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Screening for anal cancer in the HIV positive population

  • 1.  Screening for anal cancer in the HIV positive population

    Posted 03-17-2020 08:58
    There is data that suggest that anal cancer rates in the US population has been increasing. A study by Silverberg, MJ et al, 2015, Ann Int Med.;163(7):507–518 revealed that risk among HIV positive MSM is 50 times higher compared to the general US population. My colleagues and myself developed a screening program to address this but did not get the referral numbers to support this program. I would like to know what providers out there are doing in this area and if anyone has any patient who was diagnosed with anal cancer.  Are you screening your patients? if you are doing so, who are you screening, and how are you screening them?

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    Leonard Sowah
    Baltimore MD
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  • 2.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-18-2020 08:58
    Hello,

    I performed anal paps on HIV+ MSM annually and HIV-  MSM every 3yrs. I had two cases last year with LSIL - HPV.  Both patients were referred for anoscopy but didn't follow through on appts. Retaining patients in care has been difficult. I'm not sure if these cases may have progressed on to Anal Cancer. 
    How fast is the transition into cancer?

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    Vickie Cobb-Lucien, APRN, FNP-BC, AACRN
    Orlando, FL
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  • 3.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-19-2020 09:15
    I also have been seeing HIV patients since 1988 and have performed annual digital rectal exams on those who allow. I have had thousands of patients and found only a few cases of anal cancer with the exam and none without the exam. The study that many don't follow up on positive Paps and that there isn't hard evidence of the efficacy of paps I have felt that paps are Over Testing.  I can't find the article now but it said that out of a thousand anal pap smears, 80 would be positive, but just a handful would have found true cancer. The rest would have elevated anxiety, inconvenience, and costs.

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    Daniel Pearce
    Riverside Neighborhood Health Center
    Claremont CA
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  • 4.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-19-2020 11:04
    There is no good data on progression at this time. Most clinicians and researchers in the field will tell you that progression in anal dysplasia is not always linear. Some HGIL would regress even without any clear intervention so this is a field that is still evolving. There are some however who progress to cancer. I used to do anoscopies but not done one in close to 5 years but one case that I followed who was also my own HIV patient progressed to carcinoma in-situ which was excised by a colorectal surgeon. Recently a Danish group published data that suggests that among HIV positives AIN3 has 14% risk of anal cancer in 5 years compared to 3% in HIV negatives. Faber MT, et al,  Cancer Epidemiology and Prevention Biomarkers. 2020 Jan 1;29(1):185-92.
    https://cebp.aacrjournals.org/content/29/1/185?casa_token=02Z3dcr1PZsAAAAA%3A8vg1bl_ia1EntSu3F-mZ4etxI0Vs4HSzGtIbp2FxBatw84w8SSEwDcA66zOWfQQCpb9STvwp_P5eRKEnlg


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    Leonard Sowah
    Baltimore MD
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  • 5.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-20-2020 10:11
    Thank you for your reply​

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    Dr Bob Wallace MD AAHIVS
    Love the Golden Rule, Inc
    St Petersburg, Florida 33713
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  • 6.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-18-2020 08:58
    We are performing anal pap on all HIV positive patients and if positive for  HPV subtypes 16/18/45  and/or abnormal cyto then on to anoscopy but if negative them HPV vaccinations if under 45 currently, dr warner

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    Daniel Warner
    Daniel Warner MD PA
    Flagler Beach FL
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  • 7.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-19-2020 09:16
      |   view attached
    That sounds like a good idea, the guidelines in this field are not really clearly defined and practices tend to differ from place to place. The new recommendation on HPV vaccination definitely would be useful for those who are negative. However with the nonavalent vaccine though there is no research that I know of there is a believe that vaccination may be beneficial even for those who are positive to 16/18/45. The thinking is that the vaccine related risk is low and there could be some efficacy. There is data of benefit beyond age 45 years in men though one study discussed in the attached review went as far as age 66 years. 

    Derstenfeld A, Cullingham K, Ran ZC, Litvinov IV. Review of Evidence and Recommendation for Human Papillomavirus (HPV) Vaccination of Canadian Males Over the Age of 26 Years. Journal of Cutaneous Medicine and Surgery. 2020 Mar 10.

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    Leonard Sowah
    Baltimore MD
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    Attachment(s)

    pdf
    HPVVaccinationReview.pdf   474K 1 version


  • 8.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-19-2020 09:14
    I do anal Pap smears annually on my MSM.

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    Schevaughn Carr-Celestine
    Morris Heights Health Center
    Bronx NY
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  • 9.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-22-2020 08:16
    I do do anal paps on all my MSM, Fenway Health has preliminary guidelines, which tends to indicate yearly for MSM who are HIV+ and every 2 years for MSM who are not HIV positive. I also make sure to vaccinate with HPV vaccines if the individual meets CDC guidelines.. 
    I know the Anchor study is close to being done which should clear up some of the confusion.

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    Erik Wert, DO, MPH, FACOI
    Capital Internal Medicine Associates.
    Lansing, MI
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  • 10.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-23-2020 09:39
    The ANCHOR study should provide a definitive answer to whether screening & Tx of HSIL prevents cancer or not.  The NCI has bet $90M on it.  It will also be our last opportunity to get valuable data on that pathogenesis of anal HPV disease.

    ANCHOR is slated to complete enrolling by the end of this year, but now with all study visits (of nearly all clinical trials, not just ANCHOR) now on indefinite hold due to COVID-19, it could push the study timeline out further depending on how long that lasts.  And it's important to note that ANCHOR will continue for 5 yrs after the last patient is enrolled-- so we're gonna have to wait a long time for results unless an interim DSMB analysis stops it early due to either futility or efficacy.


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    Jeff Taylor
    Palm Springs CA
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  • 11.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-24-2020 10:04

    Jeff thanks for the information, I believe we met at the comorbidities conference in NY last year. I hope ANCHOR provides the well needed evidence on outcomes of anal dysplasia and the value of screening. There are many retrospective studies suggesting progression from HGAIN to anal cancer but ANCHOR will probably be the most important prospective study looking at profession and outcomes of screening and treatment vrs bi screening. 

    Continue, with the great work.



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    Leonard Sowah
    Baltimore MD
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  • 12.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-20-2020 10:11
    We have a robust High-Resolution Anoscopy Program in my clinic. For anal cytology and high risk HPV testing, we screen the following:
    • All HIV+ MSM >30 years old
    • All HIV- MSM >40 years old
    • Younger MSM with HPV-related diseases
    • Women with high-grade cervical/vulvar lesions >40 years old
    • Those who have perianal condyloma
    • All HIV+ women >30 years old (we need to improve more on this)

    For abnormal cytology or presence of hrHPV, we perform HRA.

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    Roque Anthony Velasco
    Palm Springs CA
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  • 13.  RE: Screening for anal cancer in the HIV positive population

    Posted 04-08-2020 17:45
    May I ask whether HPV testing (high risk or specific for HPV 16/18) is paid for by insurance? Which test is used and which laboratory performs it? 
    Thank you
    Ulrike

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    Ulrike Buchwald
    Jenkintown PA
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  • 14.  RE: Screening for anal cancer in the HIV positive population

    Posted 04-15-2020 16:00
    Hi Ulrike:
    Sorry it has taken so long to respond to your question.  So we use Labcorp for both our anal cytology and HPV testing.  I think Quest and several other labs offer it, too.  Insurance coverage for the HPV testing is variable, but most of my patients are Medicare or PPO, and I haven't gotten any complaints from patients re: bills for this testing yet.  I usually only do the HPV testing once with the original Pap, but I don't continue ordering HPV testing in the future, unless there is a good reason to do so.  It might be a small expense for the patient but I think that it gives valuable information, especially in patients who have negative anal cytology or in patients who have types 16 or 18 and might merit closer surveillance or more reason for continued surveillance.  I have taken several patients to HRA w/ just + HPV tests and either no cytology or negative cytology (usually referrals from outside since I believe in doing cytology as a minimum, not HPV testing alone--I only use HPV testing along with the cytology order) and they ended up having high grade disease on HRA with biopsies.  Now whether or not these patients would have progressed to cancer and whether or not I decreased morbidity or mortality with this screening and treatment is yet to be determined, I guess (ie. waiting on ANCHOR results)  I do have to say, though, that I have been successful at knocking disease burden down in patients and have helped to clear their high grade with hyfrecation in many cases.  That is the goal for me, even though metachronous lesions can sometimes occur or recurrence of previously treated areas.  I am definitely a proponent of screening and treatment, though.  It is a tough exam to get good at (HRA), but it's worth the journey, in my opinion.  Thank you, 
    James

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    James Adams
    Rancho Mirage CA
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  • 15.  RE: Screening for anal cancer in the HIV positive population

    Posted 04-15-2020 20:22
    Thank you very much James​, this is very helpful information. Are you ordering the anal cytology and HPV test on the same swab? I assume it is not reflex testing. Do you know whether Quest or LabCorp are using the Roche assay? It is also good to hear that billing has not been an issue.

    I fully agree with the value of anal cancer screening despite uncertainties and need for a better understanding of treatment methods and impact. I have done HRA in Baltimore since 2014 and have identified many high grade disease and CIS and believe the benefitted from the exam and treatment.
    Kind regards,

    Ulrike

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    Ulrike Buchwald
    Jenkintown PA
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  • 16.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-20-2020 10:11
    I would love to perform annual screening  but since we do not have anyone in the area that is willing to perform an anoscopy for abnormal results, we were advised not to start something we can properly follow up on. It's a very unfortunate predicament.

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    Monique Welbeck
    Brooklyn Plaza Medical Center
    Piscataway NJ
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  • 17.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-21-2020 12:22
    Yes MW, that is the rule I have agreed with for years. It took us several years in LA to find a proctologist willing to see our HIV+s with (public insurance) anal findings. The axiom I learned in medical school holds true: Dont order a test if you don't know what you are going to do with it when it is positive.

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    Daniel Pearce, DO FACOI, AAHIVS
    Borrego Community Health Foundation
    San Bernardino, Riverside, San Jacinto California
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  • 18.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-22-2020 08:03
    As a patient advocate, PLWHIV & anal cancer survivor, I strongly advocate that providers not withhold annual anal cytology screenings given the drastically increased risk of morbidity & mortality in PLWHIV.  I've watched too many friends die slow, painful deaths because their dr didn't feel comfortable offering anal cytology because they didn't know where to refer them for abnormal results.  In your region there are many options--including those for pts who are uninsured or whose insurance won't cover anal cytology or HIV.  

    These are some resources for finding HRA practitioners & followup treatment to whom you can refer pts with abnormal cytology results:
     
    The Anchor Study  conducted by the NCI's AIDS Malignancy Consortium conducts free anal pap and HRAs to identify PLWHIV >35 with anal HSIL to enroll in their study.  Volunteers are then randomized to either a treatment arm, or to a SOC observation arm.  Anyone developing cancer is immediately referred to care. The AMC also has a follow up studyto which pts diagnosed with cancer can be referred for treatment: A multicenter observational and feasibility study of excision of superficially invasive squamous cell carcinoma (SISCCA) of the anal canal and perianus in HIV-infected persons. In your region there are study sites at Rutgers, Bronx/Montefiore, Weill Cornell, and Laser Surgery Care Center in Manhattan.  

    International Anal Neoplasia Society

    UCSF Anal Cancer Info










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    Jeff Taylor
    Palm Springs CA
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  • 19.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-23-2020 11:01
    As an evolving HIV provider (I'm a Family Physician), I'm always referring to guidelines for assistance - CDC, WHO, AIDSinfo.nih.gov, AETC, etc. - and am thrilled to see this discussion as it continues to appear shifting & on-going (as all good science should be). I appreciate everyone's personal views & programs and links to what research may be telling us. I am a bit surprised, however about screening MSM who are HIV negative for anal cancer. I continue to review the recommendations for patients with HIV, too. Here's what I found and would like to share. 

    On the CDC website Q&A (https://www.cdc.gov/std/tg2015/qa/screening-qa.htm);

    "Question: What is the recommendation for anal Pap smears in men who have sex with men (MSM) and women who engage in anal sex?

    Currently, there are insufficient data regarding the natural history of HPV infection, and the evolution of anal dysplasia, as well as data regarding the efficacy of anal Pap smears and subsequent interventions for the prevention of anal cancer. This data would be needed to provide recommendations for the use of anal Pap screening in individuals (MSM and women) who have engaged in anal sex.  The prevalence of abnormal Pap smears is high in these populations (particularly in individuals who are HIV+), as is the finding of histologically-confirmed, high-grade disease.  However, it is not known whether treating the high-grade disease prevents anal cancer.  In the meantime, some experts perform anal Pap testing and high-resolution anoscopy (HRA) on their patients as part of regular clinical care.  If an anal Pap program is embarked upon, it is important to set up a system of follow-up for abnormal anal Pap tests (i.e., define referral patterns) prior to initiation of the program, as the frequency of abnormal Pap tests (particularly among HIV+ MSM) is high."


    And for those who are HIV+, this is what I found.

     Aidsinfo.nih.gov (https://aidsinfo.nih.gov/contentfiles/lvguidelines/glchunk/glchunk_343.pdf)

    "At this time, no national recommendations exist for routine
    screening for anal cancer. However, some specialists recommend anal cytologic screening or high resolution
    anoscopy for men and women who are HIV seropositive (CIII). An annual digital anal examination may be
    useful to detect masses on palpation that could be anal cancer (BIII). Screening for anal cancer with anal
    cytology should not be done without the availability of referral for high resolution anoscopy."

    NYS (https://www.hivguidelines.org/hiv-care/anal-dysplasia-cancer/#tab_6)
    Screening
    • For all patients with HIV ≥35 years old, regardless of HPV vaccine status, clinicians should:
      • Inquire annually about anal symptoms, such as itching, bleeding, palpable masses or nodules, pain, tenesmus, or a feeling of rectal fullness. (A2)
      • Perform a visual inspection of the perianal [b] region. (A3)
      • Provide information about anal cancer screening and engage the patient in shared decision-making regarding screening, including anal cytology prior to digital anorectal examination (DARE). (A3)
      • Perform DARE if anal symptoms are present. (A*)

    HOWEVER, given these expert opinions, shared decision-making screening recommendations, I came across this:

    British HIV association https://www.bhiva.org/news-detail.php?news_id=319

    "High-grade anal dysplasia is common among gay men living with HIV, but it often resolves spontaneously and routine treatment may not be beneficial, according to results from the Australian SPANC study presented on Wednesday at the 20th International AIDS Conference (AIDS 2014) in Melbourne."

    It makes me wonder, am I doing harm with screening/testing? Am I causing unnecessary financial strain on patients to do these procedures/screenings. I want to believe I'm providing benefit to patients but am unclear. These few sides below, I think, put things in excellent perspective.

    from AETC (AIDS Education & Training Center) lecture, "Anal Cancer: Should screening be routine?" (https://depts.washington.edu/nwaetc/presentations/uploads/54/anal_cancer_should_screening_be_routine.pdf)
    Check list if screening is beneficial
     
    I welcome your thoughts - thanks for helping me learn, progress and become a better HIV provider!




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    Kurtis Mohr
    Premise Health
    Orlando FL
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  • 20.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-24-2020 10:04
    Your center could consider training and supporting a provider to start screening for the providers in your group. My colleague and myself started such a program in our group. Our process and experience has been published in two articles attached this message. We received funding from Ryan White Part A Quality Improvement Grant for this project. Feel free to contact me if you have any questions.

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    Leonard Sowah
    Baltimore MD
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  • 21.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-23-2020 09:39
    I perform anal paps on all PLWH including women and HIV+ men who do not have sex with men or engage in anal intercourse. There are not any clear guidelines but I usually follow the recommendations out of USCF. Our group has an excellent relationship with a colorectal surgery group that does HRA. We have caught some HGSIL and they were treated by surgery or cauterization, not clear if it prevented progression. But I recently had a patient who had HGSIL on HRA and was recommended to follow up every 6 months, he progressed to invasive carcinoma within 18 months.

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    Quintin Robinson
    Absolute Care Medical Center & Pharmacy
    Atlanta GA
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  • 22.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-24-2020 10:05
    Hey Quintin my friend, good to know you are doing anoscopies, I will like to share a recent study by a Danish group in collaboration with Joel Palefsky which  revealed that 5 year risk of anal cancer in HIV negative patients with AIN3 was about 3% in 5 years compared with 14% for HIV positives. This as far as I know is one of the most compelling data suggesting that screening may be beneficial.

    Faber, Mette T., et al. "Risk of anal cancer following benign anal disease and anal cancer precursor lesions: A Danish nationwide cohort study." Cancer Epidemiology and Prevention Biomarkers 29.1 (2020): 185-192.

    Leonard




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    Leonard Sowah
    Baltimore MD
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  • 23.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-25-2020 09:53
    It baffled me at first why the anus is a site for such cancer in those who do not have intercourse in that area. i now explain it to patients that sex is a wet activity and gravity and friction might move the HPV to that area and that using toilet paper might disrupt the mucosa to help the virus enter.
    Comments?

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    Daniel Pearce, DO FACOI, AAHIVS
    Borrego Community Health Foundation
    San Bernardino, Riverside, San Jacinto California
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  • 24.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-23-2020 15:53
    Great question that has been debated for many years.  Think there is not a great answer.  
    I test all HIV+ MSM every 1-2 years. I have sent many to colo-rectal for follow-up of abnormal Pap's.  
    Sometimes there is nothing to do but follow closely, sometimes biopsy,  or therapeutic biopsy is recommended. 
    I pretty much hand it over to colo-rectal for management once I have an abnormal Pap and follow their recommendation. 

    I have been thinking about starting anal Pap testing on HIV- MSM who come to me for PrEP, though I don't have the data to support this.

    Hopefully, more studies will be avail soon (like the ANCHOR study) for both populations. 
    Seja Jackson, APRN, AAHIVS
    Burgdorf Health Center 
    Hartford, CT

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    Seja Jackson
    Burgdorf Clinic
    Glastonbury CT
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  • 25.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-24-2020 10:04
    The data on HIV negative MSM is weaker, some recommend screening that group but starting at a older age about 40 - 45 years. There is data that suggests their risk of progression is slower.

    Faber, Mette T., et al. "Risk of anal cancer following benign anal disease and anal cancer precursor lesions: A Danish nationwide cohort study." Cancer Epidemiology and Prevention Biomarkers 29.1 (2020): 185-192.



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    Leonard Sowah
    Baltimore MD
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  • 26.  RE: Screening for anal cancer in the HIV positive population

    Posted 03-26-2020 10:23
    Hi everyone, I screen my HIV + patients over 25-30 with anal cytology + HPV testing, and I also do High Resolution Anoscopy and Hyfrecation of High Grade Lesions.  It is not an easy procedure to learn, but there are experts out there who are willing to teach it and they do an amazing job (folks from UCSF like Palefsky, Naomi, Berry, Steve Goldstone from NY, Gary Bucher from NYC ,and the list goes on and on).  I also screen PrEP patients over the age of 40 and I am seeing high grade lesions in HIV negative, sometimes worse than my HIV positive patients.  Also, I have had several patients with anal cancer.  It is a horrible disease process, so whatever we can do to prevent anal cancer for our patients, men and women, should remain a priority.  The data from ANCHOR should be coming in the next few years, but I am optimistic that the results will support what we are doing.

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    James Adams
    Rancho Mirage CA
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  • 27.  RE: Screening for anal cancer in the HIV positive population

    Posted 05-14-2020 15:54
    hello! I'm very interested in this topic. I want to do a systematic review for my DNP on this. I have found one https://www.ncbi.nlm.nih.gov/pubmed/16779751
    that deals with HIV pos people; naturally we worry that PLWHIV would be more at risk but it seems like the data is just not there.
    I would want to perform anal PAP on my patients if I had a clear recommendation of what to do with that information; but it seems this is lacking. ​

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    David Cupit
    Houston TX
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  • 28.  RE: Screening for anal cancer in the HIV positive population

    Posted 05-15-2020 18:14

    Hi David,
    Despite uncertainties in the progression rate of high grade anal dysplasia (HSIL) to anal squamous cell cancer, there is clear evidence that anal SCC incidence is much higher in people living with HIV, esp. with anal receptive intercourse. There is also some evidence that anal cancer screening can have an impact on anal cancer incidence and stage of diagnosis. The ANCHOR study is an ongoing randomized trial to evaluate the impact of HSIL treatment on anal cancer incidence.

    There are several algorithms for anal cancer screening and most start with anal cytology. However, you would need to be able to refer patients with abnormal results for high-resolution anoscopy (HRA). Do you know whether there is any provider in your area offering who is trained in HRA? The University of San Francisco has a website on anal cancer screening which includes a list of HRA providers by state. I think in Houston Baylor College may offer HRA, Elizabeth Chiao is an expert.
    Best wishes,
    Ulrike



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    Ulrike Buchwald
    Jenkintown PA
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