Evaluating the performance of anal cytology and high-risk HPV genotyping for detecting anal HSIL in a clinic-based sample of people living with and without HIV in Puerto Rico

BACKGROUND

Given the disproportionately elevated anal cancer risk in high-risk populations, it is important to assess the performance of commonly used anal cancer screening tools to improve the effectiveness of detection and treatment methods. This study evaluates 1) the concordance between anal cytology and histology results and 2) the performance of cytology and high-risk human papillomavirus (HR-HPV) genotyping as screening tools for detecting histologically confirmed anal high-grade squamous intraepithelial lesions (HSIL).

METHODS

Data from the Anal Neoplasia Clinic in Puerto Rico (2014-2021; n = 466) was used. The clinical performance of anal cytology and HR-HPV genotyping to detect HSIL was compared to the gold standard: high-resolution anoscopy-guided biopsy. Sensitivity, specificity, positive predictive value, negative predictive value, and κ coefficients were calculated.

RESULTS

A total of 66.95% of the patients were men, 74.0% were people living with HIV, 76.2% had anal HR-HPV infection, and 40.34% had histologically confirmed anal HSIL. The weighted κ statistic between the tests (cytology and histology) was 0.25 (p < .001). The sensitivity and specificity of cytology alone to detect anal HSIL were 84.3% (95% confidence interval [CI], 78.3%-89.1%) and 36.0% (95% CI, 30.3%-42.0%), respectively. Anal HR-HPV genotyping had higher sensitivity (92.2%; 95% CI, 87.4%-95.6%) and similar specificity (34.8%; 95% CI, 29.2%-40.7%) compared to cytology. The two tests combined (positive results following cytology or HR-HPV test) improved sensitivity to detect anal HSIL (97.9%; 95% CI, 94.8%-99.4%), but specificity was compromised (19.2%; 95% CI, 14.7%-24.4%).

CONCLUSION

Although HR-HPV genotyping improved the detection of anal HSIL, HR-HPV testing had lower specificity than anal cytology alone.

Integration of human papillomavirus associated anal cancer screening into HIV care and treatment program in Pakistan: perceptions of policymakers, managers, and care providers

BACKGROUND

The incidence of anal cancer, largely associated with anal human papillomavirus (HPV) infection, is increasing among men who have sex with men (MSM), and transgender women living with or without HIV. Screening for anal cancer to detect anal precancerous lesions in high-risk groups is an important opportunity for prevention but still lacking in many low-and-middle-income countries. The aim of this study was to explore the readiness of Pakistan's healthcare system to integrate anal cancer and HPV screening into a national HIV program, as perceived by policymakers, health managers, and healthcare providers.

DESIGN

This qualitative study using key-informant interviews with participants influence in policy making, implementation and advocacy from public and private sector were conducted between March 2021 to August 2021 in Karachi Pakistan.

METHODS

Key informants were purposely selected from different domains of the healthcare system responsible for the target group of interest, MSM and transgender-women in general and people living with HIV in particular. A total of 18 key informants, at different levels of seniority were recruited from governmental and non-governmental organizations, high-level infectious disease healthcare managers, and United Nations Program representatives. Qualitative content analysis was used to identify the manifest and latent themes, based on socioecological framework.

RESULTS

The results were grouped into five major themes; (1) The policy context and priorities, (2) Health systems factors, (3) Community environment, (4) Healthcare setting & providers and (5) Individual-level obstacles. The policy actors expressed their concerns about their limited voice in country's health and health related priority setting. Informants reported a lack of political will and suggested that government should bring a change in the paradigm of healthcare service delivery from reactive to proactive approach. Although, participants unanimously favored integration of HPV preventive services into existing HIV program, they also identified several service delivery barriers including trained workforce shortage, limited capacity of information technology, lack of supplies needed for screening, lack of financing, and lack of services that could meet key-populations needs. Participants also predicted other implementation challenges such as stigma, social victimization, and systemic discrimination against at-risk groups at healthcare facilities.

CONCLUSION

Although policy makers and health providers in Pakistan saw a clear need to scale-up and integrate anal cancer screening for key populations, the feasibility of this is dependent on political will, financing, anti-stigma and discrimination interventions and health system efficiency.

Anal cancer screening and prevention: a review for dermatologists

The incidence of and mortality from anal cancer, predominantly squamous cell carcinoma (SCC), have been increasing since the 1980s, during an era when many common malignancies have seen decreases in mortality. Dermatologists may be more likely to see patients at an increased risk for anal SCC, such as those living with HIV, MSM and those presenting for management of anogenital warts, yet there is little guidance in the field on how to manage these patients. We underwent a project to review the evidence surrounding screening and prevention of anal SCC. HPV vaccination, the main preventative measure for anal SCC, is often underutilized and may not be effective for those most at risk. Screening methods currently include high-risk HPV and anal cytology testing, with high-resolution anoscopy (HRA) reserved for biopsy and confirmatory testing. High-risk HPV testing has been associated with high sensitivity for intraepithelial neoplasia, but low specificity in high-risk groups. Recent meta-analyses examining AIN detection using anal cytology estimate a similarly high sensitivity of 74-87%, with a relatively higher specificity (44-66%) for identifying high-grade AIN. HRA is the gold standard for diagnosis, but its accessibility and cost are deterrents from its use as a screening tool. Cervical cancer screening, initially adopted without significant evidence of its impact, has significantly decreased cervical cancer rates. The argument can be made that rates of anal SCC may also benefit from appropriate screening methods, particularly anal cytology. It is prudent for dermatologists to be aware of the methods available to them in the management of at-risk patients, the data supporting them, and the potential benefits of screening in order to counsel patients appropriately and address the increasing burden of disease.

"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.

Peripheral inflammatory biomarkers as predictors of recurrence in surgically-treated anogenital condylomata acuminata patients

The aim of this study was to examine the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) in patients with anogenital condylomata acuminata (CA) and their association with recurrence and squamous intraepithelial neoplasia development. We conducted a descriptive study in 95 patients that had undergone surgical treatment for CA. The descriptive data, disease characteristics, and pre-treatment peripheral inflammatory biomarkers (PIBs) were recorded retrospectively. All parameters were compared in those with recurrent and non-recurrent CA. All PIBs were significantly higher in patients with the greatest genital wart size of >2 cm in the squamous intraepithelial lesion (SIL) group. Human papillomavirus (HPV) types 16, 18, 31 and 33, known to carry high risk for anogenital cancer, were significantly related to higher SII. Greater wart size, high-grade squamous intraepithelial lesion (HSIL), and higher PLR and SII values were highly associated with recurrent disease (p = 0.003, 0.006, 0.005 and 0.000, respectively). Of all recurrences, 34.1% were explained by HSIL and increased PLR and SII values. The prediction of CA recurrence is important to determine those patients at high risk. PLR and SII can be used for risk analysis in selected patient groups.

[The consensus of the Portuguese Society of Andrology, Sexual Medicine and Reproduction on Male HPV: diagnosis]

HPV infection affects about 50% of sexually active individuals at least once in a lifetime. Diagnosis is made on careful inspection of the genital area and can be divided into benign lesions (genital warts or condyloma acuminatum) and pre-malignant lesions (intraepithelial neoplasia) that can lead to cancer (invasive neoplasia). Diagnostic recommendations are reviewed in Male, Female, Couple and in the immunocompromised host. Recent histological concepts are also discussed.

The Accuracy of Anal Swab-Based Tests to Detect High-Grade Anal Intraepithelial Neoplasia in HIV-Infected Patients: A Systematic Review and Meta-analysis

Background

The incidence of high-risk human papillomavirus (HR-HPV)–induced anal cancer is increasingly problematic among HIV-positive patients. Anal cancer is preceded by precursor lesions, anal intraepithelial neoplasia (AIN). AIN detection requires high-resolution anoscopy, a cumbersome and time-consuming procedure. We aggregated evidence on anal swab–based tests to detect AIN in HIV-positive patients.

Methods

We searched MEDLINE and EMBASE for cross-sectional studies on AIN detection with anal cytology, HR-HPV DNA detection, HPV E6/E7 mRNA analysis, and P16INK4a and Ki-67 immunostaining. Summary estimates of sensitivity and specificity were calculated using bivariate logistic regression. Cytology was reported using the terms squamous intra-epithelial lesion (SIL) for AIN and high-grade SIL (HSIL) for high-grade AIN (HGAIN).

Results

We included 22 studies. Using cytology with a cutoff of any SIL to detect HGAIN, we detected a sensitivity of 82% (95% CI, 74%–87%) and specificity of 45% (95% CI, 44%–66%); with the cutoff of HSIL, the sensitivity was 44% (95% CI, 45%–67%) and the specificity was 79% (95% CI, 69%-87%). The sensitivity of HPV DNA to detect HGAIN was 91% (95% CI, 82%–95%) and the specificity was 27% (95% CI, 21%–33%). For MSM, the positive predictive value (PPV) of cytology with a cutoff of any SIL was 36% (95% CI, 23%–50%) and the negative predictive value (NPV) was 87% (95% CI, 78%–93%), whereas cytology with a cutoff of HSIL had a PPV of 62% (95% CI, 50%–73%) and an NPV of 78% (95% CI, 65%–87%). The PPV of HR-HPV DNA detection was 37% (95% CI, 20%–57%) and the NPV was 87% (95% CI, 79%–93%).

Conclusions

Given its sensitivity, cytology with a cutoff of any SIL could be considered as a triaging method, whereas cytology with a cutoff of HSIL had better specificity and could be used for quality assurance. HR-HPV DNA detection had poor specificity and PPV, making it unsuitable for triage.

History of High-Resolution Anoscopy

High-resolution anoscopy (HRA) is a form of low-resolution anal microscopy currently utilized in the screening and management of anal squamous dysplasia. No randomized controlled trials, national or international guidelines exist on the use of HRA for this purpose. Much of our understanding of this entity has been adapted from the literature on cervical squamous dysplasia, including the technique of HRA itself. Epidemiologic evidence has shown that the prevalence and incidence of anal dysplasia is highest in HIV-positive populations. The history of this technique parallels the evolution of our understanding of anal dysplasia. To understand the history of the use of HRA and its place in the screening and management of anal squamous dysplasia, we discuss key advances in the understanding of human papillomavirus-related squamous dysplasia. We begin with early reports in the field establishing the link between this virus and squamous dysplasia, through the marked increase in anal cancer seen with the onset of the HIV epidemic, the identification of relevant populations at risk, the performance of the test itself, to its use today.

Clinical evaluation of anal intraepithelial neoplasia: are we missing the boat?

BACKGROUND

Anal intraepithelial neoplasia (AIN) is dysplasia in the epithelium of the anus and is a pre-malignant condition associated with a low rate of progression to invasive squamous cell carcinoma (SCC). The natural history of progression for AIN to anal SCC is poorly defined. This study aims to review our experience with AIN and investigate the natural history of progression.

METHODS

Data on all patients with AIN from January 2005 to December 2015 were retrospectively reviewed. Three separate databases were searched - Colorectal, Radiation Oncology and Infectious Diseases. All databases were cross-referred to obtain a complete but non-duplicated data set. Electronic charts were reviewed to obtain clinical information.

RESULTS

Twenty-eight patients were identified with AIN of various grades. There were 25 males, three females. Twenty of the male patients were human immunodeficiency virus (HIV) positive. Mean length of follow up was 56 months. Complete regression of AIN to normal was noted in 13 patients (46%). Four patients had persisting AIN III with no evidence of regression or malignant transformation. Nine patients with pre-existing AIN developed SCC (32%). Seven were positive for HIV infection (all males). Median time to progression was 36 months. None of the patients demonstrated clear linear pattern of progression of AIN to SCC.

CONCLUSION

High grade AIN may progress to anal SCC and surveillance is indicated. The exact natural history of progression for AIN is difficult to predict. There is no linear progression over time evident. HIV patients with AIN are at higher risk of developing SCC.

Acceptability of high-resolution anoscopy for anal cancer screening in HIV-infected patients

OBJECTIVES

HIV-infected individuals are at increased risk of anal cancer. Screening for anal cancer precursors using high-resolution anoscopy (HRA) may be clinically beneficial. In this study, we examined patient tolerability of this procedure.

METHODS

The acceptability of HRA was evaluated among HIV-infected patients who completed a first-time HRA between July 2008 and December 2013 at Kaiser Permanente Northern California. We reviewed electronic medical records to identify lack of HRA acceptability, which was defined as receipt of HRA with sedation, dispensation of opioid analgaesia, and/or an urgent care visit following HRA, and to evaluate factors associated with patients not returning for a recommended repeat HRA (proxy for HRA acceptability). HRA acceptability was also assessed via a survey mailed to patients who completed HRA between January 2014 and August 2014. Logistic regression was used to model lack of acceptability of initial HRA and likelihood of not returning for a repeat HRA.

RESULTS

Of 1857 HIV-infected patients, 94 were prescribed opioids and one had an urgent care visit. Lack of HRA acceptability was more likely in patients with pre-existing anal conditions [e.g. warts or fissure; adjusted odds ratio (aOR) 4.02; 95% confidence interval (CI) 2.4-6.7], those who had ever smoked (aOR 1.6; 95% CI 1.0-2.5) and women (aOR 5.3; 95% CI 1.6-17.5). Fifty per cent of patients returned for a repeat HRA, with younger patients less likely to return (per 10-year age interval, aOR 0.8; 95% CI 0.7-0.9). Of 48 survey respondents, 91.7% reported acceptable pain levels and all reported willingness to return for a repeat HRA.

CONCLUSIONS

HRA was generally well tolerated and may be an acceptable screening approach for patients at high risk of anal cancer.

Human Immunodeficiency Virus/AIDS, Human Papillomavirus, and Anal Cancer

Anal cancer is an increasingly common non-AIDS-defining cancer among individuals infected with the human immunodeficiency virus (HIV). It is associated with human papillomavirus (HPV). HPV16 is the most common genotype detected in anal cancers. The HPV types detected in anal cancer are included in the 9-valent vaccine. HPV vaccines have demonstrated efficacy in reducing anal precancerous lesions in HIV-infected individuals. Standard treatment has been fluorouracil and mitomycin (or cisplatin) plus radiation. Continued studies are needed to test new treatment strategies in HIV-infected patients with anal cancer to determine which treatment protocols provide the best therapeutic index.

Anal human papillomavirus infection: prevalence, diagnosis and treatment of related lesions

Human papillomavirus (HPV) infection is mostly asymptomatic, but may also have many diverse clinical signs encompassing benign ano-genital lesions, and carcinomas. Recently, interest has also particularly focused on anal cancer since, over the last decades, its incidence has been greatly increasing in developed countries, both in women and men and is drastically higher in specific risk groups, such as men who have sex with men (MSM) and HIV-1 infected individuals. Approximately 88% of anal cancer cases worldwide are associated with HPV infection. This review summarizes our current understanding of anal HPV infection, discussing its epidemiology and risk factors in various populations, and the state of the art in the detection of anal HPV infection and its related lesions through both cytology and histology. Finally, we discuss the clinical management and therapy for these lesions.

HPV Update: Vaccination, Screening, and Associated Disease

Human papillomavirus (HPV) infection is the causative agent in cervical cancer, and is associated with numerous other genital cancers, including vulvar, vaginal, and anal cancer. Primary prevention with HPV vaccination is safe and efficacious, and a recently approved HPV vaccine will provide even more extensive protection against several oncogenic HPV strains. Screening strategies for HPV are rapidly evolving, reflecting the essential role that HPV infection plays in cervical cancer. This article highlights new evidence regarding the efficacy of the recently approved 9-valent HPV (9vHPV) vaccine and the use of primary high-risk HPV testing in cervical cancer screening. We consider the utility of urinary HPV testing in routine clinical practice and review current guidelines regarding anal HPV screening.

Gay and Bisexual Men's Willingness to Use a Self-Collected Anal Cancer Screening Test

OBJECTIVE

We investigated gay and bisexual men's willingness to self-administer an anal cancer screening test at home.

METHODS

We conducted 2 national, online cross-sectional surveys of self-identified gay and bisexual men: Study I in 2009 with men ages 20 to 59 (n = 306) and Study II in 2013 with men ages 18 to 26 (n = 428). We used multivariate logistic regression analyses to determine variables associated with willingness to self-administer the screening test.

RESULTS

Most men were willing to self-administer an anal cancer screening test (78% Study I; 67% Study II). In Study I, willingness was higher among men who trusted anal Paps to find treatable cancer (adjusted odds ratio [aOR] = 1.47; 95% CI, 1.04-2.09) and who believed that men who have sex with men should be screened for anal cancer between 1 and 3 years vs. other intervals (aOR = 2.19; 95% CI, 1.17-4.10). In Study II, willingness was higher among men who perceived greater likelihood of anal cancer (aOR = 1.57; 95% CI, 1.12-2.20). Their most common concerns were not performing the test correctly and inaccuracy of results.

CONCLUSIONS

Many gay and bisexual men were willing to self-administer anal cancer screening tests at home. If routine screening is warranted, self-collected home testing could improve participation.

The value of a transformation zone component in anal cytology to detect HSIL

BACKGROUND

In a cytology-based screening program intended to prevent anal cancer, the anal transformation zone (TZ) should be adequately sampled because it is the site most susceptible to the development of the cancer precursor, high-grade squamous intraepithelial lesion (HSIL). An adequate TZ component is defined as comprising at least 10 rectal columnar or squamous metaplastic cells. In the current study, the authors examined whether the presence of a TZ component in anal cytology correlated with the detection of histological HSIL.

METHODS

In a natural history study of anal human papillomavirus infection in homosexual men, all participants underwent liquid-based cytology and high-resolution anoscopy (HRA) with or without biopsy at each visit. True-negative cytology (negative cytology with non-HSIL biopsy or negative HRA), false-negative cytology (negative cytology with HSIL biopsy), and true-positive cytology (abnormal cytology with HSIL biopsy) were compared with regard to the presence or absence of a TZ component.

RESULTS

Of 617 participants, baseline results included 155 true-positive results, 191 true-negative results, and 31 false-negative results. The absence of an adequate TZ component was found to be significantly higher for false-negative (32.3%) than for either true-positive (11.0%; P = .0034) or true-negative (13.1%; P = .0089) results.

CONCLUSIONS

Significantly more false-negative cases lacked a TZ component compared with either true-positive or true-negative cases. TZ cells may be an important indicator of sample quality for anal cytology because, unlike cervical sampling, the anal canal is not visualized during cytology sampling. Cancer Cytopathol 2016;124:596-601. © 2016 American Cancer Society.

[Effectiveness of human papillomavirus genotyping for detection of high-grade anal intraepithelial neoplasia compared to anal cytology]

INTRODUCTION

The incidence of high-grade anal intraepithelial neoplasia (HGAIN) -with an aetiological based on high-risk types of human papillomavirus- is increasing in some high-risk groups. Screening for HGAIN includes routine anal cytology and, more recently, HPV genotyping. The main objective of this study was to determine the sensitivity and specificity of anal cytology and HPV genotyping for the detection of HGAIN.

MATERIALS AND METHODS

This is a study to determine the correlation of cytological and microbiological findings with anal biopsy findings in a cohort of patients at high risk of developing AIN referred to the department of sexually transmitted infections of the Hospital Costa del Sol, Spain, between January 2008 and December 2014.

RESULTS

Of the 151 patients subjected to screening, a total of 92 patients, all of them with the result of three screening test (anal cytology, genotyping and biopsy) were included in the study. Just under two-thirds (62%) of them were HIV-positive. The sensitivity and specificity of anal cytology to detect HGAIN were 52.8 and 85.7%, respectively (k: 0.328), and 78 and 62.8% to detect two or more HPV oncogenic genotypes (k: 0.417). The detection of oncogenic HPV genotypes allowed the identification of 23 new cases of HGAIN that had been underdiagnosed with anal cytology, with 14 cases containing at least three high-risk genotypes.

CONCLUSION

Anal cytology did not show enough sensitivity in HGAIN screening. HPV genotyping has shown to be a useful tool to detect HGAIN cases, although it could lead to an over-diagnosis as a solitary screening procedure.

Is there a role for the thinprep imaging system in reporting anal cytology?

BACKGROUND

The ThinPrep Imaging System (TIS) is an accurate time-saving method of reading cervical ThinPrep slides in screening programs. As anal and cervical cytology are morphologically similar, TIS can potentially be used for anal cytology. We assessed the performance of TIS on anal ThinPrep slides from homosexual men in a natural history study of human papillomavirus-related anal abnormalities.

METHODS

Four hundred nineteen anal cytology slides were processed by TIS and classified by a cytologist as either No further review (slide archived) or Manual review (slide requiring full manual screen). The results were compared with the original manual screening report for all slides and specifically for those screening episodes accompanied by a high-grade squamous intraepithelial lesion (HSIL) on concurrent biopsy.

RESULTS

One hundred seventy six of 419 (42.0%) slides were classified as No further review, with a trend of decreasing proportions as the degree of severity of the cytological abnormality increased. Thirteen (27.7%) slides with an original unsatisfactory report were classified as No further review. Eighty two (92.1%) of those with biopsy HSIL and cytological abnormality were classified for Manual review, including all 45 (100%) with cytological HSIL.

CONCLUSION

The cervical algorithm of TIS performed best on anal samples when HSIL was present both cytologically and histologically. The 27.7% unsatisfactory slides classified as No further review may indicate need for use of different criteria from cervical cytology. Because of the high prevalence of abnormalities, and hence the large proportion of slides needing manual review, the cytologist time-saving would compare unfavorably with use of TIS in cervical screening.

Loss of histone variant macroH2A2 expression associates with progression of anal neoplasm

Aims

The macroH2A histone variants are epigenetic marks for inactivated chromatin. In this study, we examined the expression of macroH2A2 in anal neoplasm from anal intraepithelial neoplasia (AIN) to anal squamous cell carcinoma (SCC).

Methods

AIN and anal SCC samples were analysed for macroH2A2 expression, HIV and human papilloma virus (HPV). The association of macroH2A2 expression with clinical grade, disease recurrence, overall survival and viral involvement was determined.

Results

macroH2A2 was expressed in normal squamous tissue and lower grade AIN (I and II). Expression was lost in 38% of high-grade AIN (III) and 71% of anal SCC (p=0.002). Patients with AIN with macroH2A2-negative lesions showed earlier recurrence than those with macroH2A2-positive neoplasm (p=0.017). With anal SCC, macroH2A2 loss was more prevalent in the HPV-negative tumours.

Conclusions

Loss of histone variant macroH2A2 expression is associated with the progression of anal neoplasm and can be used as a prognostic biomarker for high-grade AIN and SCC.

Baseline findings from the Anal Cancer Examination (ACE) study: screening using digital ano-rectal examination in HIV-positive men who have sex with men

OBJECTIVE

Cytological screening for anal cancer precursors is not always possible. We investigated digital ano-rectal examination (DARE) as a means of early anal cancer detection in HIV-positive men who have sex with men (MSM).

METHODS

We recruited 327 HIV-positive MSM aged 35 and over from clinics with HIV physicians in Melbourne, Australia, to receive an annual DARE. We analyzed baseline data from patient questionnaires regarding general, anal and sexual health, adverse effects from the anal examination, cancer worry, and quality of life.

RESULTS

The majority of men (82%, 95% CI:78-87) felt relaxed during the DARE, 1% (95% CI:0-3) complained of pain, and 1% (95% CI:0-4) reported bleeding after the examination. Nearly all men (99%, 95% CI:96-100) were willing to continue with an annual DARE. Quality of life was unaffected with utility scores of 0.76 before examination vs. 0.77 two weeks after examination, (p = 0.41). An anal abnormality was detected in 86 men (27%, 95% CI:22-31), with one anal cancer identified. The specialist referral rate following DARE was 5% (95% CI:3-8). Recruitment rates were significantly associated with the clinic setting (sexual health centre 78%, general practice 13%, hospital 14%, p = 0.002) and specialty (sexual health physician 67%, general practitioner 20%, infectious disease physician 14%, p = 0.031).

CONCLUSION

Annual DARE to detect anal cancer in HIV-positive MSM was acceptable for patients, with minimal side effects. Strategies to increase HIV physician's patient recruitment would be needed if DARE were to be implemented in anal cancer screening.

Oncogenic human papillomavirus is not helpful for cytology screening of the precursor lesions of anal cancers in Taiwanese men who are infected with human immunodeficiency virus

BACKGROUND

Homosexual men infected with human immunodeficiency virus (HIV) are at increased risk of developing anal cancer. The aim of this study was to assess the clinical sensitivity of anal cytology analysis and oncogenic human papillomavirus (HPV) detection for predicting histological anal intraepithelial neoplasia.

METHODS

Between March 2011 and December 2013, we enrolled 196 HIV-positive men in Taoyuan General Hospital, Taiwan. We analyzed the results of thin-preparation anal Pap smears, HPV genotyping, and histology of anoscopic biopsy samples.

RESULTS

The mean age (±standard deviation) was 31.43 (±8.74) years. The proportion (95 % confidence interval) with abnormal thin-preparation anal cytology was 36.2 % (29.8-43.2 %): 16.8 % (12.2-22.7 %) atypical squamous cells of undetermined significance, 14.8 % (10.5-20.4 %) low-grade squamous intraepithelial lesions, and 4.6 % (2.4-8.5 %) high-grade squamous intraepithelial lesions. At least one HPV genotype was detected in 90.8 % of subjects, and the mean number of HPV infection types was 4.41 (±3.24).The frequency of histological high-grade anal intraepithelial lesions was 7.14 % (95 % confidence interval 4.3-11.6 %). Anal cytology yielding atypical squamous cells of undetermined significance or higher grades resulted in a sensitivity of 64.3 %, specificity of 65.9 %, positive predictive value of 12.7 %, and negative predictive value of 96 %. Using both oncogenic HPV and cytology did not provide better performance.

CONCLUSIONS

Anal cytology yielding atypical squamous cells of undetermined significance or higher grades could detect two-thirds of high-grade anal intraepithelial neoplasias in HIV-infected men and should be promoted for anal cancer prevention.

High-resolution anoscopy or expectant management for anal intraepithelial neoplasia for the prevention of anal cancer: is there really a difference?

BACKGROUND

High-resolution anoscopy has been shown to improve identification of anal intraepithelial neoplasia but a reduction in progression to anal squamous-cell cancer has not been substantiated when serial high-resolution anoscopy is compared with traditional expectant management.

OBJECTIVE

The aim of this study was to compare high-resolution anoscopy versus expectant management for the surveillance of anal intraepithelial neoplasia and the prevention of anal cancer.

DESIGN

This is a retrospective review of all patients who presented with anal squamous dysplasia, positive anal Pap smears, or anal squamous-cell cancer from 2007 to 2013.

SETTING

This study was performed in the colorectal department of a university-affiliated, tertiary care hospital.

PATIENTS

Included patients had biopsy-proven anal intraepithelial neoplasia from 2007 to 2013.

INTERVENTIONS

Patients were treated with high-resolution anoscopy with ablation or standard anoscopy with ablation. Both groups were treated with imiquimod and followed every 6 months indefinitely.

MAIN OUTCOME MEASURES

The incidence of anal squamous-cell cancer in each group was the primary end point.

RESULTS

From 2007 to 2013, 424 patients with anal squamous dysplasia were seen in the clinic (high-resolution anoscopy, 220; expectant management, 204). Three patients (high-resolution anoscopy, 1; expectant management, 2) progressed to anal squamous-cell cancer; 2 were noncompliant with follow-up and with HIV treatment, and the third was allergic to imiquimod and refused to take topical 5-fluorouracil. The 5-year progression rate was 6.0% (95% CI, 1.5-24.6) for expectant management and 4.5% (95% CI, 0.7-30.8) for high-resolution anoscopy (p = 0.37).

LIMITATIONS

This was a retrospective review. There is potential for selection and referral bias. Because of the rarity of the outcome, the study may be underpowered.

CONCLUSIONS

Patients with squamous-cell dysplasia followed with expectant management or high-resolution anoscopy rarely develop squamous-cell cancer if they are compliant with the protocol. The cost, morbidity, and value of high-resolution anoscopy should be further evaluated in lieu of these findings.

Regional and national guideline recommendations for digital ano-rectal examination as a means for anal cancer screening in HIV positive men who have sex with men: a systematic review

Background

Although anal cancer is common in HIV positive men who have sex with men, few centres offer systematic screening. Regular digital ano-rectal examination (DARE) is a type of screening that has been recommended by some experts. How widely this forms part of HIV management guidelines is unclear.

Methods

The protocol was registered prospectively (CRD42013005188; http://www.crd.york.ac.uk/PROSPERO/). We systematically reviewed 121 regional and national HIV guidelines and searched for guidelines from http://hivinsite.ucsf.edu/global?page=cr-00-04#SauguidelineX, PubMed and Web of Science databases up to 5^th August 2013 for recommendations of DARE as a means of anal cancer screening in HIV positive MSM. Guidelines were examined in detail if they were clinical guidelines, including both prevention and treatment protocols and were in English. Guidelines were excluded if they were restricted to limited areas (e.g. antiretroviral therapy only, children or pregnant women, strategies for prevention/testing). Information was extracted regarding recommendation of DARE as a screening method, the frequency of DARE recommended, target population for screening and the strength of evidence supporting this.

Results

30 regional and national guidelines were included and examined in detail. Only 2 recommended DARE. The ‘European AIDS Clinical Society Guidelines’ recommends DARE every 1–3 years for HIV positive MSM whilst the ‘US Guideline for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents’ recommends an annual DARE for the HIV + population in general. None of these guidelines specify the age of commencing screening. In each case, the highest level of evidence supporting these two recommendations was expert opinion.

Conclusions

Few HIV guidelines discuss or recommend DARE as a means of anal cancer screening. Studies of the efficacy, acceptability and cost-effectiveness of DARE are needed to assess its role in anal cancer screening.

Human papillomavirus-related cancers among people living with AIDS in Puerto Rico

The objective of this study was to estimate the incidence of cancer and human papillomavirus (HPV)–related cancers and the risk of death (by cancer status) among people living with AIDS (PLWA) in Puerto Rico. We used data from the Puerto Rico AIDS Surveillance Program and Central Cancer Registry (1985–2005). Cancers with highest incidence were cervix (299.6/100,000) for women and oral cavity/oropharynx for men (150.0/100,000); the greatest excess of cancer incidence for men (standardized incidence ratio, 86.8) and women (standardized incidence ratio, 52.8) was for anal cancer. PLWA who developed a cancer had decreased survival and increased risk of death compared with those who did not have cancer. Cancer control strategies for PLWA will be essential for improving their disease survival.

Can an asymptomatic screening pathway for men who have sex with men be introduced safely at a level 3 sexual health service in the UK?

Summary

To manage the rising demand on sexual health services in the UK, many clinics have introduced asymptomatic screening pathways for heterosexuals, which omit examination. In men who have sex with men however the screening of extragenital sites poses additional challenges. This study aimed to establish whether omitting examination of asymptomatic men who have sex with men would lead to clinically significant diagnoses being missed. The notes of all men who have sex with men who attended a UK level 3 sexual health clinic between 1 July 2011 and 30 June 2012 were retrospectively reviewed. Exclusion criteria included HIV-positive patients attending for HIV-related care, attendances for follow-up consultations not requiring a full sexual health screen, symptomatic patients, contacts of sexually transmitted infections and patients requesting an examination or a repeat prescription of a regularly used medication. In all, 920 consultations occurred during 12 months, of which 893 were reviewed; 476 (53.3%) consultations would have been eligible for screening on an asymptomatic pathway and, of these, 21 (4.4%) had abnormalities found at examination. Findings included genital warts, minor dermatological conditions and three cases of minor asymptomatic urological conditions. There were no clinically significant findings on examination of asymptomatic men who have sex with men requiring treatment, indicating that examination in this cohort may be of little benefit.