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 routinescreening for anal cancer. However, some specialists recommend anal cytologic screening or high resolutionanoscopy for men and women who are HIV seropositive (CIII). An annual digital anal examination may beuseful to detect masses on palpation that could be anal cancer (BIII). Screening for anal cancer with analcytology 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)
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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Original Message:
Sent: 03-22-2020 03:02
From: Jeff Taylor
Subject: Screening for anal cancer in the HIV positive population
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:
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Jeff Taylor
Palm Springs CA
Original Message:
Sent: 03-21-2020 09:58
From: Daniel Pearce
Subject: Screening for anal cancer in the HIV positive population
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
Original Message:
Sent: 03-20-2020 08:23
From: Monique Welbeck
Subject: Screening for anal cancer in the HIV positive population
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
Original Message:
Sent: 03-17-2020 07:05
From: Leonard Sowah
Subject: Screening for anal cancer in the HIV positive population
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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