The role of cytology (Pap tests) and human papillomavirus testing in anal cancer screening

Screening for anal neoplasia: anal cytology - sampling, processing and reporting

Anorectal cytology (ARC) is increasingly accepted as a valid screening tool for the diagnosis of squamous intraepithelial lesions in populations at increased risk for anal cancer. As with cervical cancer screening protocols, proper patient preparation, specimen collection and specimen processing are essential for obtaining an optimal cytological sample. With attention and experience, the clinician can collect the best possible ARC specimen for laboratory evaluation. The incorporation of repeated interval anal cytology into standard surveillance practices for high-risk individuals is a valuable tool for the early detection of human papillomavirus-related anal squamous epithelial lesions and the prevention of anal squamous cell carcinomas.

Prevalence and predictors of high-grade anal intraepithelial neoplasia in a community-based sample of homosexual men

BACKGROUND

We report the prevalence and predictors for high-grade anal intraepithelial neoplasia (HGAIN) in community-based cohorts of HIV-negative and HIV-positive homosexual men in Sydney, Australia.

METHODS

A cross-sectional study of consecutive participants in both cohorts was performed in 2005 (204 HIV-negative and 128 HIV-positive men). Anal swabs collected by a research nurse underwent cytological analysis, using the ThinPrep procedure, and human papillomavirus (HPV) testing. Participants who had cytological abnormalities other than low-grade squamous epithelial lesions (SIL) were referred for high resolution anoscopy (HRA).

RESULTS

A total of 114 men had cytological abnormalities (24.3% of HIV-negative and 57.5% of HIV-positive men, odds ratio (OR)=4.21, 95% confidence interval (CI) 2.57-6.90). However, only three (2.3%) HIV-positive men and no HIV-negative men had high-grade SIL on anal cytology. Seventy-seven men were referred for HRA, of whom 63 (81.8%) attended. Histologically confirmed HGAIN was detected in 21 (33.3%). The prevalence of HGAIN was higher in HIV-positive men (10.8%) than in HIV-negative men (5.0%, OR=2.29, 95% CI 0.93-5.63, P=0.071). HGAIN was not related to age but was strongly associated with the detection of high-risk types of anal HPV (OR=10.1, 95% CI 1.33-76.2) rather than low-risk types (OR=1.97, 95% CI 0.74-5.25).

CONCLUSION

HGAIN was prevalent in homosexual men across all age groups and was more than twice as common in HIV-positive men compared with HIV-negative men. The presence of high-risk anal HPV was highly predictive of HGAIN.

Anal cytology as a predictor of anal intraepithelial neoplasia in HIV-positive men and women

Human immunodeficiency virus (HIV)-infected individuals have increased risk of anal intraepithelial neoplasia (AIN) and squamous cell carcinoma (SCC). Cytologic screening is invaluable in the detection of cervical neoplasia, therefore many clinicians have adopted anal cytology as part of anal cancer screening in patients at high-risk for anal neoplasia. The purpose of this study is to determine whether anal cytology is a valuable screening test for identifying AIN in HIV+ patients. The cohort included 228 HIV+ patients who underwent anal cancer screening with collection of 318 anal cytology specimens between January 2006 and December 2009. Of this group, 74 (32.5%) patients had associated anal biopsies within a 6-month period, with a total of 89 comparison cases. The anal cytology samples were classified using the 2001 Bethesda System terminology. The sensitivity of anal cytology in detecting ASC-US, AIN 1-3 or SCC was 93%. Cytology was 88% sensitive for detecting low-grade AIN (AIN 1), but only 20% sensitive for detecting high-grade AIN (AIN 2-3) or SCC. Atypical squamous cells of undetermined significance cases were distributed evenly between low- and high-grade AIN, with two cases having normal histology. Only six cases had negative cytology, all of which were associated with AIN on biopsy, for a false negative rate of 7%. Anal cytology is a good predictor of AIN, as confirmed by the high degree of sensitivity. However, there is poor correlation between the cytological and histological grade of AIN. Cytology underestimates the grade of dysplasia compared to the corresponding biopsy.

The role of human papillomavirus in nongenital cancers

Human papillomavirus (HPV), one of the most common sexually transmitted diseases worldwide, has an established role in the pathogenesis of genital malignancies such as cervical cancer. The virus has also been implicated in the oncogenesis of nongenital cancers including head and neck malignancies (specifically oropharyngeal cancers) as well as anal cancer. There is less clarity regarding its role in lung and esophageal cancers. Worldwide, the incidence and prevalence of HPV-associated oropharyngeal cancer has been increasing over time. These patients have improved outcomes compared with those with HPV-negative oropharyngeal cancers, and there is continued interest in designing treatments specifically for this HPV-positive subgroup. Clinicians continue to gain an understanding of HPV in anal cancers and the risk factors associated with infection and progression to malignancy. This has potential implications for the eventual screening of high-risk groups. While HPV vaccination is currently approved for the prevention of cervical cancer, it also has potential in the prevention of all HPV-associated malignancies. In this review, current understanding of the role of HPV in nongenital cancers is discussed, as well as future implications for treatment and prevention.

Presence of high-risk human papillomavirus genotype and human immunodeficiency virus DNA in anal high-grade and low-grade squamous intraepithelial lesions

Human immunodeficiency virus type 1 (HIV)-infected individuals are at risk for anal cancer, which is caused by human papillomavirus (HPV). The relationship between HIV and HPV that leads to anal cancer remains unclear. Recent data, however, suggest that the continued persistence of HIV DNA in patients treated with combined antiretroviral therapy leads to progression of HIV disease and other HIV-associated complications. Therefore, we investigated the relationship among anal low- and high-grade squamous intraepithelial lesions (LGSIL/HGSIL), high-risk HPV genotypes, and high HIV DNA copy numbers. Anal cytology specimens were assayed for HPV genotype and HIV DNA copy number. High-risk HPV genotypes (odds ratio OR: 3.73; 95% confidence interval CI: 1.08-12.91; p=0.04) and high HIV DNA copy numbers (OR(per 100 HIV DNA copies): 1.13; 95% CI: 1.01-1.27, p=0.04) were both associated with LGSIL/HGSIL. When considering both high-risk HPV genotypes and HIV DNA copy numbers in predicting LGSIL/HGSIL, HIV DNA copy number was significant (OR(per 100 HIV DNA copies): 1.09; 95% CI: 0.96-1.23, p=0.04) but not high-risk HPV genotypes (OR: 2.30, p=0.28), which did not change when adjusted for nadir CD4 cell count and HIV RNA levels. The findings warrant further investigation of HIV DNA and its relationship with HPV in LGSIL/HGSIL pathogenesis.

Risk factors for abnormal anal cytology over time in HIV-infected women

OBJECTIVE

The objective of the study was to assess the incidence of, and risk factors for, abnormal anal cytology and anal intraepithelial neoplasia (AIN) 2-3 in human immunodeficiency virus (HIV)-infected women.

STUDY DESIGN

This prospective study assessed 100 HIV-infected women with anal and cervical specimens for cytology and high-risk human papillomavirus (HPV) testing over 3 semiannual visits.

RESULTS

Thirty-three women were diagnosed with an anal cytologic abnormality at least once. Anal cytology abnormality was associated with current CD4 count less than 200 cells/mm(3), anal HPV infection, and a history of other sexually transmitted infections (STIs). Twelve subjects were diagnosed with AIN2-3: 4 after AIN1 diagnosis and 4 after 1 or more negative anal cytology. AIN2-3 trended toward an association with history of cervical cytologic abnormality and history of STI.

CONCLUSION

Repeated annual anal cytology screening for HIV-infected women, particularly for those with increased immunosuppression, anal and/or cervical HPV, a history of other STIs, or abnormal cervical cytology, will increase the likelihood of detecting AIN2-3.

Relative accuracy of cervical and anal cytology for detection of high grade lesions by colposcope guided biopsy: a cut-point meta-analytic comparison

Background

We recently reported, using a receiver operating characteristic area metric, the first meta-analytic comparison of the relative accuracy of cervical and anal cytology in detecting moderate or severe histopathologic lesions by magnification directed punch biopsy. The aim of the present research was to meta-analytically examine cut-point specific operating characteristics (sensitivity, specificity) of cervical and anal cytology in detecting high grade squamous intraepithelial lesion (HSIL) histopathology by colposcope directed punch biopsy.

Methodology/Principal Findings

The primary eligibility requirement was availability of tabulated cytology (normal, atypical cells of unclear significance [ASCUS], low grade squamous intraepithelial lesion, HSIL or atypical squamous cells cannot rule out high grade [ASC-H]) and biopsy (<HSIL, ≥ HSIL) counts. Meta-analysis and meta-regression of diagnostic accuracy was performed with examination of study quality criteria and heterogeneity. Thirty-three cervical and 11 anal publications were eligible between 1990 and 2010. Meta-analytically cut-point analysis showed that using a cut-point of ASCUS the sensitivity in both settings is similar while anal cytology is less specific than cervical cytology (specificity [95% confidence interval] 0.33 [0.20–0.49] vs. 0.53[0.40–0.66], p = 0.04) for the detection of HSIL histopathology by colposcope directed punch biopsy.

Conclusions/Significance

Using a cytology cut-point of HSIL or ASC-H, anal cytology is less sensitive but comparably specific to cervical cytology. However, using a cut-point of ASCUS, differences in accuracy were of borderline significance.

Association of human papillomavirus infection and abnormal anal cytology among HIV-infected MSM in Beijing, China

Background

In the recent years, dramatic increases in HIV transmission among men who have sex with men (MSM) have been observed in China. Human papillomavirus (HPV) infection related anal cancer is more common among HIV-infected MSM as compared to the general population. However, HPV infection and anal cytology has been rarely studied in HIV-infected MSM in China.

Methods

HIV-infected MSM in Beijing, China were invited to participate in this study between January and April 2011. Anal swabs were collected for examining cytology and HPV genotypes.

Results

Ninety-five eligible participants with complete questionnaire and laboratory data were included in the analyses. Thirty six of them (37.9%) showed abnormal anal cytology as follows: atypical squamous cells of undetermined significance (ASC-US) in 19 (20.0%), atypical squamous cells but cannot exclude HSIL (ASC-H) in 1 (1.1%), low-grade squamous intraepithelial lesion (LSIL) in 15 (15.8%), and high-grade squamous intraepithelial lesion (HSIL) in 1 (1.1%). HPV6 (20.0%), HPV16 (10.9%), HPV56 (10.9%), HPV52 (9.1%) and HPV39 (9.1%) were observed most frequently among those with normal anal cytology, while different distribution was found in the ones with abnormal anal cytology as HPV6 (19.4%), HPV16 (19.4%), HPV45 (16.7%), HPV52 (16.7%) and HPV18 (11.1%). In addition, HPV16, HPV45, HPV52 and HPV18 were the most frequent high-risk types in patients with abnormal anal cytology. HPV multiplicity was found to be significantly related to the prevalence of abnormal anal cytology (p for trend = 0.04).

Conclusions

High prevalence of HPV infection and abnormal anal cytology was observed among HIV-infected MSM in China. Infection of multiple HPV types or high-risk types was found to be associated with an increased risk of abnormal anal cytology.

Assessing urine human papillomavirus polymerase chain reaction testing as a tool for screening anal HPV infection in HIV-positive MSM

Multiple types of human papillomavirus (HPV) are responsible for most cervical cancers but also cause anal cancers-especially in HIV-positive patients. Furthermore, men who have sex with men (MSM) are twice as likely to develop anal cancers as non-MSM. A simple screening test for HPV infection would be useful in these patients. The aim of our study was to evaluate the detection of HPV by real-time polymerase chain reaction (PCR) in urine as a marker of anal infection in MSM. The study included 52 HIV-positive MSM treated at Amiens University Hospital (Amiens, France). After obtaining informed consent, we performed an anal swab and gathered 10 mL of first-void urine. Samples were extracted and amplified in a real-time PCR. Genotypes were determined with a PapilloCheck(®) system (Greiner Bio-One, Frickenhausen, Germany). The anal test was the gold standard for calculating the characteristics of the urine test. The sensitivity of the urine test for diagnosing anal HPV infection was 15%, the specificity was 66%, the positive predictive value was 87.5%, and negative predictive value was 4.5%. The prevalence of anal HPV infection in the study population was 94%. Genotype 42 was the most common. The anal HPV viral load was significantly lower in men in a stable relationship than in single men. However, there was no statistically significant relationship between anal viral load and anal intraepithelial lesions. We conclude that urine-based HPV is a poor predictor of anal HPV infection in HIV-positive MSM.

Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis

BACKGROUND

Men who have sex with men (MSM) are at greatly increased risk of human papillomavirus (HPV)-associated anal cancer. Screening for the presumed cancer precursor, high-grade anal intraepithelial neoplasia (AIN), followed by treatment in a manner analogous to cervical screening, has been proposed. We aimed to assess available data for anal HPV disease that can inform pre-cancer screening programmes.

METHODS

We searched PubMed, OVID Medline, and Embase for all studies published before Nov 1, 2011, that reported prevalence and incidence of anal HPV detection, AIN, and anal cancer in MSM. We calculated summary estimates using random-effects meta-analysis.

FINDINGS

53 studies met the inclusion criteria, including 31 estimates of HPV prevalence, 19 estimates of cytological abnormalities, eight estimates of histological abnormalities, and nine estimates of anal cancer incidence. Data for incident HPV and high-grade AIN were scarce. In HIV-positive men, the pooled prevalence of anal HPV-16 was 35·4% (95% CI 32·9-37·9). In the only published estimate, incidence of anal HPV-16 was 13·0% (9·6-17·6), and clearance occurred in 14·6% (10·2-21·2) of men per year. The pooled prevalence of histological high-grade AIN was 29·1% (22·8-35·4) with incidences of 8·5% (6·9-10·4) and 15·4% (11·8-19·8) per year in two estimates. The pooled anal cancer incidence was 45·9 per 100,000 men (31·2-60·3). In HIV-negative men, the pooled prevalence of anal HPV-16 was 12·5% (9·8-15·4). Incidence of HPV-16 was 11·8% (9·2-14·9) and 5·8% (1·9-13·5) of men per year in two estimates. The pooled prevalence of histological high-grade AIN was 21·5% (13·7-29·3), with incidence of 3·3% (2·2-4·7) and 6·0% (4·2-8·1) per year in two estimates. Anal cancer incidence was 5·1 per 100,000 men (0-11·5; based on two estimates). There were no published estimates of high-grade AIN regression.

INTERPRETATION

Anal HPV and anal cancer precursors were very common in MSM. However, on the basis of restricted data, rates of progression to cancer seem to be substantially lower than they are for cervical pre-cancerous lesions. Large, good-quality prospective studies are needed to inform the development of anal cancer screening guidelines for MSM.

FUNDING

Australian Government Department of Health and Ageing.

Evaluation of the hybrid capture 2 assay for detecting anal high-grade dysplasia

Hybrid Capture 2 (HC2) Human Papillomavirus (HPV) DNA Test® is FDA approved and is a proven aid in detecting HPV infections of the cervix and as an aid in diagnosing, with cytology, cervical disease. A prospective feasibility study was conducted to determine if HC2 testing has utility when screening for high-grade anal dysplasia (AIN2+). We enrolled 298 patients (45% HIV+) who had AIN2+ screening with cytology, histology and HC2 testing for two specimens: a swab into liquid-based cytology medium and either a swab or a brush collection in specimen transport medium (STM). High-resolution anoscopy was performed on all patients with biopsy of AIN2+ suspicious lesions. Cytology was benign (42%), atypical squamous cells of undetermined significance (30%), low-grade squamous intraepithelial lesion (18%), high-grade squamous intraepithelial lesion (1%), ASCUS possibly high-grade dysplasia (1.7%) and nondiagnostic (7%) and 36% had AIN2+ histology. Sensitivity and specificity for predicting AIN2+ histology for any abnormal cytology were 77 and 52%, whereas HC2 sensitivity and specificity were 91 and 40% (p = 0.005 for sensitivity), respectively. There was no significant difference in HC2 sensitivity or specificity between brush and swab or STM and residual cells from cytology. AIN2+ was found in 20% of patients with benign cytology. Only nine AIN2+ specimens were HC2-. This prospective study indicates that HC2 may be useful when screening for anal dysplasia; however, a larger study is recommended.

Comparison of the performance of anal cytology and cervical cytology as screening tests

Cervical cytology screening has a long history and has successfully reduced the impact of cervical cancer in many countries. Anal cytology is a relative newcomer and anal screening is currently offered in only a few centres around the world. Many questions need to be answered before anal screening is more widely adopted. While there are many similarities between cervical and anal squamous cell carcinoma, there are also important differences: differences in the prevalence of disease, in the ‘at-risk’ target populations and possibly in the robustness of the reference standard of biopsy. The performance of cytology as a screening test in the literature varies widely but it is essential to understand that some of this variability is due to differences in the definitions of key parameters in the various studies. For cervical screening, estimates of sensitivity have ranged from 19% to 94% and specificity from 94% to 98%. For anal screening, data are fewer and more limited. Estimates of the sensitivity of anal cytology in men who have sex with men and HIV-positive populations have ranged from 55% to 87% and specificity from 37% to 76%. Ultimately, rather than comparing anal with cervical cytology, it may be more helpful to assess the value of anal cytology independently through well designed trials.

The cost-effectiveness of screening for anal cancer in men who have sex with men: a systematic review

Anal cancer is a relatively rare neoplasm, related to human papillomavirus (HPV), with an incidence that does not warrant general screening. However, as many cases occur in identifiable high-risk populations, targeting these groups may be cost-effective. Screening for anal cancer in men who have sex with men (MSM) may be appropriate, given their elevated risk of anal cancer. Examining existing cost-effectiveness analyses can help inform the design and conduct of future clinical and economic studies. A review of the literature was performed using three databases to identify studies that assessed the cost-effectiveness of anal cancer screening in MSM. Five analyses were identified: four modelled the cost-effectiveness of cytological screening over a patient’s lifetime, and estimated final health outcomes as survival or quality adjusted survival. The fifth presented a decision analysis with intermediate health outcomes only and did not extrapolate to longer-term health outcomes. Several factors influenced the incremental cost-effectiveness ratios. These factors were related to a paucity of primary data and included: availability of longer-term epidemiological and natural history data; availability of utility-based quality of life data from an appropriate respondent population; appropriate resource use information; and availability of information on screening adherence. There is considerable uncertainty in model results: analyses from the United States suggest screening is almost always cost-effective; analyses from the United Kingdom suggest that screening is unlikely to be cost-effective. Uncertainty is primarily driven by data paucity; by summarising key uncertainties in existing models, this review can inform the design and conduct of future studies.

Comparative accuracy of anal and cervical cytology in screening for moderate to severe dysplasia by magnification guided punch biopsy: a meta-analysis

Background

The accuracy of screening for anal cancer precursors relative to screening for cervical cancer precursors has not been systematically examined. The aim of the current meta-analysis was to compare the relative accuracy of anal cytology to cervical cytology in discriminating between histopathologic high grade and lesser grades of dysplasia when the reference standard biopsy is obtained using colposcope magnification.

Methods and Findings

The outcome metric of discrimination was the receiver operating characteristic (ROC) curve area. Random effects meta-analysis of eligible studies was performed with examination of sources of heterogeneity that included QUADAS criteria and selected covariates, in meta-regression models. Thirty three cervical and eleven anal screening studies were found to be eligible. The primary meta-analytic comparison suggested that anal cytologic screening is somewhat less discriminating than cervical cytologic screening (ROC area [95% confidence interval (C.I.)]: 0.834 [0.809–0.859] vs. 0.700 [0.664–0.735] for cervical and anal screening, respectively). This finding was robust when examined in meta-regression models of covariates differentially distributed by screening setting (anal, cervical).

Conclusions

Anal cytologic screening is somewhat less discriminating than cervical cytologic screening. Heterogeneity of estimates within each screening setting suggests that other factors influence estimates of screening accuracy. Among these are sampling and interpretation errors involving both cytology and biopsy as well as operator skill and experience.

Cancer screening in patients infected with HIV

Non-AIDS-defining cancers are a rising health concern among HIV-infected patients. Cancer screening is now an important component of health maintenance in HIV clinical practice. The decision to screen an HIV-infected patient for cancer should include an assessment of individualized risk for the particular cancer, life expectancy, and the harms and benefits associated with the screening test and its potential outcome. HIV-infected patients are at enhanced risk of several cancers compared to the general population; anal cancer, hepatocellular carcinoma, Hodgkin's lymphoma, and lung cancer all have good evidence demonstrating an enhanced risk in HIV-infected persons. A number of cancer screening interventions have shown benefit for specific cancers in the general population, but data on the application of these tests to HIV-infected persons are limited. Here we review the epidemiology and background literature relating to cancer screening interventions in HIV-infected persons. We then use these data to inform a conceptual model for evaluating HIV-infected patients for cancer screening.

The changing picture of high-grade anal intraepithelial neoplasia in men who have sex with men: the effects of 10 years of experience performing high-resolution anoscopy

BACKGROUND

Ten years ago, we published findings from anal dysplasia screening in a metropolitan surgical practice where the majority of men who have sex with men had biopsy-proven high-grade anal intraepithelial neoplasia.

OBJECTIVE

This study aimed to determine the effect of 10 years of experience in anal dysplasia screening on the prevalence of high-grade anal intraepithelial neoplasia.

DESIGN

A retrospective chart review was performed of all anal cytology results of 1189 men who have sex with men screened in a 1-year period, with subsequent high-resolution anoscopy and biopsy as necessary.

PATIENTS

The patients studied were men who have sex with men.

MAIN OUTCOME MEASURE

The main outcome measure was biopsy-proven high-grade anal intraepithelial neoplasia.

RESULTS

: There were 315 (37.2%) biopsy-verified instances of high-grade anal intraepithelial neoplasia. Regression analysis determined that age, HIV status, infection by high-risk human papillomavirus, and abnormal cytology results were significant predictors of high-grade anal intraepithelial neoplasia. In a 1-year period, the number of men who have sex with men screened was nearly 7 times greater than in the 2-year period studied 10 years earlier.

LIMITATIONS

We did not separately analyze patients who had previously been treated for high-grade anal intraepithelial neoplasia.

CONCLUSIONS

Severity of cytology and infection with high-risk human papillomavirus are the most significant predictors of high-grade anal intraepithelial neoplasia, underscoring the importance of anal dysplasia screening. Our ability to identify high-grade anal intraepithelial neoplasia has improved with 10 years of experience performing high-resolution anoscopy.

[Early detection of anal intraepithelial neoplasia in high-risk patients]

The incidence of anal squamous cell carcinoma has increased alarmingly, particularly in high-risk groups such as men who have sex with men and immunosuppressed patients. Infection with an oncogenic strain of the human papillomavirus in the anal canal or perianal skin leads to anal intraepithelial neoplasias (AIN), progressive dysplastic intraepithelial lesions that are the precursors of anal squamous cell carcinoma. AIN can be diagnosed through cytological screening and biopsy guided by high-resolution anoscopy and can be treated using a range of procedures in an effort to prevent progression to invasive anal carcinoma. Given the recent advances in the understanding of this disease, and the increasing calls from experts for the establishment of screening programs to identify AIN, we review current knowledge on the condition, its diagnosis, and treatment from the point of view of dermatology.

Skin infections in HIV-infected individuals in the era of HAART

PURPOSE OF REVIEW

Clinicians should be aware of the shift in the cutaneous infectious disease burden in human immunodeficiency virus-infected individuals as a reflection of immune restoration in the era of highly active antiretroviral therapy (HAART).

RECENT FINDINGS

As in the general population but to greater extent, methicillin-resistant Staphylococcus aureus (MRSA) soft-tissue infection is a rising problem among those with human immunodeficiency virus (HIV). Human papilloma virus (HPV) is exceedingly prevalent and persistent despite HAART, and HPV-associated malignancy is increasing as those with HIV live longer. Herpes, syphilis, and Kaposi's sarcoma continue to plague individuals with HIV. Immune reconstitution inflammatory syndrome (IRIS) is common and often presents with infectious cutaneous manifestations.

SUMMARY

This review implicates the importance of the acknowledgment of MRSA infections risk factors, screening for HPV-related neoplasia, continuance of trials to establish the efficacy of herpes vaccines, and awareness of prevalent cutaneous infections presenting with IRIS in those with HIV.

Secondary complications and co-infections in the HIV-infected adolescent in the antiretroviral era

PURPOSE OF REVIEW

The number of HIV-infected adolescents is increasing dramatically. With combination antiretroviral therapy, they are expected to live well into adulthood. However, complications are emerging at a higher rate in the HIV-infected population compared to the general population. HIV-infected adolescents are also at a high risk of sexually transmitted co-infections. This article reviews the main secondary complications and co-infections in the HIV-infected adolescent.

RECENT FINDINGS

HIV-infected adolescents are at a high risk of sexually transmitted infections. A careful, age-appropriate and developmentally appropriate inquiry into the individual's sexual behavior to assess risk is paramount, in addition to regular screening at medical visits. Treating co-infections is not only important for HIV-infected individuals, but also limits HIV transmission to others. In addition, monitoring and addressing modifiable secondary risk factors for complications such as renal disease, osteopenia or osteoporosis, and cardiovascular disease are critical, well before the onset of clinically apparent disease. Using antiretroviral therapy to suppress viral replication and inflammation appears to be a promising strategy for decreasing secondary complication risk, and likely overshadows the toxicities associated with the long-term use of certain antiretrovirals.

SUMMARY

Assessing and addressing the risk of secondary complications and co-infections in the HIV-infected adolescent is crucial for optimal length and quality of life.

Prevalence of anal intraepithelial neoplasia in women with genital neoplasia

BACKGROUND

Anal intraepithelial neoplasia is believed to be a precursor of anal cancer, and it appears to be related to high-risk human papillomavirus. Women with genital neoplasia have been shown to be at increased risk for anal cancer.

OBJECTIVE

The aim of this study is to determine the prevalence of anal intraepithelial neoplasia in women with genital neoplasia.

DESIGN

This is a cross-sectional study.

SETTING

This study took place at Hospital Nossa Senhora da Conceição, Porto Alegre, Brazil, from May 2008 to April 2010.

PATIENTS

Included in the study were 106 immunocompetent women with a histopathological diagnosis of genital neoplasia and 74 women without gynecologic neoplasia.

MAIN OUTCOME MEASURE

All women underwent high-resolution anoscopy with biopsies of acetowhite areas or abnormal vascular features such as punctation and mosaics for histopathological diagnosis of anal intraepithelial neoplasia.

RESULTS

: The overall prevalence of anal intraepithelial neoplasia was 6.6%. In women with genital neoplasia, the prevalence was 10.4% (95% CI, 5.6%-17.3%), whereas the prevalence was 1.4% (95% CI, 0.07%-6.5%) in women without genital neoplasia (P = .016). The prevalence ratio was 7.68 (95% CI, 1.01-58.21).

LIMITATION

Women with normal results on high-resolution anoscopy were not submitted to random biopsies for ethical reasons. Small lesions could be missed, and thus our findings might be underestimated.

CONCLUSION

The prevalence of anal intraepithelial neoplasia is higher in women with genital neoplasia.

Cost-effectiveness of screening for anal precancers in HIV-positive men

OBJECTIVE

To assess the cost-effectiveness of high-resolution anoscopy (HRA), anal cytology, and anal human papillomavirus (HPV) detection in screening for histologic high-grade anal intraepithelial neoplasia (AIN 2/3) in HIV-positive MSM.

DESIGN

Participants were 401 HIV-positive MSM who were screened for anal cancer in a tertiary care HIV clinic.

METHODS

A decision analytical model was used to determine the cost-effectiveness of three anal cancer screening strategies: the direct use of HRA; HRA only if anal cytology was abnormal; and HRA only if oncogenic HPV was present. The model included the use of different thresholds for abnormal cytology and also combined cytology and HPV testing. The outcome was the number of AIN 2/3 cases detected. Costs were estimated from institutional data and sensitivity/specificity of cytology and HPV tests were obtained from the screening study.

RESULTS

The costs ($ US) per procedure for HRA, cytology, and HPV testing were $193, $90, and $95, respectively. The direct use of HRA was the most cost-effective strategy. It detected 98 individuals with AIN 2/3 and had a cost-effectiveness of $809 per AIN 2/3 case detected. Using probabilistic sensitivity analysis, three other strategies had similar costs per case detected and might be as cost-effective as HRA.

CONCLUSION

In HIV-infected MSM, the direct use of HRA is the most cost-effective strategy for detecting AIN 2/3. The higher cost per use for HRA was offset by the high sensitivity and low specificity of HPV and cytology testing.

The psychological impact of being screened for anal cancer in HIV-infected men who have sex with men

BACKGROUND

Anal cancer screening may be considered in HIV-infected men who have sex with men because they are at increased risk. Cancer screening can provoke anxiety, which may lead to poorer screening compliance.

OBJECTIVE

This study aimed to measure the psychological consequences of anal cancer screening in HIV-infected men who have sex with men.

DESIGN

This investigation is a prospective cohort study.

SETTING

This study was conducted in primary and tertiary care HIV clinics in Toronto, Canada.

PATIENTS

One hundred four HIV-infected men who have sex with men were studied.

MAIN OUTCOME MEASURES

: Psychological impact was measured at 4 time points (before screening, after screening, after receiving results, and before follow-up) using the Impact of Events Scale, the Illness Intrusiveness Ratings Scale, and the Psychological Consequences Questionnaire.

RESULTS

Median age was 44, 77% were receiving antiretroviral therapy, and 11% had high-grade anal dysplasia (anal intraepithelial neoplasia 2/3). Fifteen to 32% of the patients reported high levels of negative psychological consequences across the 4 time points; the highest levels occurred at time 2. Higher HIV symptom count and baseline level of negative impact were significantly associated with higher Impact of Events scores, whereas younger age and a higher baseline level of negative impact were significantly associated with higher scores with use of the Illness Intrusiveness Ratings Scale.

CONCLUSIONS

Anal cancer screening is not associated with greater adverse psychological impact in most HIV-infected men who have sex with men. Younger patients, those with more HIV-related symptoms and greater baseline psychological distress, are at risk for increased psychological distress during screening.

Anal cancer and cervical cancer screening: key differences

Cervical cancer and anal cancer share many similarities including causation by oncogenic human papillomaviruses; however, significant differences exist in their epidemiology, risk factors, biologic behavior, management, and treatment. Although rare, the incidence of anal cancer is alarmingly high and continues to increase in high-risk populations, particularly men who have sex with men regardless of their human immunodeficiency virus (HIV) status. There are no national screening guidelines for anal cancer. Using the success of cervical cancer screening as a model, anal cancer screening approaches apply anal cytology, high-resolution anoscopy, and directed biopsy to guide treatment and management strategies. Although much has been learned about the natural history and epidemiology of anal intraepithelial neoplasia (AIN), the rate of progression of high-grade anal intraepithelial neoplasia (HGAIN) to invasive squamous cell carcinomas is not known. The impact of screening and treatment of HGAIN on morbidity and mortality from anal cancer are also unknown. Because the incidence of HGAIN and anal squamous cell carcinoma continue to increase, it is imperative to find pathways for effective screening, early detection, and therapeutic intervention. This article provides an overview of anal cancer screening while highlighting its differences from cervical cancer screening and the remaining obstacles and controversies to implementation of a successful anal cancer screening program.

HIV-associated anal cancer

HIV-associated anal carcinoma, a non-AIDS-defining cancer, is a human papillomavirus-associated malignancy with a spectrum of preinvasive changes. The standardized incidence ratio for anal cancer in patients with HIV/AIDS is 20-50. Algorithms for anal cancer screening include anal cytology followed by high-resolution anoscopy for those with abnormal findings. Outpatient topical treatments for anal intraepithelial neoplasia include infrared coagulation therapy, trichloroacetic acid, and imiquimod. The development of cost-effective national screening programs for HIV-associated anal cancer remains a challenge.

Topical 5-fluorouracil treatment of anal intraepithelial neoplasia in human immunodeficiency virus-positive men

BACKGROUND

Anal intraepithelial neoplasia (AIN), a human papillomavirus (HPV)-induced potential precursor lesion of anal cancer, is frequent among human immunodeficiency virus (HIV)-positive men who have sex with men (MSM). So far, only a few prospective studies have been performed on the topical treatment of AIN, especially at the intra-anal location.

OBJECTIVES

To evaluate the efficacy and safety of self-administered topical 5-fluorouracil (5-FU) treatment of AIN in HIV-positive MSM.

METHODS

High-resolution anoscopy (HRA) was performed and patients with AIN (grade 1-3) were treated with 5-FU twice weekly for a total of 16 weeks. HRA-guided lesional biopsies were repeated after 5-FU treatment for histopathological evaluation. Lesional swabs were obtained before and after treatment for HPV typing and HPV-DNA load determination of the high-risk types HPV16, 18, 31 and 33. Responding patients returned 6 months after treatment for follow-up.

RESULTS

A total of 46 patients with AIN were included in this open prospective pilot study; 76% had multifocal disease and 74% had high-grade lesions (AIN 2 or 3). In an intention-to-treat analysis, 26 of 46 patients (57%) responded to 5-FU treatment. Eighteen patients (39%) had a complete clearance of AIN and eight patients (17%) had a partial response. Seventeen patients (37%) did not respond (unchanged grade of AIN in 16 patients and progression from low- to high-grade AIN in one patient). 5-FU treatment led to a significant decrease of HPV16-DNA load and cumulative high-risk HPV-DNA load in both responding and nonresponding patients. Thirty-nine patients (85%) experienced side-effects during therapy, but only two discontinued 5-FU treatment. One patient was lost to follow-up. Six months later, 50% of the complete responders had a recurrence.

CONCLUSIONS

A substantial proportion of HIV-positive MSM with AIN completely cleared their lesions with topical 5-FU treatment. In those with partial response, pretreatment with topical 5-FU might facilitate subsequent ablative therapy.