Size of anal squamous cell carcinomas at diagnosis: a retrospective case series

Anal cancer: a 20-year retrospective study from Australia

BACKGROUNDS

Anal cancer is an uncommon condition, occurring at higher rates in specific subpopulations. Clinical experience is limited and substantial changes have recently occurred in our understanding of this condition. We, therefore, set out to characterize patients presenting with anal cancer and investigate whether there have been any changes over the past 20 years.

METHODS

Retrospective audit of cases identified from pathology and clinical databases during the period 1 January 2000 to 31 December 2019.

RESULTS

Two hundred and sixteen patients had anal squamous cell carcinomas, comprising 160 (74%) males and 56 (26%) females. Mean age at initial diagnosis was 55.1 ± 11.20 for males and 60.6 ± 15.18 for females (P = 0.02). At initial diagnosis, HIV-positive cases were significantly younger than HIV negative cases (mean 52.2 ± 9.35 vs. 62.8 ± 11.61, P < 0.001); 46% of cases were classified as intra-anal, 29% perianal and 25% both; 52% were > 2 cm at diagnosis. At presentation, intra-anal cases were larger and more advanced than perianal cases (P = 0.049). Compared with the period 2000-2009, anal cancers presented more commonly in 2010-2019 (148 vs. 76), were more likely to occur in HIV-negative people and to be diagnosed at a similar stage.

CONCLUSION

The number of anal cancer cases almost doubled over the study period and people living with HIV presented 10 years younger than others. Perianal cases presented earlier than those originating in intra-anal locations. Together with the large size at diagnosis, this suggests the potential value of screening, particularly for intra-anal cancers in those at high risk.

Perianal Malignancies: A Review for the Dermatologic Surgeon

BACKGROUND

Perianal malignancies are rare tumors with unique presentations and treatment options.

OBJECTIVE

To review published literature about primary malignancies that present on perianal skin and published guidelines and treatment options.

MATERIALS AND METHODS

A PubMed search was conducted for original articles about perianal malignancies.

RESULTS

Squamous cell carcinoma, basal cell carcinoma, melanoma, and extramammary Paget disease are the most common tumors to present on perianal skin. Anal squamous cell carcinoma incidence is increasing and certain populations may benefit from screening. Surgical management is often recommended for localized perianal tumors.

CONCLUSION

Dermatologic surgeons should be familiar with the presentation and treatment options available for perianal malignancies.

Digital Anal Rectal Examination Usage Among Individuals at Increased Risk for Anal Cancer

OBJECTIVE

Multiple organizations recommend an annual digital anal rectal examination (DARE) for people at highest risk for anal cancer. The authors assessed DARE usage among sexual minority men and transgender women.

METHODS

Community-recruited and asymptomatic individuals from a mid-sized US city were enrolled into the Prevent Anal Cancer Self-Swab Study, a longitudinal clinical trial of anal cancer screening. Self-reported data from the baseline survey were used to assess usage of DARE in the last year and during the lifetime. Adjusted odds ratios (aORs) and CIs for factors associated with each outcome were determined using multivariable logistic regression.

RESULTS

Among 241 participants, median age was 46 years (interquartile range, 33-57 years), 27.0% were living with HIV, and 24.5% reported a previous diagnosis of anal warts. A total of 13.7% (95% CI = 9.4%-18.0%) of individuals reported a DARE in the previous year, whereas 53.9% (95% CI = 47.7%-60.2%) reported a DARE during the lifetime. The following were associated with a DARE in the previous year: increasing age (aOR = 1.04; 95% CI = 1.01-1.08 for each additional year), any previous anal cytology (aOR = 2.62; 95% CI = 1.19-5.80, compared with no previous test or no knowledge of a test), and preferred receptive position during anal sex (aOR = 4.93; 95% CI = 1.17-20.86 compared with insertive).

CONCLUSIONS

Despite guidelines recommending an annual DARE, it was uncommonly reported. There is an urgent need to understand barriers to conducting DARE among individuals most vulnerable to anal cancer and their health care providers.

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.

Clinical characteristics and prognosis of anal squamous cell carcinoma: a retrospective audit of 144 patients from 11 cancer hospitals in southern China

Background

The incidence of anal squamous cell carcinoma (SCC) has been steadily growing globally in the past decade. Clinical data on anal SCC from China are rare. We conducted this study to describe the clinical and epidemiological characteristics of anal SCC in China and explore prognostic factors of outcomes among patients with anal SCC.

Methods

We audited demographic characteristics, relevant symptoms, risk factors, treatment modalities and outcomes for patients diagnosed with anal SCC at 11 medical institutions in China between January 2007 and July 2018.

Results

A total of 144 patients (109 females) were diagnosed with SCC during this period. Median age at initial diagnosis was 52.0 (interquartile range: 46.0–61.8) years. The most common symptoms were bleeding (n = 93, 64.6%), noticing a lump (n = 49, 34.0%), and pain (n = 47, 32.6%). The proportion of patients at the American Joint Committee on Cancer (AJCC) stages I-IV were 10 (6.9%), 22 (15.3%), 61 (42.4%) and 8 (5.6%), respectively, and AJCC stages in 43 (29.9%) patients were unknown. Thirty-six patients (25.0%) underwent abdominoperineal resection initially. Univariable analysis showed that T stage predicted recurrence-free survival (RFS) (Hazard ratio [HR] = 3.03, 95% Confidence interval [CI]: 1.10–8.37, p = 0.032), and age group (HR = 2.90, 95% CI: 1.12–7.49, p = 0.028), AJCC stage (HR = 4.56, 95% CI: 1.02–20.35, p = 0.046), and N stage (HR = 3.05, 95% CI: 1.07–8.74, p = 0.038) predicted overall survival (OS).

Conclusions

T stage was identified as prognostic factor of RFS, and age, AJCC stage, and N stage were identified as prognostic factors of OS. Improving symptom awareness and earlier presentation among patients potentially at risk for anal SCC should be encouraged. Familiarity with the standard treatment among health care providers in China should be further improved.

The Utility of Digital Anal Rectal Examinations in a Public Health Screening Program for Anal Cancer

OBJECTIVES

There are no uniform screening recommendations for anal cancer. Medical practice guidelines are now available on the use of Digital Anal Rectal Examinations (DARE) for the detection of anal cancer; however, because screening can result in more harm than benefit, our objective was to assess the evidence for use of DARE as a public health screening tool.

MATERIALS AND METHODS

We conducted a current critical appraisal of anal cancer literature using World Health Organization criteria for assessing the potential utility of a public health screening program.

RESULTS

Digital Anal Rectal Examination satisfies most, but not all, World Health Organization criteria for a public health program that seeks to detect early invasive anal cancer in populations at high risk for anal cancer, most notably HIV-positive men who have sex with men; however, DARE is not appropriate when facilities for treatment are nonexistent. In addition, there are insufficient data on DARE sensitivity and specificity.

CONCLUSIONS

The mildly invasive nature of DARE, limited likelihood of adverse procedure-related events, cost-effectiveness and patient acceptability, as well as wide availability of DARE support consideration of its integration into screening for populations at high risk of anal cancer, especially HIV-positive men who have sex with men.

Anal cancer in people living with HIV: A case series

Human papillomavirus (HPV) causes almost 5% of all cancers worldwide including cervical cancer, oropharyngeal cancers, vulval cancer, penile cancer and anal cancer. HPV-associated anal squamous cell carcinoma is a rare occurrence in the general population; however, the incidence is increasing. Certain groups including people living with HIV are disproportionately affected. In this case series, we report baseline demographics, clinical characteristics and outcome of anal cancer cases presenting in people living with HIV over a ten-year period (2006–2015).

Transplant Recipients and Anal Neoplasia Study: Design, Methods, and Participant Characteristics of a Prevalence Study

Supplemental digital content is available in the text.

Kidney recipients have anal cancer rates 3 times higher than the general population in Australia and New Zealand. High-risk human papillomavirus (HPV) genotypes are implicated in the majority of anal cancers. Establishing the epidemiology of anal HPV infection and precursors of anal cancer in transplant recipient populations is 1 consideration in any potential screening program. The Transplant and Anal Neoplasia Study is a cross-sectional study of the prevalence of anal cytological abnormalities and HPV deoxyribonucleic acid in kidney transplant recipients, as well as evaluating the acceptability of an anal cancer screening intervention. The study aims to recruit 100 kidney transplant recipients, older than 18 years, in Australia. Transplant recipients attending for a protocol biopsy at 3 and 12 months and annually posttransplant are approached to participate. Participants undergo an anal swab, which is then analyzed using liquid-based cytological examination and tested for the detection of 37 anogenital HPV deoxyribonucleic acid genotypes. Participants also complete a demographic and behavioral questionnaire that covers sexual behavior, history of anal symptoms, and possible anal cancer risk factors. Associations will be tested using multiple regression analysis. Recruitment for the study began in 2015 and is ongoing. To date, 96 (77%) of 125 kidney transplant recipients approached have consented to the study. The mean age is 48 (median, 47 y; range, 20–76 y), 59% are male, and Northwest European (58%) represented the largest ethnic group. No participants self-identified as Aboriginal or Torres Strait Islander. High consent rates and positive qualitative results suggest that a larger screening program may be well received by kidney transplant recipients, with increased resources and some modification to the timing of approach. Further results of the study will inform the possible implementation of a larger screening trial for prevention of anal cancers in kidney and other solid organ transplant recipients.

Incorporating digital anorectal examinations for anal cancer screening into routine HIV care for men who have sex with men living with HIV: a prospective cohort study

INTRODUCTION

Men who have sex with men (MSM) living with HIV have a high risk of anal cancer, which is often detected at late stages, when morbidity and mortality are high. The objective of this study was to describe the feasibility and challenges to incorporating regular digital anorectal examination (DARE) into routine HIV care for MSM living with HIV, from the perspective of patients, physicians and the health service.

METHODS

In 2014, we recruited 327 MSM living with HIV, aged 35 and above from one major sexual health centre (n = 187), two high HIV caseload general practices (n = 118) and one tertiary hospital (n = 22) in Melbourne, Australia. Men were followed up for two years and DARE was recommended at baseline, year 1 and year 2. Data were collected regarding patient and physician experience, and health service use. An ordered logit model was used to assess the relationship between sociodemographic factors and the number of DAREs performed.

RESULTS

Mean age of men was 51 (SD ± 9) years, 69% were Australian born, 32% current smokers, and mean CD4 was 630 (SD ± 265) cells per mm3 , with no significant differences between clinical sites. Overall, 232 (71%) men received all three DAREs, 71 (22%) received two DAREs, and 24 (7%) had one DARE. Adverse outcomes were rarely reported: anal pain (1.2% of total DAREs), bleeding (0.8%) and not feeling in control of their body during the examination (1.6%). Of 862 DAREs performed, 33 (3.8%) examinations resulted in a referral to a colorectal surgeon. One Stage 1 anal cancer was detected.

CONCLUSION

Incorporation of an early anal cancer detection programme into routine HIV clinical care for MSM living with HIV showed high patient acceptability, uncommon adverse outcomes and specialist referral patterns similar to other cancer screening programmes.

Association of anal symptoms with anal high grade squamous intraepithelial lesions (HSIL) among men who have sex with men: Baseline data from the study of the prevention of anal cancer (SPANC)

BACKGROUND

The association between anal high-grade squamous intraepithelial lesion (HSIL) and anal symptoms has not been systematically investigated.

METHODS

The Study of Prevention of Anal Cancer is a prospective cohort study of men who have sex with men (MSM) ≥ 35 years old in Sydney, Australia. Self-reported symptoms were collected. Anal cytology and high-resolution anoscopy were undertaken. Using baseline visit data, men negative for squamous intra-epithelial lesion (SIL) were compared with men diagnosed with composite-HSIL (cytology and/or histology). Logistic regression analyses were performed to assess the association of symptoms with HSIL.

RESULTS

Among 414 MSM included (composite-HSIL (n = 231); negative for SIL (n = 183)), 306 (73.9%) reported symptom(s) within the last 6 months. There was no association between any symptom and composite-HSIL. A significant association between anal lump and a larger burden of HSIL (at least 2 intra-anal octants) (anal lump within last month: p = 0.014; anal lump within last 6 months: p = 0.010) became non-significant after adjusting for HIV-status and recent anal warts (anal lump within last month: p = 0.057; anal lump within last 6 months: p = 0.182).

CONCLUSIONS

Among MSM age 35 years and older, most anal symptoms are not a useful marker of anal HSIL.

Development and Calibration of a Mathematical Model of Anal Carcinogenesis for High-Risk HIV-Infected Men

OBJECTIVES

Men who have sex with men who are living with HIV are at highest risk for anal cancer. Our objective was to use empirical data to develop a comprehensive disease simulation model that reflects the most current understanding of anal carcinogenesis, which is uniquely positioned to evaluate future anal cancer screening strategies and provide insight on the unobservable course of the disease.

SETTING

North America.

METHODS

The individual-based simulation model was calibrated leveraging primary data from empirical studies, such as a longitudinal HIV-positive men who have sex with men cohort study [Human Immunodeficiency and Papilloma Virus Research Group (HIPVIRG); n = 247] and the North American AIDS Cohort Collaboration on Research and Design [(NA-ACCORD); n = 13,146]. We used the model to infer unobservable progression probabilities from high-grade precancer to invasive anal cancer by CD4 nadir and human papillomavirus (HPV) genotype.

RESULTS

The calibrated model had good correspondence to data on genotype- and age-specific HPV prevalence; genotype frequency in precancer and cancer; and age- and nadir CD4-specific cancer incidence. The model-projected progression probabilities differed substantially by HPV genotype and nadir CD4 status. For example, among individuals with CD4 nadir <200, the median monthly progression probability from a high-grade lesion to invasive cancer was 0.054% (ie, 6.28% 10-year probability) and 0.004% (ie, 0.48% 10-year probability) for men with an HPV-16 infection versus without a detectable HPV infection, respectively.

CONCLUSIONS

We synthesized existing evidence into a state-of-the-art anal cancer disease simulation model that will be used to quantify the tradeoffs of harms and benefits of alternative strategies, understand critical uncertainties, and inform national anal cancer prevention policy.

Cost-effectiveness of screening for anal cancer using regular digital ano-rectal examinations in men who have sex with men living with HIV

Introduction

Anal cancer in men who have sex with men (MSM) living with HIV is an important issue but there are no consistent guidelines for how to screen for this cancer. In settings where screening with anal cytology is unavailable, regular anal examinations have been proposed in some guidelines but their cost-effectiveness is unknown.

Methods

Our objective was to estimate the cost-effectiveness of regular anal examinations to screen for anal cancer in HIV-positive MSM living in Australia using a probabilistic Markov model. Data sources were based on the medical literature and a clinical trial of HIV-positive MSM receiving an annual anal examination in Australia. The main outcome measures for calculating effectiveness were undiscounted and discounted (at 3%) lifetime costs, life years gained, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratio (ICER).

Results

Base-case analysis estimated the average cost of screening for and management of anal cancer ranged from $195 for no screening to $1,915 for lifetime annual screening of men aged ≥ 50. Screening of men aged ≥ 50 generated ICERs of $29,760 per QALY gained (for screening every four years), $32,222 (every three years) and $45,484 (every two years). Uncertainty for ICERs was mostly influenced by the cost (financially and decrease in quality of life) from a false-positive result, progression rate of anal cancer, specificity of the anal examination, the probability of detection outside a screening program and the discount rate.

Conclusions

Screening for anal cancer by incorporating regular anal examinations into routine HIV care for MSM aged ≥ 50 is most likely to be cost-effective by conventional standards. Given that anal pap smears are not widely available yet in many clinical settings, regular anal exams for MSM living with HIV to detect anal cancer earlier should be implemented.

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.

Exposing the gaps in awareness, knowledge and estimation of risk for anal cancer in men who have sex with men living with HIV: a cross-sectional survey in Australia

Introduction

The incidence of anal cancer is significantly higher in men who have sex with men (MSM) living with HIV when compared to the general population. We aimed to assess their awareness, knowledge and perceived level of personal risk for anal cancer to help inform educational strategies targeting this group.

Methods

A cross-sectional study of 327 HIV positive MSM in Melbourne, Australia, attending clinical settings (a sexual health centre, tertiary hospital HIV outpatients and high HIV caseload general practices) completed a written questionnaire in 2013/14. Poor knowledge was defined as those who had never heard of anal cancer, or scored 5 or less out of 10 in knowledge questions amongst those who reported ever hearing about anal cancer. Underestimation of risk was defined as considering themselves as having the same or lower risk for anal cancer compared to the general population.

Results

Of 72% (95% confidence interval (CI): 67–77) who had heard of anal cancer, 47% (95% CI: 41–53) could not identify any risk factors for anal cancer. Of total men surveyed, 51% (95% CI: 46–57) underestimated their risk for anal cancer. Multivariate analysis showed that men who underestimated their risk were older (OR 1.04 (per year increase in age), 95% CI: 1.01–1.07), had poor anal cancer knowledge (OR 2.06, 95% CI: 1.21–3.51), and more likely to have ever had an anal examination (OR 2.41, 95% CI: 1.18–4.93). They were less likely to consult a physician if they had an anal abnormality (OR 0.54, 95% CI: 0.31–0.96), to have had receptive anal sex (OR 0.12, 95% CI: 0.02–0.59) or speak English at home (OR 0.28, 95% CI: 0.09–0.90).

Conclusions

This survey of MSM living with HIV demonstrated limited awareness, knowledge level and estimation of risk for anal cancer. Further educational and public health initiatives are urgently needed to improve knowledge and understanding of anal cancer risk in MSM living with HIV.

HPV and anal cancer in HIV-infected individuals: a review

HIV infection is one of the strongest risk factors for anal squamous cell cancer (ASCC). Most ASCC are caused by HPV, and most HPV-associated ASCC are caused by HPV-16. Anal HPV infections are very common in men who have sex with men (MSM), and nearly universal among HIV-infected MSM. High-grade anal intraepithelial neoplasia (HGAIN), the precursor for ASCC, is present in about 30 % of HIV+ MSM, but neither the progression rate to ASCC nor the regression rate are known. The incidence rate of ASCC among HIV-infected people has risen in the first decade after cART became available, but appears to be plateauing recently. Anal cytology has poor sensitivity and specificity. High resolution anoscopy (HRA) is advocated by some as a screening tool in high-risk groups, but is cumbersome and time-consuming and it is unknown whether HRA followed by treatment of HGAIN prevents ASCC. More research is needed on progression and regression rates of HGAIN, on effective therapy of HGAIN, and on biomarkers that predict HGAIN or anal cancer. HPV vaccination and earlier start of cART may prevent most anal cancers in the long run.

Why are we not screening for anal cancer routinely - HIV physicians' perspectives on anal cancer and its screening in HIV-positive men who have sex with men: a qualitative study

Background

Anal cancer is a priority health issue in HIV positive men who have sex with men. Anal cancer screening may be aimed at either detecting the precursor lesion (high grade anal intraepithelial neoplasia(HGAIN)) or early anal cancer. To date no qualitative study has explored the views of HIV physicians regarding anal cancer and its screening.

Methods

We conducted indepth interviews with 20 HIV physicians (Infectious diseases, Immunology, Sexual health, General practice) in different settings (hospital, sexual health centres, general practice) from around Australia. Framework analysis was used to identify themes.

Results

HIV physicians viewed anal cancer as a significant health issue and all agreed on the importance of anal cancer screening amongst HIV positive MSM if a valid screening method was available. Barriers for utilizing anal cytology was based primarily on the theme of insufficient evidence (e.g. no studies demonstrating reduction in mortality following screening or effective treatments for HGAIN). Barriers for utilizing DARE for early cancer detection were based on systemic factors (e.g. lack of opportunity, lack of priority, differences in HIV care practices); health provider factors (lack of evidence, difficulty discussing with patients, lack of confidence in DARE) and patient factors (perceived discomfort of DARE for patients, low anal cancer risk awareness). Physicians were willing to consider the idea of patient self-examination and partner-examination although concerns were raised regarding its reliability and issues surrounding partner dynamics.

Conclusions

HIV physicians remain ambivalent regarding the most effective means to screen for anal cancer. More research is needed to address the physicians’ concerns before anal cancer screening can be implemented into routine HIV care.

Exploring anal self-examination as a means of screening for anal cancer in HIV positive men who have sex with men: a qualitative study

BACKGROUND

Anal cancer is relatively common in HIV-positive men who have sex with men(MSM). However there are no clear guidelines on how to effectively screen for anal cancer. As earlier diagnosis of anal cancer is associated with increased survival, innovative ways such as utilizing anal self-examination to identify anal cancer should be explored.

METHOD

Semi-structured interviews were conducted with 20 HIV-positive MSM from a range of ages (35 to 78 years). This study explored acceptability and barriers to implementing ASE as a method of anal cancer screening. Framework analysis was used to identify themes.

RESULTS

Seventeen out of 20 men had conducted an ASE before--six (35%) were for medical reasons, six (35%) for sexual reasons, three (18%) for both medical and sexual reasons, and two (12%) for cleaning purposes. Only 5 men were currently confident in detecting an abnormality. Whilst men were generally comfortable with the idea of utilizing ASE as a means for detecting anal cancer, potential barriers identified operated at three levels: attitudinal (discomfort with any anal examinations, anxiety about finding an abnormality, preference for health professional examination), knowledge (lack of awareness of anal cancer risk and ignorance of anal cancer symptoms) and practical (inadequate physical flexibility, importance of hygiene).

CONCLUSION

ASE may be an acceptable means for anal cancer detection in HIV-positive MSM but training in detecting abnormalities is needed. The preference for health professional examination and inadequate physical flexibility may preclude its use for some men. Future trials to confirm its wider acceptability will be needed before undertaking an effectiveness trial for detecting anal cancer.

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.

Acceptability of digital anal cancer screening examinations in HIV-positive homosexual men

OBJECTIVES

Anal cancer is more common in HIV-positive homosexual men than in HIV-negative homosexual men and the general population. Earlier diagnosis leads to improved prognosis. We aimed to determine if regular anal inspection and digital examination of asymptomatic homosexual men attending for routine HIV care were acceptable and to record the rate of referral for diagnosis of potentially malignant anal lesions.

METHODS

We offered anal examinations to consecutive homosexual men with HIV infection aged ≥ 35 years during their routine HIV clinic visits, aiming to complete three examinations over a 12-month period. Acceptability questionnaires were completed at baseline and after each examination and doctors recorded examination findings and all resulting interventions. Hospital referral outcomes were collected and interventions were costed using the Australian Medical Benefits Schedule.

RESULTS

Of 142 men who were offered enrolment in the study, 102 [72%; 95% confidence interval (CI) 64-79%] participated. Following the initial anal examinations, four men were referred to surgeons. Cancer was excluded in three men (3%; 95% CI 1-8%) and one was diagnosed with anal squamous cell carcinoma (SCC). Three men had anoscopy performed at the time and two were referred for colonoscopy. Ninety-eight per cent (95% CI 93-100%) of respondents said that they would probably have the examination next time. The intervention was estimated to cost approximately Australian $16 per examination.

CONCLUSIONS

Regular anal digital examinations are an acceptable and inexpensive addition to the routine care of homosexual men with HIV infection.