Anal Cancer Screening in HIV-Infected Patients: Is It Time to Screen Them All?

1 Department of Medicine, Rochester General Hospital, Rochester, New York 2 Anal Dysplasia Clinic, University of Rochester Medical Center, Rochester, New York 3 Infectious Diseases Division, University of Rochester Medical Center, Rochester, New York 4 Department of Surgery, University of Rochester Medical Center, Rochester, New York 5 AIDS Care, Rochester, New York.
Diseases of the Colon & Rectum (Impact Factor: 3.75). 12/2012; 55(12):1244-50. DOI: 10.1097/DCR.0b013e31826ab4fb
Source: PubMed


: Annual screening for anal cancer is recommended only for HIV patients at increased risk: men who have sex with men, individuals with a history of anogenital warts, and women with cervical dysplasia.
: The aim of this study was to examine the screening outcomes between HIV populations with and without these risk factors.
: We reviewed the records of all HIV patients referred for anal cytology and high-resolution anoscopy from June 2009 to June 2010. Patients were stratified into an increased-risk group or a standard-risk group.
: Of the 329 evaluable patients, 285 (89.8% men, 10.2% women, mean age 46 ± 10 years) were classified to the increased-risk group, whereas 44 (72.7% men, 27.3% women, mean age 52 ± 8 years) were included in the standard-risk group. Male sex, white race, sexual orientation, past and current receptive anal intercourse, noncompliance with condom use, and absence of a new sexual partner were significantly different in the increased-risk group in comparison with the standard-risk group. In the increased-risk group, 187 (66.5%) patients had biopsy-proven dysplasia of which 118 (42.0%) had high-grade disease. In the standard-risk group, 15 (34.9%) patients had biopsy-proven dysplasia of which 7 (16.3%) had high-grade disease. Cytology detected biopsy-confirmed high-grade dysplasia only in 23 of 118 (19.5%) patients in the increased-risk group and in 2 of 7 (28.6%) patients in the standard-risk group. Kappa agreement in detecting high-grade disease was low for both increased-risk and standard-risk groups: 0.16 (95% CI 0.07-0.23) and 0.40 (95% CI 0.02-0.40).
: Our study is a chart-based retrospective review of data with a small female population. Histology reports came from 2 different laboratories.
: High-grade anal dysplasia was prevalent even among HIV patients who only have standard risk factors. Anal cytology and high-resolution anoscopy have poor agreement. We suggest considering annual screening by using high-resolution anoscopy in addition to cytology for all HIV patients regardless of risk factors.

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    ABSTRACT: To determine rates of anal dysplasia in a cohort of HIV-infected MSM, women, and heterosexual men with abnormal anal cytology. We evaluated histologic findings in 728 HIV-infected MSM, women, and heterosexual men referred for high-resolution anoscopy (HRA) after abnormal anal cytology in a single-center cohort study. Using multivariable logistic regression, we evaluated predictors of high-grade squamous intraepithelial lesion (HSIL) histology or invasive carcinoma including age, sexual behavior, receptive anal intercourse (RAI), anogenital warts, smoking status, antiretroviral therapy, CD4 T-cell count, and HIV-1 plasma viral load. A total of 2075 HIV-positive patients were screened with anal cytology and 62% of MSM, 42% of women, and 29% of heterosexual men had abnormal findings (P <0.001). Of the 728 HIV-infected patients with abnormal anal cytology who underwent HRA, 71% were MSM, 23% women, and 6% heterosexual men. HSIL/cancer was found in 32% of MSM, 26% of women, and 23% of heterosexual men (P = 0.3). There were five cases of anal squamous cell carcinoma (0.7%), four in MSM and one in a heterosexual man. In a multivariable adjusted analysis, biopsy-proven HSIL/cancer was associated with RAI [odds ratio (OR) 2.2; 95% confidence interval (CI) 1.3-3.7]. CD4 T-cell counts more than 500/μl conferred a lower risk of HSIL/cancer (OR 0.5; 95% CI 0.3-0.9). Rates of anal HSIL histology are high in HIV-infected patients of all sexual risk groups with abnormal anal cytology. Consequently, all HIV-infected patients may warrant anal cancer screening.
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    ABSTRACT: The incidence of anal cancer is higher in women than men in the general population and has been increasing for several decades. Similar to cervical cancer, most anal cancers are associated with human papillomavirus (HPV), and it is believed that anal cancers are preceded by anal high-grade squamous intraepithelial lesions (HSIL). Our goals were to summarize the literature on anal cancer, HSIL, and HPV infection in women and to provide screening recommendations in women. A group of experts convened by the American Society for Colposcopy and Cervical Pathology and the International Anal Neoplasia Society reviewed the literature on anal HPV infection, anal SIL, and anal cancer in women. Anal HPV infection is common in women but is relatively transient in most. The risk of anal HSIL and cancer varies considerably by risk group, with human immunodeficiency virus-infected women and those with a history of lower genital tract neoplasia at highest risk compared with the general population. While there are no data yet to demonstrate that identification and treatment of anal HSIL leads to reduced risk of anal cancer, women in groups at the highest risk should be queried for anal cancer symptoms and required to have digital anorectal examinations to detect anal cancers. Human immunodeficiency virus-infected women and women with lower genital tract neoplasia may be considered for screening with anal cytology with triage to treatment if HSIL is diagnosed. Healthy women with no known risk factors or anal cancer symptoms do not need to be routinely screened for anal cancer or anal HSIL.
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