Routine Screening for Anal Cancer: Are We There Yet?

May 9th, 2011

Routine Screening for Anal Cancer: Are We There Yet?

A paper recently published in AIDS evaluated the cost effectiveness of various strategies for anal cancer screening in HIV positive men-who-have-sex-with-men (MSM).

The “bottom line” (ahem):

In HIV-infected MSM, the direct use of high resolution anoscopy is the most cost-effective strategy for detecting anal intraepithelial neoplasia

Over on our Journal Watch AIDS Clinical Care site, Tim Wilkin from Cornell offers his perspective:

High-resolution anoscopy without any prior testing was the most cost-effective of 18 strategies assessed for initial anal cancer screening… This study suggests that direct use of HRA is a reasonable strategy for initial anal cancer screening in a population with a high prevalence of disease. Several other strategies were also effective at a moderate cost, including the one used in my own practice: initial anal cytology, with referral to HRA for individuals found to have atypical squamous cells (ASCUS) or greater.

We covered this area of controversy around a year ago on this site, at which time Joel Gallant admitted to an even less aggressive strategy — namely, not referring patients with ASCUS for HRA at all, but simply monitoring them with yearly pap smears.

His rationale?

My patients don’t enjoy going through HRA, biopsy, and ablation, the parallels between anal and cervical dysplasia aren’t perfect, and the protocols around anal Pap smear are written without much evidence backing them up.

As you might have guessed, I have tremendous ambivalence about what to do about anal cancer screening as of May 9, 2011 (today). On one side: this is a highly morbid (and potentially fatal) complication of HIV, a screening protocol, however vague, is out there, and there are advocates who strongly support screening.

On the other side are the issues cited by Joel, the lack of recommendations for anal cancer screening in published guidelines, and the fact that at one of my two practice sites, there has been no single provider who readily offers HRA.

Just speculation here, but on a national level, this last factor might be the most important driver in how often HRA is done at all.

And just like any situation where test availability drives volume, there’s something not quite right about that.

HIV and ID Observations

An ongoing dialogue on HIV/AIDS, infectious diseases,
all matters medical, and some not so medical.

May 9th, 2011