess whether important differences arise in late toxicities and if further prospective evaluation is warranted.

Anal human papillomavirus prevalence and risk factors among men who have sex with men in Vietnam

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HPV infection in men having sex with men (MSM) was studied in two cities of Vietnam

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Prevalence of any HPV and HPV16/18 among MSM was 32.3% and 11.0%, respectively

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High-risk HPV infections in MSM were associated with risky sexual behaviours

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A targeted HPV vaccination strategy would be beneficial for MSM in Vietnam

Objectives

Men who have sex with men (MSM) are at risk of human papillomavirus (HPV)-related cancers, while published data are scarce. This study determined HPV prevalence and risk factors in MSM in Vietnam to inform HPV prevention strategies in this key population.

Methods

A cross-sectional study of 799 MSM aged 16-50 years was conducted in Vietnam in 2017-2018. Information was collected on risk behaviours, and knowledge of HPV and anal cancer; rectal swabs were taken to detect anal HPV infection. An in-house polymerase chain reaction and Genoflow HPV array test kit were used for HPV detection and genotyping.

Results

The median age of the study participants was 25 years (range 18-52). Overall prevalence of any HPV and HPV16/18 infection was 32.3% and 11.0%, respectively. A higher prevalence of high-risk HPV infection to all 14 types tested was found in Ho Chi Minh City (30.9%) than in Hanoi (18.4%). High-risk HPV infection was associated with inconsistent condom use and history of engaging in sex under the influence of drugs (adjusted odds ratio (aOR), 2.27; 95% CI, 1.48-10.67), as well as having multiple sexual partners (aOR, 1.01; 95% CI, 1.00–1.02).

Conclusions

High-risk anal HPV infections in Vietnamese MSM were significantly associated with risky sexual behaviours. A targeted HPV vaccination strategy would have substantial benefit for MSM in Vietnam.

A Novel Model for Papillomavirus-Mediated Anal Disease and Cancer Using the Mouse Papillomavirus

Up to 95% of all anal cancers are associated with infection by human papillomavirus (HPV); however, no established preclinical model exists for high-grade anal disease and cancer mediated by a natural papillomavirus infection. To establish an infection-mediated model, we infected both immunocompromised NSG and immunocompetent FVB/NJ mice with the recently discovered murine papillomavirus MmuPV1, with and without the additional cofactors of UV B radiation (UVB) and/or the chemical carcinogen 7,12-dimethylbenz(a)anthracene (DMBA). Infections were tracked via lavages and swabs for MmuPV1 DNA, and pathology was assessed at the endpoint. Tissues were analyzed for biomarkers of viral infection and papillomavirus-mediated disease, and the localization of viral infection was investigated using biomarkers to characterize the anal microanatomical zones.

Radiology of anal and lower rectal cancers

Lower rectal and anal cancers are distinct from neoplasms involving rest of the rectum. These are relatively difficult to manage owing to important relationships with the sphincter muscles. Involvement of the latter portends a poorer prognosis and increased chance of recurrence. Lymphatic drainage of these tumours is into the systemic circulation and the exact set of lymph nodes involved depends on the precise location of the tumour. The role of imaging includes assessment of local invasion, infiltration of adjacent pelvic organs, assessment of locoregional lymphatic spread and metastasis, post-chemoradiation restaging as well as post-treatment surveillance.

"That's Only for Women": The Importance of Educating HIV-Positive Sexual Minority Men on HPV and High Resolution Anoscopy (HRA)

Gay, bisexual, and other men who have sex with men (MSM) experience disproportionately high burdens of Human Papilloma Virus (HPV)-associated anal cancers. Recent focus has shifted to anorectal cancer prevention through high-resolution anoscopy (HRA); however, little is known about sexual minority men's perceptions, attitudes, or beliefs regarding HRA. We conducted 4 qualitative Focus Group Discussions (FGDs) (n = 15) with sexual minority men, focusing on their beliefs, attitudes, and perceptions of undergoing HRA. Participants discussed their experiences of HPV/HRA as influenced by both their gender and sexuality, including unawareness of HPV disease as a male health issue, challenges relating to female-oriented HPV/HRA language, conception of HPV/HRA as related to prostate health, and connecting their sexual behavior identification as "bottoms" to their need for HRA. As efforts to improve HRA knowledge, access, and uptake among sexual and gender minority communities increase, special attention should be paid to language and messaging choices around HRA.

Gay and Bisexual Men in the US Lack Basic Information About Anal Cancer

OBJECTIVE

The purpose of this study was to assess knowledge of human papillomavirus (HPV) as a cause of anal cancer among at-risk gay, bisexual, and other men who have sex with men (GBM).

MATERIALS AND METHODS

Secondary analysis was conducted of cross-sectional data from 3 cycles of the Health Information National Trends Survey (2017, 2018, 2019). Results were reported for the subset of adults who identified as GBM (N = 212). Knowledge that HPV can cause anal cancer was the main outcome. Differences in knowledge were evaluated (using χ2 and multiple logistic regression) by demographic, health information factors, and access to care.

RESULTS

Sixty-eight percent of GBM were aware of HPV. Knowledge that HPV causes anal cancer was low (<20%) in the overall sample and sample of GBM (17.9%; 95% CI = 11.0-24.7). Gay, bisexual, and other men who have sex with men were no more knowledgeable that HPV causes anal cancer than heterosexual men (14.8%; 95% CI = 12.9-16.9; p = .376). College-educated GBM had higher odds (adjusted odds ratio = 3.50; 95% CI = 1.02-11.97) of knowing HPV causes anal cancer than GBM with no college degree. No other factors were associated with knowledge.

CONCLUSIONS

Gay, bisexual, and other men who have sex with men are largely unaware that HPV can cause anal cancer, despite high awareness of HPV itself. This is concerning given that GBM are at increased risk of HPV-associated anal cancer than the general population. Our findings suggest that information about anal cancer and health information about the benefits of HPV vaccination for anal cancer prevention are only reaching a small subset of college-educated GBM. Targeted anal cancer education programs are needed.

Distribution of HPV Genotypes in Patients with a Diagnosis of Anal Cancer in an Italian Region

Objectives: Anal cancer is a rare disease. However, its incidence is increasing in some population groups. Infection caused by Human Papillomavirus (HPV) is strongly associated with the risk of anal cancer, whose variability depends on samples, histology, and HPV detection methods. The aim of the study was to assess prevalence and distribution of HPV genotypes in patients diagnosed with anal carcinoma. Methods: An observational, retrospective study was carried out in a tertiary care hospital in North Sardinia, Italy. Specimens of anal cancer diagnosed from 2002-2018 were selected. Demographic, epidemiological, and clinical variables were collected to assess their relationship with the occurrence of anal cancer. Results: The overall HPV positivity was 70.0% (21/30), with HPV-16 being the predominant genotype (~85%). The highest prevalence of anal cancer was in patients aged ≥55 years. HPV positivity was higher in women (p-value > 0.05) and in moderately differentiated samples (G2) (p-value < 0.05). p16INK4a and E6-transcript positivity were found in 57% and 24% of the HPV positive samples, respectively. The OS (overall survival) showed a not statistically significant difference in prognosis between HPV positive sand negatives (10, 47.6%, vs. 4, 44.4%; p-value = 0.25). Conclusions: HPV-DNA and p16INK4a positivity confirmed the role of HPV in anal carcinoma. Our findings could support the implementation and scale-up of HPV vaccination in males and females to decrease the incidence of HPV-associated cancers. Further studies are needed to better clarify the prognostic role of HPV/p16 status.

Insurance status and level of education predict disparities in receipt of treatment and survival for anal squamous cell carcinoma

INTRODUCTION

Anal squamous cell carcinoma (ASCC) is relatively rare, but its incidence and mortality have been steadily climbing in marginalized populations. We explored the impact of insurance status, education, and income on survival and receipt of chemoradiation therapy.

METHODS

We included patients with ASCC from the Surveillance, Epidemiology, and End Results Program database from 2004 to 2016. Socioeconomic variables included insurance status, level of education, income, and unemployment rate. Cox proportional hazards and multivariate logistic regression were used to determine predictors of survival and receipt of chemoradiation.

RESULTS

We included a total of 10,868 cases of ASCC. The median age was 55, 10.4 % were black, and 65.4 % were female. Overall, 74.1 % of patients received combination chemoradiation. In multivariate analysis, poorer survival was found for Medicaid (HR 1.52, 95 % CI 1.34-1.74) and uninsured (HR 1.68, 95 % CI 1.35-2.10) patients, and for communities with the lowest rates of high school education (HR 1.17, 95 % CI 1.02-1.38), lowest income (HR 1.29, 95 % CI 1.08-1.54), and highest unemployment (HR 1.21, 95 % CI 1.03-1.40). Patients were less likely to receive combination treatment if they were black (OR 0.76, 95 % CI 0.55-0.92), had Medicaid insurance (OR 0.54, 95 % CI 0.33-0.88) or lower education (OR 0.59, 95 % CI 0.46-0.76).

CONCLUSION

Insurance status, level of education, income, and employment impact survival and receipt of treatment in patients with ASCC. Identifying high risk patients and developing targeted interventions to improve access to treatment is integral to reducing these disparities and improving cancer survival.

Lubricant Investigation in Men to Inhibit Transmission of HPV Infection (LIMIT-HPV): design and methods for a randomised controlled trial

INTRODUCTION

Gay, bisexual and other men who have sex with men (gbMSM) have an increased risk of human papillomavirus (HPV) infection and HPV-associated diseases, such as anal cancer and anogenital warts. A carrageenan-based lubricant could prevent HPV infection, thereby reducing the disease burden in this population. This paper describes the protocol for the Lubricant Investigation in Men to Inhibit Transmission of HPV Infection (LIMIT-HPV) study, an ongoing randomised controlled trial (RCT), evaluating efficacy of a carrageenan-based personal lubricant in reducing type-specific anal HPV incidence and prevalence among sexually active gbMSM, efficacy by HIV status, safety and tolerability of the gel and participant adherence to the intervention.

METHODS AND ANALYSIS

The study is a double-blinded, placebo-controlled RCT. Volunteer gbMSM 18 years and older are randomly assigned 1:1 to receive the treatment (a self-applied anal microbicide gel with carrageenan) or placebo (a self-applied placebo gel). At each visit, computerised questionnaires are used to collect data on sociodemographic and clinical variables, lifestyle, sexual behaviour and the gels' safety and tolerability. At baseline and each follow-up visit (months 1, 2, 3, 6, 9 and 12), nurses collect anal specimens tested for 36 HPV types (linear array assay). HIV status is determined at baseline and 12 months. The primary outcome is incidence of type-specific anal HPV infection(s) undetected at baseline. Secondary outcomes are prevalence of type-specific anal HPV infection, safety, tolerability and adherence. We aim to recruit 380 participants to attain the study's objectives. Data will be analysed using intention-to-treat and per-protocol approaches with subgroup analyses by HIV status.

ETHICS AND DISSEMINATION

Ethics approval was obtained by the Research Ethics Boards of McGill University, the McGill University Health Centre, Concordia University and Centre Hospitalier de l'Université de Montréal. Trial results will be disseminated through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT02354144.

HYPHYCA: a prospective study in 613 patients conducting a comprehensive analysis for predictive factors of physiological 18F-FDG anal uptake

Background

Anal cancer is a relatively rare tumor of which incidence increases in developed countries. ¹⁸F-FDG PET has been increasingly used for its post radio-chemotherapy evaluation. However, several authors have reported the risk of local false-positive findings leading to low specificity and positive predictive values. These false-positive results could be due to post-radiotherapy inflammation or infection but certainly also to physiological anal canal uptake that is observed on a regular basis in clinical practice. The purpose of this prospective study (NCT03506529; HYPHYCA) was therefore to seek predictive factors of physiological anal canal hypermetabolism.

Materials and methods

Over a 2-month period, patients aged 18 years old and more, referred for ¹⁸F-FDG PET-CT at two EARL-accredited PET centers were included, after obtaining their informed and written consent. They were asked to fill in a questionnaire including seven closed questions about usual intestinal transit, ongoing medications relative to intestinal transit, history of digestive, and anal and/or pelvic diseases. Age, gender, and body mass index (BMI) were recorded. A single nuclear medicine physician visually and quantitatively analyzed anal canal uptake (SUV_{max_EARL}) and assessed visual rectal content (air, feces, or both) and the largest rectal diameter (mm).

Results

Six hundred and thirteen patients were included (sex ratio F/M = 0.99) and 545 (89%) questionnaires were entirely completed. Significantly more males presented anal canal hypermetabolism (sex ratio (M/F) = 1.18 versus 0.85, p = 0.048). Moreover, patients with anal canal hypermetabolism had higher BMI (27.6 (5.7) kg/m² versus 23.9 (4.5) kg/m², p < 0.0001), higher rate of hemorrhoid history (43% versus 27%, p = 0.016), and higher rate of rectum filled with only feces (21% versus 12%, p = 0.019) as compared to patients with no anal canal uptake. On logistic regression, all these variables were found to be independent predictors of the occurrence of an anal canal hypermetabolism. Odds ratio were 1.16 (1.12–1.20) per unit of BMI (kg/m²) (p < 0.0001), 1.48 (1.04–2.11) for males (p = 0.030), 1.64 (1.10–2.45) for hemorrhoids history (p = 0.016), and 1.94 (1.147–3.22) for the rectum filled with only feces (p = 0.010).

Conclusion

According to our study, the predictive factors of physiological anal canal hypermetabolism are high BMI, male gender, hemorrhoid history, and rectum filled with only feces. This may pave the way to a more specific interpretation of post radio-chemotherapy PET evaluations of anal canal cancer, provided that other studies are conducted in this specific population.

Trial registration

This prospective study was registered at Clinicaltrial.gov: NCT03506529; HYPHYCA on April 24, 2018

Pelvic Exenteration for Anal and Urogenital Squamous Cell Carcinoma: Experience and Outcomes from an Exenteration Unit Over 12 Years

BACKGROUND

Pelvic exenteration has increasingly been shown to improve disease-free and overall survival for patients with locally advanced pelvic malignancies. Squamous cell carcinoma (SCC) is the second most common pelvic malignancy requiring exenteration.

OBJECTIVE

The aim of this study was to report the clinical and oncological outcomes from patients treated with pelvic exenteration for anal and urogenital SCC from a single, high-volume unit.

METHODS

A review of a prospectively maintained database from 1991 to 2018 at a high-volume specialised institution was performed. Primary endpoints included R0 resection rates, local recurrence and overall survival (OS) rates.

RESULTS

From January 1999 to July 2018, 361 patients underwent pelvic exenteration of which 31 patients were identified with SCC (15 anal SCC, 16 urogenital SCC). The majority of patients were females (n = 24, 77.4%). Median age was 59 (range 35-81). Twenty-seven patients underwent resection with curative intent with an R0 resection rate of 81.5%. Four patients underwent a palliative procedure [R1 = 3 (8%), R2 = 1 (3.3%)]. Mean hospital length of stay was 32 days (range 8-122 days). Disease-free survival was significantly increased in anal SCC with no significant difference in OS compared to urogenital SCC (p = 0.03, p = 0.447 respectively). Advanced pathological T stage was associated with decreased OS (p = 0.023). In the curative intent group the disease-free survival and OS rate was 59.3% and 70% at 24 months, respectively.

CONCLUSION

Complete R0 resection is achievable in a high proportion of patients. Urogenital SCC is associated with significantly worse disease-free survival, and advanced T-stage was a significant prognostic factor for OS.

Prevalence and associations of larger burden of intra-anal high-grade squamous intraepithelial lesions at baseline in an Australian cohort of gay and bisexual men: The Study of the Prevention of Anal Cancer

OBJECTIVES

To investigate factors associated with larger burden of intra-anal high-grade squamous intraepithelial lesions (HSIL) in a natural history study of HSIL.

METHODS

617 gay and bisexual men (GBM) attended a baseline visit. High-resolution anoscopy-directed biopsy was performed of suspected HSIL. GBM with biopsy-confirmed HSIL (bHSIL) affecting a single-octant were compared with those who had bHSIL affecting a larger area.

RESULTS

Of 196 men with bHSIL at baseline, 73 (37.2 %) had larger bHSIL burden. Larger burden was independently associated with anal HPV16 detection (aOR 2.06, 95 % CI 1.09-3.89, p = 0.026) and infection with a greater number of high-risk HPV types (aOR per type increase 1.25, 95 % CI 1.05-1.49, p-trend = 0.010).

CONCLUSION

The observation that men with a larger burden of HSIL also had more risk factors for anal cancer suggests this group may warrant closer observation to ensure earlier detection, and thus improved prognosis, of individuals whose HSIL may progress to anal cancer.

Video anoscopy: results of routine anal examination during colonoscopies

Background and study aims  Anal examination and video anoscopy (VA) are rarely performed during colonoscopies. The aim of this study is to demonstrate that anal examination and VA provide important information in all routine colonoscopies. Patients and methods  A cross-sectional study was conducted on 12,151 patients screened by VA which were performed during routine outpatient colonoscopy between 2006 and 2018. The aspects studied were: normal examination; hemorrhoidal disease; thrombosed hemorrhoids; anal fissure; perianal Crohn's Disease; perianal fistula; condyloma; polyps; neoplasms; stenosis; bleeding. Results  Of the colonoscopies performed on 12,151 patients, 9,364 cases (77.06 %) presented some alterations. Internal I degree hemorrhoids (5911 - 48.65 %); internal hemorrhoids of II, III and IV degrees (2362 - 19.44 %); thrombosed hemorrhoids (120 - 0.99 %); bleeding (56 - 0.46 %); fissure (415 - 3.42 %); perianal fistula (42 - 0.35 %); perianal Crohn's Disease (34 - 0.28 %); condylomas (18 - 0.15 %); anal stenosis (30 - 0.25 %); other findings (310 - 2.55 %); polyps (62 - 0.51 %), one of which was adenomatous with high-grade dysplasia; four cases of anal canal neoplasia (0.03 %): two cases of squamous cell carcinoma and two cases of adenocarcinoma. Conclusion  The association of routine video anoscopy during colonoscopy improved diagnosis of neoplastic anal lesions, allowed correct classification of the degree of hemorrhoidal disease, helped to confirm the bleeding site and detected other anal pathologies. The main findings were hemorrhoidal diseases, fissures and perianal fistulas. The study suggests that VA should be used in all colonoscopies.

Diagnosing uncertainty: The challenges of implementing medical screening programs for minority sub-populations in Canada

The social science literature on medical screening has documented a notable disjuncture between the promises of population-based screening programs and the complex realities of their rollout in everyday practice. We contribute to this scholarship by examining how healthcare providers confront numerous uncertainties associated with the implementation of anal cancer screening programs in Canada given the absence of standardized national evidence-based guidelines. The data was derived from in-depth interviews conducted with 13 physicians and 2 clinical researchers about anal cancer screening for gay, bisexual and other men who have sex with men living with HIV, the minority sub-population at the highest risk for HPV-associated anal cancer. Despite having unknown utility and low specificity, an initial anal Pap test was used to triage patients into anal dysplasia clinics for high-resolution anoscopy. This process led to technological scepticism toward the Pap's accuracy, diagnostic ambiguity related to the interpretation of the cytology results and increased patient anxiety regarding abnormal results. Physicians navigated a tension between wanting to avoid exposing their patients to additional uncertainties caused by screening and pre-cancer treatment and wanting to ensure that their patients did not develop anal cancer under their care. A high number of abnormal anal Pap results paradoxically reintroduced some of the capacity issues that the Pap was meant to resolve, as the existing dysplasia clinics were incapable of seeing all patients with abnormal results. We define this sequence as the epistemic-capacity paradox, a dynamic whereby seeking evidence to improve healthcare capacity simultaneously produces evidence that introduces capacity challenges and generates additional uncertainty. The epistemic-capacity paradox demonstrates the limitations of evidence-based medicine frameworks at determining best practices in the context of rarer health conditions affecting minority sub-populations, where smaller population numbers and limited institutional support pose systemic challenges to the acquisition of sufficient evidence.

Socioeconomic disparities in timeliness of care and outcomes for anal cancer patients

Background

Socioeconomic status (SES) is associated with diagnostic and treatment delays and survival in multiple cancers, but less data exist for anal squamous cell carcinoma (ASCC). This study investigated the association between SES and outcomes for patients undergoing definitive chemoradiation therapy for ASCC.

Methods

One hundred and eleven patients diagnosed with nonmetastatic ASCC between 2005 and 2018 were retrospectively reviewed. Socioeconomic predictor variables included primary payer, race, income, employment, and partnership status. Outcomes included the tumor‐node (TN) stage at diagnosis, the duration from diagnosis to treatment initiation, relapse‐free survival (RFS), and overall survival (OS). Age, gender, TN stage, and HIV status were analyzed as covariates in survival analysis.

Results

SES was not associated with the TN stage at diagnosis. SES factors associated with treatment initiation delays were Medicaid payer (P = .016) and single partnership status (P = .016). Compared to privately insured patients, Medicaid patients had lower 2‐year RFS (64.4% vs 93.8%, P = .021) and OS (82.9% vs 93.5%, P = .038). Similarly, relative to patients in the racial majority, racial minority patients had lower 2‐year RFS (53.3% vs 93.5%, P = .001) and OS (73.7% vs 92.6%, P = .008). Race was an independent predictor for both RFS (P = .027) and OS (P = .047).

Conclusions

These results highlight the impact of social contextual factors on health. Interventions targeted at socioeconomically vulnerable populations are needed to reduce disparities in ASCC outcomes.