Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer

Access to Care in the LGBTQIA+ Population

Access to surgical health care for the LGBTQIA+ community is often limited by education gaps, systemic biases, and stigmatization. Sexual and gender minority (SGM) individuals, who face higher risks of certain health issues like cancer, mental health disorders, and STIs, often encounter barriers such as provider knowledge gaps and fear of prejudice. Addressing these challenges requires comprehensive education for both providers and patients, workforce development, and policy changes. Effective solutions include tailored health approaches, such as proper STI screenings, HPV vaccination, and affirming care practices. Expanding access to knowledgeable, inclusive providers and implementing supportive health care policies can improve health outcomes for SGM patients, ensuring equitable and patient-centered care.

Human papilloma virus (HPV) mediated cancers: an insightful update

Human papillomavirus (HPV), a DNA virus, is a well-documented causative agent of several cancers, including cervical, vulvar, vaginal, penile, anal, and head & neck cancers. Major factors contributing to HPV-related cancers include persistent infection and the oncogenic potential of particular HPV genotypes. High-risk HPV strains, particularly HPV-16 and HPV-18, are responsible for over 70% of cervical cancer cases worldwide, as well as a significant proportion of other genital and head and neck cancers. At the molecular level, the oncogenic activity of these viruses is driven by the overexpression of E6 and E7 oncoproteins. These oncoproteins dysregulate the cell cycle, inhibit apoptosis, and promote the accumulation of DNA damage, ultimately transforming normal cells into cancerous ones. This review aims to provide a comprehensive overview of the recent advances in HPV-related cancer biology and epidemiology. The review highlights the molecular pathways of HPV-driven carcinogenesis, focusing on the role of viral oncoproteins in altering host cell targets and disrupting cellular signalling pathways. The review explores the therapeutic potential of these viral proteins, and discusses current diagnostic and treatment strategies for HPV-associated cancers. Furthermore, the review highlights the critical role of HPV in the development of various malignancies, emphasizing the persistent challenges in combating these cancers despite advancements in vaccination and therapeutic strategies. We also emphasize recent breakthroughs in utilizing biomarkers to monitor cancer therapy responses, such as mRNAs, miRNAs, lncRNAs, proteins, and genetic markers. We hope this review will serve as a valuable resource for researchers working on HPV, providing insights that can guide future investigations into this complex virus, which continues to be a major contributor to global morbidity and mortality.

Prevention and management strategies of anal squamous cell carcinoma among men who have sex with men living with HIV

The incidence of anal squamous cell carcinoma (SCCA) has been rapidly increasing in recent years. The burden of the disease is expected to increase in the forthcoming years. Men who have sex with men living with HIV (MSMLWH) have a higher incidence of SCCA than the general population. The progression of SCCA usually develops from high risk human papillomavirus (HR-HPV) infection to high grade squamous intra-epithelial lesions (HSIL). HPV infection is highly prevalent in MSMLWH and is considered the most important risk factor for SCCA in MSMLWH. Although the prevalence worldwide is largely similar, the distribution of high-risk HPV genotypes varies. Education on sexuality and lifestyle, use of condoms, fixed sexual partner, effective antiretroviral therapy (ART), smoking cessation, and preventive male circumcision could reduce HPV infection in MSMLWH. Screening and treatment of HSIL have been widely applied to prevent SCCA, but divergence still exists in many studies. When treating HSIL, patients of different ages and risk factors need more consideration to develop standardized management strategies, especially for MSMLWH. Very few studies have examined the treatment of SCCA with MSMLWH. ART has dramatically changed the treatment of SCCA in MSMLWH. The safety and outcome of treatment are still primary concerns for MSMLWH. More studies in this field are necessary to develop treatment strategies for MSMLWH.

Advances in the Management, Treatment, and Surveillance of Anal Squamous Cell Cancer

Anal cancer is a rare diagnosis, but incidence has been increasing over the past decade. Anal cancer is associated with the human papilloma virus (HPV), specifically the high-risk subtypes of 16 and 18. In addition, the precursor lesion for anal cancer is high-grade squamous intraepithelial lesions (HSILs) and its treatment and surveillance has been emphasized over the last 5 years. The current standard of care for anal cancer includes the Nigro protocol, concurrent chemoradiation, typically radiation with systemic mitomycin and 5-fluorouracil (5-FU). The protocol's efficacy laid the foundation for sphincter preservation and non-operative management. This review will detail the essential clinical trials in the treatment and surveillance of premalignant lesions and anal squamous cell cancer, including alterations in radiation dosing, systemic chemotherapy, and immunotherapy over the last several decades.

Prevention and control of HPV-related cancers in people living with HIV

The advent of effective antiretroviral therapy (ART) has increased the lifespan of many people living with HIV. As a result, cancers driven by high-risk human papillomavirus (HPV) infection have emerged as an increasingly important cause of mortality in this population. The complex interplay between HIV and HPV necessitates a deep understanding of the HPV-related cancer burden in people living with HIV and the integration of effective prevention strategies into their care. Although cervical cancer is a global concern, anal cancer is more important among people living with HIV in settings where HIV is more concentrated among men who have sex with men. High HPV prevalence, coupled with resource constraints, particularly in sub-Saharan Africa, where the majority of people living with HIV reside, creates substantial barriers to successful prevention and management of HPV-related malignancies. Implementing preventive measures, such as HPV vaccination and comprehensive screening programmes, is crucial and will require addressing existing health inequities and developing tailored interventions for people living with HIV. The development of enhanced secondary prevention tools and innovative treatment modalities is essential to mitigate the burden of HPV-associated cancers and improve the overall health outcomes for this vulnerable population.

Recent Guidelines on Anal Cancer Screening: A Systematic Review

OBJECTIVES

Reports have recently been published on the risk stratification of anal squamous cell carcinoma (SCC) in several populations and the benefits of treating precancerous anal lesions to reduce the risk of progression to anal SCC. These studies have led several societies to publish new recommendations for anal cancer screening. This study systematically reviews anal cancer screening recommendations across different societies and institutes published after the ANCHOR trial.

METHODS

The authors systematically reviewed society recommendations for anal cancer screening that have been published since July 2022.

RESULTS

This study included 6 publications: 3 societies made recommendations only for individuals living with HIV, and 3 made recommendations for other high-risk groups, such as women with vulvar cancer/high-grade squamous intraepithelial lesions (HSILs) and female transplant recipients. Four societies recommended anal cytology, with or without human papillomavirus (HPV) testing, as the first screening method. One society recommended anal cytology, HPV testing, or cotesting as possible options, while 1 suggested HPV type 16 testing. Only 1 society has made recommendations on screening discontinuation. High-resolution anoscopy was recommended during follow-ups for individuals with abnormal results, although the referral threshold varied between societies according to the screening method results. All societies that mentioned anal HSIL treatment recommended it. Four societies expanded their recommendations beyond screening and treatment to include smoking cessation and/or HPV vaccination.

CONCLUSIONS

Currently, there are several recommendations for anal cancer screening that include target groups, screening methods, treatment, follow-up, and other anal SCC prevention methods.

National Analysis of More Than 48,000 Veterans With HIV Demonstrates CD4/CD8 Ratio as a Risk Marker for Anal Intraepithelial Lesions and Anal Cancer

BACKGROUND

Anal squamous intraepithelial lesions are identifiable and treatable precancerous lesions that lack defined risk factors determining screening necessity.

OBJECTIVE

Assess the prevalence and risk factors associated with low- and high-grade anal squamous intraepithelial lesions and anal squamous-cell carcinoma.

DESIGN

Retrospective cohort analysis of veterans with HIV between 1999 and 2023.

SETTINGS

National multicenter study of the Department of Veterans Affairs.

PATIENTS

Veterans with HIV who had >1 year of follow-up and no anal squamous intraepithelial lesions or anal cancer diagnosis before the study period.

MAIN OUTCOME MEASURES

Primary outcomes include the prevalence, disease-free survival rates, and HRs associated with risk factors for developing anal squamous intraepithelial lesions and/or anal cancer.

RESULTS

A total of 48,368 patients were analyzed. The mean age of patients at study initiation was 47.8 years, with a mean follow-up of 12.3 years. Seven thousand five hundred seventy-two patients (16%) had at least 1 anal cytopathology or histopathology result. The prevalence of anal disease was recorded for low-grade disease (n = 1513; 3.1%), high-grade disease (n = 1484; 3.1%), and cancer (n = 664; 1.4%). Mean (SD) times to first incident low-grade disease, high-grade disease, and cancer were 8.5 (6.0), 9.1 (6.0), and 9.7 (6.2) years, respectively. Five-year, 10-year, and 20-year disease-free survival rates for the development of low-grade disease, high-grade disease, or cancer were 97.5%, 94.5%, and 88.4%, respectively. Cox regression modeling demonstrated that CD4/CD8 ratios of <0.5 were associated with an increased risk of anal cancer (HR, 3.93; 95% CI, 3.33-4.63; p < 0.001).

LIMITATIONS

Retrospective study that focused almost exclusively on male US veterans. Results might not apply to non-male, non-US populations.

CONCLUSIONS

National analysis of more than 48,000 veterans with HIV demonstrates that 16% had anal cytopathology or histopathology results with an anal cancer prevalence of 1.4%. CD4/CD8 ratios of <0.5 correlate strongly with the severity of anal disease and can help identify patients at the highest risk for anal cancer to prioritize screening efforts. See Video Abstract.

ANLISIS NACIONAL DE MS DE VETERANOS CON VIH DEMUESTRA QUE LA RELACIN CD/CD ES UN MARCADOR DE RIESGO DE LESIONES INTRAEPITELIALES ANALES Y CNCER ANAL

ANTECEDENTES:Las lesiones intraepiteliales escamosas anales son lesiones precancerosas identificables y tratables que carecen de factores de riesgo definidos que determinen la necesidad de detección.OBJETIVO:Evaluar la prevalencia y los factores de riesgo asociados con las lesiones intraepiteliales escamosas anales de grado bajo y alto y el carcinoma de células escamosas anal.DISEÑO:Análisis de cohorte retrospectivo de veteranos con VIH entre 1999 y 2023.ESTABLECIMIENTO:Estudio multicéntrico nacional del Departamento de Asuntos de Veteranos.PACIENTES:Veteranos con VIH que tuvieron >1 año de seguimiento y sin lesiones intraepiteliales escamosas anales ni diagnóstico de cáncer anal antes del período de estudio.PRINCIPALES RESULTADOS Y MEDIDAS:Los resultados primarios incluyen la prevalencia, las tasas de supervivencia libre de enfermedad y los cocientes de riesgo asociados con los factores de riesgo para desarrollar lesiones intraepiteliales escamosas anales y/o cáncer anal.RESULTADOS:Se analizaron 48.368 pacientes. La edad promedio de los pacientes al inicio del estudio fue de 47,8 años con un seguimiento medio de 12,3 años. 7.572 (16%) pacientes tuvieron al menos un resultado de citopatología o histopatología anal. Se registró la prevalencia de enfermedad anal para enfermedad de bajo grado (n = 1.513, 3,1%), enfermedad de alto grado (n = 1.484, 3,1%) y cáncer (n = 664, 1,4%). Los tiempos medios hasta el primer incidente de enfermedad de bajo grado, enfermedad de alto grado y cáncer fueron 8,5 (DE = 6,0), 9,1 (DE = 6,0) y 9,7 (DE = 6,2) años, respectivamente. Las tasas de supervivencia libre de enfermedad a 5 años, 10 años y 20 años para el desarrollo de enfermedad de bajo grado, enfermedad de alto grado o cáncer fueron 97,5%, 94,5% y 88,4%, respectivamente. El modelo de regresión de Cox demostró que los índices CD4/CD8 <0,5 se asociaban con un mayor riesgo de cáncer anal (HR: 3,93, IC del 95 %: 3,33-4,63, p < 0,001).LIMITACIONES:Estudio retrospectivo que se centra casi exclusivamente en veteranos estadounidenses de sexo masculino. Los resultados podrían no aplicarse a poblaciones no masculinas ni estadounidenses.CONCLUSIONES:El análisis nacional de más de 48 000 veteranos con VIH demuestra que el 16 % tenía resultados de citopatología o histopatología anal con una prevalencia de cáncer anal del 1,4 %. Los índices CD4/CD8 <0,5 se correlacionan fuertemente con la gravedad de la enfermedad anal y pueden ayudar a identificar a los pacientes con mayor riesgo de cáncer anal para priorizar los esfuerzos de detección. (Traducción-Dr Yolanda Colorado ).

Males Have Lower Anal Pap Smear Screening in a Miami Safety-Net HIV Clinic

BACKGROUND

Although people with HIV have a markedly higher risk of anal squamous cell carcinoma (ASCC), there are few evaluations of anal Pap screening determinants within safety-net HIV clinics.

METHOD

We conducted an evaluation of anal Pap screening correlates within a safety-net HIV clinic in Miami. Medical records were reviewed for 298 people ages 45 and older receiving HIV primary care. Demographic information and the prevalence of anal Pap screening over 1 year (i.e., 2018-2019) were extracted.

RESULTS

Between 2018 and 2019, approximately half (46%) of patients completed anal Pap screening although this varied by sex assigned at birth. More than three-fourths of females (77%) compared to one-fourth (23%) of males were screened between 2018 and 2019 (p < 0.0001).

CONCLUSION

Findings underscore the need for multi-level intervention approaches to optimize anal Pap screening among males with HIV within the Miami-based safety-net clinic.

Barriers and facilitators to anal cancer screening among men who have sex with men: a systematic review with narrative synthesis

BACKGROUND

Increasing trends of anal cancer among men who have sex with men (MSM) highlight the importance of anal cancer screening. However, the screening rate of anal cancer among MSM remains relatively low. This systematic review aims to identify and critically evaluate studies examining barriers and facilitators influencing MSM's participation in anal cancer screening.

METHODS

Systematic searches were performed in five databases (Web of Science, Medline, Embase, PsycINFO, and CINAHL). Evidence from qualitative, quantitative, and mixed methods studies was extracted and synthesized. Mixed Methods Appraisal Tool (MMAT) was used for quality assessment. Two researchers underwent selection and appraisal independently. PROSPERO registration number: CRD42024601449.

RESULTS

305 studies were identified with a total of 32 studies included, including 11 qualitative studies, 18 quantitative studies, and 3 mixed methods studies. The barriers and facilitators to anal cancer screening were categorized into four domains: individual factors, healthcare system factors, healthcare provider factors, and screen-related factors. Among the four domains, the most frequently reported barriers and facilitators to anal cancer screening were individual factors. A lack of knowledge about the risks of HPV, anal cancer, and anal screening (n = 16) was the most significant barrier. In contrast, a greater perceived understanding of anal cancer and screening (n = 6) was identified as the primary facilitator.

CONCLUSIONS

This systematic review provided a comprehensive assessment of barriers and facilitators to anal cancer screening among MSM, highlighting the need for targeted comprehensive intervention programs to enhance acceptance of screening. Implementing effective strategies to address potential barriers and promote facilitators across all domains of public health could significantly increase screening uptake.

PAP-HPV Co-Testing in Anal Cancer Screening: An Italian Experience

Background/Objectives: Squamous cell carcinoma of the anus (SCCA) remains a relatively rare form of cancer linked to high-risk human papillomavirus (HR-HPV) infection; however, its incidence has been increasing globally. Anal cytology and HR-HPV testing can identify precursors, though standardized screening guidelines are still lacking. This study aimed to assess the correlation between high-resolution anoscopy (HRA) findings and primary screening results through PAP-HPV co-testing in high-risk patients. Methods: A retrospective, single-center study was conducted collecting data from the joint multidisciplinary anal cancer clinic of Piero Palagi Hospital in Florence (Italy), between August 2019 and September 2022. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of anal cytology, HR-HPV testing, and PAP-HPV co-testing were assessed. Results: In 577 HRAs, histology revealed 31 AIN2+ lesions (5.4%) and 220 AIN1 lesions (38.1%), while 326 (56.5%) were negative. Cytology alone showed a sensitivity of 74.2% and specificity of 63.3% for AIN2+ lesions, while HR-HPV testing alone had a sensitivity of 96.8% and specificity of 38.1%. Co-testing demonstrated 100% sensitivity and a 100% NPV for AIN2+ lesions. Among men who have sex with men (MSM), no significant differences in outcomes were observed between HIV-positive and HIV-negative patients, likely reflecting similar high-risk behaviors and effective HIV treatments. Conclusions: Co-testing with anal cytology and HR-HPV testing provides the most reliable screening for high-grade lesions (AIN2+), surpassing the reliability of individual methods. Tailored co-testing strategies are crucial for early detection and effective prevention in high-risk groups.

Sexually transmitted human papillomavirus and related sequelae

SUMMARYMore than 40 types of sexually transmitted human papillomavirus (HPV) infect the oropharyngeal and anogenital mucosa-high-risk types are associated with precancerous and cancerous lesions of the cervix, vagina, vulva, penis, anus, and oropharynx, and low-risk types cause non-malignant disease, such as anogenital warts. Though most HPV infections resolve spontaneously, immunodeficiencies may result in persistent infection and increased risk of HPV-related sequelae. The mechanism by which HPV results in malignant transformation is multifaceted, involving interactions with numerous cellular pathways, the host immune system, and potentially the host microbiome. Vaccination against HPV is highly efficacious in the prevention of infection and related sequelae, and there now exist several approved formulations that protect against both high- and low-risk types. Despite the advent of vaccination, early detection and treatment of cervical and anal precancerous lesions continues to be integral to secondary prevention-molecular HPV testing, cytology, and tissue biopsy allow for triaging of patients, after which appropriate treatment with close follow-up can avert cancer development.

A Predictive Model Using Six Genes DNA Methylation Markers to Identify Individuals With High Risks of High-Grade Squamous Intraepithelial Lesions and Cervical Cancer

Background

Cervical cancer is preceded by low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL). Human papillomavirus (HPV) test is a sensitive method for cervical cancer screening, but it is less specific compared with cytological examination, leading to overtreatment and reduced patient compliance. Therefore, new detection methods that can improve the accuracy of cervical cancer screening are needed.

Methods

In the present study, cervical exfoliated cell samples were collected from 228 Chinese individuals, including 114 healthy control individuals, 46 patients with LSIL, 21 patients with HSIL and 47 patients with cervical cancer. The DNA methylation levels of 12 cervical cancer-related genes were detected using quantitative multiplex methylation-specific PCR. All individuals were divided into high- or low-risk groups. Patients with HSIL and cervical cancer were assigned to the high-risk group, whereas healthy controls and patients with LSIL were assigned to the low-risk group. The ability to predict cancer risks was evaluated using ROC curves and a predictive model for cancer risk was constructed by linear regression analysis.

Results

The methylation levels were significantly higher for all 12 genes in individuals with cervical cancer or HSIL, compared with those in LSIL or normal group. Family with sequence similarity 19 member A4 (FAM19A4), phosphatase and actin regulator 3 (PHACTR3), somatostatin (SST), Zic family member 1 (ZIC1), paired box 1 (PAX1) and zinc finger protein 671 (ZNF671) were used to construct a predictive model for cancer risk prediction, with a specificity of 89.6% and a sensitivity of 95.0%.

Conclusion

The present study demonstrated the methylation levels of 12 cervical cancer-related genes were higher in Chinese patients with HSIL or cervical cancer. Also, a predictive model was constructed to distinguish cervical cancer or HSCL from individuals with low risk.

Health-Related Quality of Life for Persons Treated or Monitored for Anal High-Grade Squamous Intraepithelial Lesions (AMC-A01)

PURPOSE

The Anal Cancer/High-grade squamous intraepithelial lesions Outcomes Research (ANCHOR) trial demonstrated that treating precancerous anal HSIL reduces the incidence of anal cancer by 57% in people with HIV. It remains unclear how HSIL treatment or monitoring without treatment affects patient-reported health-related quality of life (HRQoL). We evaluated differences in HRQoL for individuals who were randomly assigned to active monitoring (AM) or treatment for anal HSIL.

METHODS

Using an index designed and validated for use in ANCHOR, HRQoL was assessed before random assignment (T1), 2-7 days (+3 days) after random assignment/treatment (T2), and 28 days (±7 days) after random assignment/treatment (T3).

RESULTS

ANCHOR participants living with HIV (N = 124; mean [standard deviation, SD] age, 52.6 years [10.3]; n = 101 [81.5%] men; n = 65 [52.4%] White; n = 95 [76.6%] non-Hispanic; treatment n = 70 [56.4%]; and AM n = 54 [43.6%]) were included. Treatment arm participants had significant mean worsening from T1-T2 in physical symptoms (mean [SD] difference, 0.31 [0.51]; P = .0001) and impact on psychological functioning (mean [SD] difference, 0.25 [0.64]; P = .022) that significantly improved to T1 levels from T2-T3 (ie, mean [SD] difference, -0.25 [0.52]; P = .003; and mean [SD] difference, -0.07 [0.23]; P = .039, respectively). AM arm participants experienced significant mean improvement in impact on psychological functioning from T1-T3 (mean [SD], difference, -0.20 [0.50]; P = .017). After adjusting for T1, treatment arm participants had a larger mean improvement than AM arm participants in physical symptoms from T2-T3 (mean [SD] difference, -0.25 [0.52]; P = .024); no between-arm differences were observed for impact on physical or psychological functioning.

CONCLUSION

Treatment arm participants experienced significant worsening in physical symptoms and impact on psychological functioning from T1-T2 but returned to prerandomization levels by T3, indicating that any immediate anal HSIL treatment-related impacts to HRQoL are temporary. Further research is needed to determine long-term impacts of anal HSIL treatment on HRQoL.

The value of routine histopathological examination after haemorrhoidectomy in patients at low and high risk of anal squamous intraepithelial lesions and cancer

AIM

Routine histopathological evaluation of haemorrhoidectomy specimens is not ubiquitous amongst surgeons as its utility is debatable. This is the first study to assess the detection rate of anal squamous intraepithelial lesions (aSIL) and anal squamous cell carcinoma (aSCC) in low- and high-risk patients.

METHOD

This 9-year retrospective study assessed electronic medical records of all patients who underwent excisional haemorrhoidectomy within an Australian tertiary referral hospital. Patients with sinister clinical examination findings were excluded from the study. Data collected included patient demographics, pertinent history, relevant risk factors, histopathology reports and digital rectal examination findings. Cost-benefit analysis of routine pathology submission and a city-wide survey of surgeons to ascertain current practices were also undertaken.

RESULTS

The overall prevalence of incidental aSIL and aSCC was 27 (8.1%); 19 patients (5.7%) had low-grade squamous intraepithelial lesions (LSILs), seven (2.1%) had high-grade squamous intraepithelial lesions (HSILs) and one patient (0.3%) had aSCC. More than three out of four were detected in low-risk patients, with most cases being LSIL. Comparing low-risk and high-risk patients, the observed incidental detection rate of aSIL and aSCC was 6.8% (95% CI 4.49-10.17) and 23.1% (95% CI 11.03-52.05), respectively. Multivariate logistic regression showed a large, significant association between high-risk risk factors and detecting aSIL and aSCC (OR 3.76, 95% CI 1.32-10.68, P = 0.013). A city-wide survey of surgeons demonstrated that 28.6% do not request routine histopathological evaluation and 64.3% thought that the prevalence of sinister incidental pathology in haemorrhoids was 1% or less. The total cost of conducting routine histopathological evaluation per patient was $96.80 AUD ($59.20 EUR, $65.30 USD).

CONCLUSION

Given the non-negligible incidental detection rate of aSIL and aSCC in both low-risk and high-risk patients, coupled with the cost-effectiveness of histopathological examination, this study suggests that routine histopathological examination should not be restricted solely to high-risk patients. Further study of the benefit of surveillance following clinical detection in low- and high-risk patients is needed.

Electrocautery ablation therapy for anal intraepithelial carcinoma with high-resolution anoscopy

OBJECTIVE

This study investigated the efficacy and safety of electrocautery ablation for high-grade squamous intraepithelial lesions (HSILs) in men who have sex with men (MSM) including people with human immunodeficiency virus, using comprehensive biopsy with high-resolution anoscopy (HRA).

METHODS

This single-arm, open-label pilot study included 20 MSM with HSIL who were treated with electrocautery ablation. The participants were recruited from the National Center for Global Health and Medicine and followed up using HRA with a comprehensive biopsy approach at 3- and 6-months post-ablation. A comprehensive biopsy was defined as at least 1 biopsy taken from each of the 6 segments of the anal canal regardless of any abnormal findings. The primary endpoint was the local HSIL cure rate at 6 months. Secondary endpoints included the total cure rate, recurrence rates, and adverse events.

RESULTS

The median age of the 20 participants was 45 years, and 90 % were HIV-positive. The local cure rates were 40 % at 3 months and 50 % at 6 months. The total cure rates were 35 % and 40 % at 3 and 6 months, respectively. Ectopic recurrence occurred in 27.8 % of the participants. Most adverse events were mild and self-limiting.

CONCLUSION

Electrocautery ablation was a moderately effective and safe treatment for HSIL among MSM in Japan. However, the recurrence rates were high, indicating that conducting biopsies on normal-appearing lesions did not sufficiently prevent ectopic recurrence. Further research with larger sample sizes and longer follow-up periods is warranted to improve outcomes. This trial was registered in the Japan Registry of Clinical Trials: Clinical Trial Plan Number: jRCTs032210649.

Early Detection of Cancer and Precancerous Lesions in Persons With HIV Through a Comprehensive Cancer Screening Protocol

BACKGROUND

Non-AIDS defining malignancies present a growing challenge for persons with human immunodeficiency virus (HIV, PWH), yet tailored interventions for timely cancer diagnosis are lacking. The Spanish IMPAC-Neo protocol was designed to compare two comprehensive cancer screening strategies integrated into routine HIV care. This study reports baseline data on the prevalence and types of precancerous lesions and early-stage cancer among participants at enrolment. Acceptability of the procedure was additionally assessed.

METHODS

Cross-sectional analysis of a comprehensive screening protocol to detect precancer and cancer. The readiness of healthcare providers to implement the protocol was evaluated using a validated 4-item survey.

RESULTS

Among the 1430 enrolled PWH, 1172 underwent 3181 screening tests, with positive findings in 29.4% of cases, leading to further investigation in 20.7%. Adherence to the protocol was 84%, with HIV providers expressing high acceptability (97.1%), appropriateness (91.4%), and feasibility (77.1%). A total of 145 lesions were identified in 109 participants, including 60 precancerous lesions in 35 patients (3.0%), 9 early-stage cancers in 9 patients (0.8%), and 76 low-risk lesions in 65 subjects (5.5%). Adverse events related to screening occurred in 0.8% of participants, all mild. The overall prevalence of cancer precursors or early-stage cancer was 3.8% (95% confidence interval [CI], 2.74%-5.01%), with highest rates observed in individuals screened for anal and colorectal cancers.

CONCLUSIONS

The baseline comprehensive cancer screening protocol of the IMPAC-Neo study successfully identified a significant proportion of PWH with precancerous lesions and early-stage cancer. High adherence rates and positive feedback from providers suggest effective implementation potential in real-world healthcare settings.

Challenges in the implementation of a high-resolution anoscopy clinic for people with HIV in an oncologic center in Mexico City

BACKGROUND

Anal cancer incidence is increased in people with HIV (PWH), up to 60 times higher in men who have sex with men, and almost 15 times higher among women with HIV. Screening and treating high-grade lesions (HSIL) have proven to reduce the incidence of invasive anal cancer. In 2020, we started implementing a high-resolution anoscopy (HRA) clinic at INCan, a tertiary care oncologic center, as part of a screening program for PWH from the HIV clinic.

OBJECTIVES

We describe the barriers and difficulties in implementing an HRA Clinic from January 2020 to April 2021, including physician training, the certification process, discrepancies between cytology and histopathologist results, and the lack of experience of gastrointestinal pathologists in HPV-related lesions.

RESULTS

During the first 18 months of the HRA clinic implementation, 124 studies were performed, and 85 biopsies were done. The prevalence of HSIL was 22%. Initially, when a gastrointestinal pathologist reviewed anal canal biopsies, a second opinion was requested from a genitourinary pathologist who examined 72 of the biopsies; there were discrepancies in the diagnosis in 61% of the cases, with more advanced intraepithelial lesions in 43% of cases. Specifically, gastrointestinal pathologists missed 68% of HSILs. The difficulties we faced were not having access to adequate anoscopes. Training and certification are a long way to go. Also, women's reachability was low.

CONCLUSIONS

Diagnosis and management of anal HSIL have become a standard of care in the prevention of Anal Carcinoma in PWIH, the population with the highest incidence of this neoplasia. Implementing HRA programs requires correct supplies and equipment, which are not always locally available; investing in physicians' training and an experienced pathologist in HPV-associated lesions interpretation is also imperative. More advocacy is needed for HIV programs to incorporate and invest in anal cancer screening.

Anal Cancer Screening Practices Among Higher-Risk Populations in an Academic Medical System

BACKGROUND

Although some experts recommend anal cancer screening for disproportionally affected populations including people living with HIV (PWH), condyloma acuminata, human papillomavirus-associated gynecologic dysplasia and cancers, and solid organ transplants, actual screening practices remain understudied. Our objective was to characterize anal cancer screening practices among higher-risk populations in an academic medical system with access to high-resolution anoscopy.

METHODS

We extracted outpatient clinical data for the aforementioned populations from January 1, 2015, to August 1, 2022, at 3 sites of an academic medical system. Data included patients' demographics, medical comorbidities, and anal cytology and human papillomavirus testing results. We used χ2 tests and logistic regression to assess for associations between patient characteristics and anal cancer screening.

RESULTS

Of 7654 patients, 6.3% received anal cytology screening at least once including 21.7% of PWH, 13.8% of people with condyloma acuminata, 1.1% of people with gynecologic cancers, and 0.5% of people with solid organ transplants. In multivariable analysis, Black patients were 46% less likely to receive screening than White patients (95% confidence interval [CI], 0.40-0.71), and cisgender women were 73% less likely to receive screening than cisgender men (95% confidence interval, 0.20-0.38). Of 485 individuals who received anal cytology screening, 37.5% were only screened once and 70.5% had abnormal cytology on one or more screenings.

CONCLUSION

Only one-fifth of PWH received anal cancer screening, and other higher-risk populations had even lower screening rates. Black patients and women were also less likely to be screened. Strategies to improve equitable screening practices for anal cancer are needed.

Stratified Mucin-producing Lesions of the Anus: Insights into an Emerging Histologic Type of HPV-driven Anal Neoplasia

Primary anal cancers are rare and typically driven by high-risk human papillomavirus (HPV) infection. Though squamous cell carcinoma is most common, a spectrum of HPV-related nonsquamous anogenital neoplasms with similarities to cervical stratified mucin-producing carcinoma has been reported. In this study, we mined our institutional archives to characterize the clinicopathologic features of this emerging entity. Six cases were identified from the files at 2 institutions, including 4 cases of invasive stratified mucin-producing carcinoma and 2 stratified mucin-producing intraepithelial lesions (SMILE). Four patients were women, and the mean age was 70 years. Patients presented with rectal/anal mass or polyp, rectal bleeding or pain, weight loss, or at the time of screening colonoscopy. Tumors displayed histologic features as described in the gynecologic tract. Cases of invasive stratified mucinous carcinoma showed infiltrative tumor nests with variable intracytoplasmic mucin, peripheral palisading, prominent apoptosis, and neutrophilic infiltrate. One invasive stratified mucinous carcinoma associated with high grade glandular dysplasia, whereas 1 SMILE was next to conventional low-grade squamous intraepithelial lesion. All lesions stained with p16 showed block-like p16 expression. HPV in situ hybridization was performed in 5 cases, 4 of which were positive; one was interpreted as equivocal. Follow-up information, available in 4 patients, revealed 1 local recurrence followed by death due to unrelated causes in a patient with invasive stratified mucin-producing carcinoma. We report the first series of HPV-associated primary anal stratified mucin-producing neoplasms analogous to those seen in the gynecologic tract, further broadening the spectrum of HPV-related anal neoplasia.

Implementation of a Screening Program for High-Grade Anal Dysplasia in High-Risk Patients in a Tertiary Cancer Center

INTRODUCTION

The incidence of anal squamous cell carcinoma (SCC) has been increasing over the last decades. Human papillomavirus (HPV) infection accounts for more than 90% of anal cancers, and HIV co-infection increases the risk of invasive cancer. Men who have sex with men (MSM) with HIV are the highest risk group for developing anal high-grade squamous intraepithelial lesions (aHSILs), which can be found in 45%-50% of these patients and are precursor lesions for invasive cancer. Anal cytology is an effective screening tool, but it lacks sensitivity. High-resolution anoscopy (HRA) is the gold standard procedure for diagnosis and treatment of aHSILs. Recent data suggest that early detection and treatment of aHSILs could prevent the development of invasive cancer in this population.

OBJECTIVE

The objective of the study was to describe the implementation of an office-based screening program for anal cancer prevention in a Comprehensive Cancer Center in Brazil.

METHODS

Training included participation in the International Anal Neoplasia Society (IANS) HRA course at UCSF Medical Center Mount Zion in San Francisco, CA, USA, by three colorectal cancer surgeons. In-person and hands-on training was provided by a specialist through the AIDS Malignancy Consortium (AMC) of the US NIH. Equipment purchased and provided by the AMC included a colposcope with a digital camera, a hands-free mouse pedal, and a photo documentation imaging software program that allows images to be recorded for documentation and training purposes.

RESULTS

The program was implemented in 2022 after a delay of more than two years due to the COVID-19 pandemic. An average of 24 exams are performed monthly. Patients with HIV aged 35 years or older who are undergoing antiretroviral therapy were recruited from the metropolitan area of Rio de Janeiro and referred by primary care providers for screening. Patients diagnosed with aHSILs are scheduled for in-office ablative treatment in the clinic. From March 2022 to June 2024, 324 exams were performed, and aHSIL was found in 38.2% of 220 high-risk patients, including 45 of 129 MSMs (34.9%), 6 of 19 transgender women (31.6%), and 33 of 72 women living with HIV (45.8%). A total of 69 treatments for aHSIL were performed in 62 patients. Patients are followed on a regular basis and long-term results are awaited, including the effectiveness of local therapy for aHSIL.

CONCLUSIONS

The screening and treatment program was successfully implemented in a tertiary comprehensive Cancer Center. Team training and external proctorship were decisive for the achievement of benchmark standards. The program aims to permanently provide screening for the prevention of anal cancer through the detection and treatment of aHSIL within the National Cancer Institute of Brazil for populations considered at-risk for anal cancer.

Does use of anal cytology as a triage test improve the performance of high-risk human papillomavirus screening in gay and bisexual men for anal cancer prevention?

Anal high-risk human papillomavirus (HRHPV) testing-based anal cancer screening gay and bisexual men (GBM) is associated with high sensitivity, but low specificity. We report the potential role of triage use of anal cytology with HRHPV testing in detecting 12-month persistent anal high-grade squamous epithelial lesions (HSIL) in a cohort of GBM in Sydney, Australia. Participants were GBM from the Study of the Prevention of Anal Cancer (SPANC) who underwent annual anal HPV testing, cytology, and high-resolution anoscopy (HRA)-guided histology. The sensitivity and specificity of five screening algorithms based on HRHPV test results with triage use of anal cytology (atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells, cannot exclude HSIL (ASC-H) used as referral thresholds) were compared to these of HRHPV testing and anal cytology alone. A total of 475 men who had valid HRHPV, cytological, and histological results at both baseline and first annual follow-up visits were included, median age 49 years (inter-quartile range: 43-56) and 173 (36.4%) GBM with human immunodeficiency virus. Of all triage algorithms assessed, two had comparable sensitivity with HRHPV testing alone in detecting persistent anal HSIL, but ~20% higher specificity and 20% lower HRA referral rates. These two algorithms involved the immediate referral of those with HPV16 and for those with non-16 HRHPV either immediate or delayed (for 12 months) referral, depending on cytology result at baseline. Triage use of anal cytology in GBM testing positive for anal HRHPV increases specificity and reduces referral rates while maintaining high sensitivity in detection of HSIL.

A Sequential Mixed-Methods Study of Factors Associated with Low High-Resolution Anoscopy Completion in Transgender Women with Abnormal Anal Cytology

In a cohort of transgender women (TGW) with abnormal anal cytology (AAC) in Washington, DC, we determined the rates of and factors associated with completion of high-resolution anoscopy (HRA). This mixed-methods study used a sequential study design. In an academic-community clinic, we recruited TGW who provided blood samples, anal swabs for anal cytology, and completed surveys. For the quantitative phase of this study, we used χ2 test to compare factors associated with HRA completion among TGW with AAC. From that cohort, we used purposive sampling to recruit 16 TGW for qualitative interviews, based on their HRA completion status. We used thematic analysis to analyze the qualitative data. Of 75 TGW, 36 (48%) had AAC, 32 (43%) were referred to HRA, and 15 (20%) completed HRA. HRA completion was associated with being employed (75% vs. 25%; p = 0.01) in the quantitative phase, and low socioeconomic status (SES) was considered a barrier to completing HRA in the qualitative phase. HRA completion was associated with suppressed HIV (67% vs. 18%; p = 0.01) in the quantitative phase. In the qualitative phase, trans-affirming care, receptive anal sex, and engaging in sex work were identified as motivators to completing HRA. In a population of TGW, we found high rates of AAC and low rates of HRA completion. Interventions targeting this gap should address barriers associated with low SES and HIV viremia in TGW. Trans-affirming care and the impact on anal sexual practices should be used as motivators to engage TGW in anal cancer screening.

Real-time diagnosis of a lesion of the anal canal observed by endocytoscopy

Anal canal cancer (ACC) is a rare yet noteworthy malignancy that is strongly associated with high-risk human papillomaviruses (HPVs). This case report highlights the diagnostic utility of endocytoscopy (EC) in distinguishing high-grade squamous intraepithelial lesions (HSILs) from low-grade lesions (LSILs) in a 57-year-old male presenting with hematochezia. Traditional magnifying endoscopy was inconclusive; however, EC provided detailed visualization of cellular and vascular changes, facilitating a diagnosis of HPV-associated HSIL or carcinoma in situ. Subsequent en bloc resection by endoscopic submucosal dissection was performed successfully, with no recurrence at the 6-month follow-up. This case underscores the value of EC in enhancing diagnostic accuracy for anal lesions, suggesting potential benefits for broader diagnostic applications.

Access to High-Resolution Anoscopy and Colorectal Surgery Support Identified as Important Facilitators to Successful Veterans Affairs Anal Cancer Screening Programs

BACKGROUND

Anal cancer disproportionately affects people living with HIV. The Department of Veterans Affairs is the largest single provider of health care to people living with HIV in the United States and recommends all veterans living with HIV be screened for anal cancer annually. There are barriers to developing successful anal cancer screening programs, and screenings within Veterans Affairs have been underused.

OBJECTIVE

This study aims to identify facilitators to anal cancer screening programs in Veterans Affairs.

DESIGN

This is a qualitative study involving semistructured virtual interviews. Thematic analysis was used to identify themes in the interview data.

SETTINGS

Study participants included Veterans Affairs infectious disease providers and colorectal surgeons who care for veterans living with HIV. Participants were asked to discuss factors that influence anal cancer screenings in Veterans Affairs.

MAIN OUTCOME MEASURES

Themes were mapped to theoretical constructs and domains related to behavioral change using the Theoretical Domains Framework.

RESULTS

A total of 23 Veterans Affairs providers from all major United States geographical regions were interviewed. Important facilitators identified included access to high-resolution anoscopy and colorectal surgery support. The themes for successful anal cancer screening programs were mapped to 15 behavior-influencing constructs and categorized into 6 domains: 1) knowledge, 2) skills, 3) professional role and identity, 4) goals, 5) environmental context and resources, and 6) social influences.

LIMITATIONS

This study involves health care providers who are invested in caring for veterans living with HIV, and their perspectives might not be representative of all Veterans Affairs providers.

CONCLUSIONS

Access to a clinician with high-resolution anoscopy training and colorectal surgery support were identified as integral components of a successful anal cancer screening program. This study provides a framework for improving anal cancer screenings in veterans living with HIV by use of evidence-based interventions that incorporate the identified facilitators. See Video Abstract .

Early detection of anal squamous cell carcinoma with the use of high-resolution anoscopy

In the UK, few (12%) anal squamous cell carcinomas (aSCCs) are diagnosed early at stage 1 (T1N0M0). The Homerton Anogenital Neoplasia Service (HANS) is a highly specialized tertiary centre where high-resolution anoscopy (HRA) is performed to diagnose and treat anal intraepithelial neoplasia (AIN), a precursor to cancer. In some cases, aSCC (here defined as anal canal cancers and perianal cancers up to 5 cm from the anal verge) is found on referral for AIN; in others, aSCC may develop during management of AIN. We reviewed aSCC diagnoses at our specialist unit to establish whether HRA offers added value in the early detection of aSCC in a high-risk cohort. A cross-sectional analysis was performed of all primary aSCC diagnoses at HANS between January 2016 and June 2021. Patient records and histopathology and radiology reports were reviewed to define anal cancer stage per TNM classification (AJCC version 8). The results were compared with national anal cancer data published by the Office for National Statistics (AJCC version 8). Fifty-three aSCC diagnoses were made at HANS; 35 (66%) were stage 1 (14 prevalent, 21 incident), 11 (21%) stage 2 (9 prevalent, 2 incident) and 6 (11%) stage 3 (5 prevalent, 1 incident). None were stage 4, and one cancer was unstageable due to further management at another unit. By comparison, 5836 aSCCs were diagnosed in the UK between 2013 and 2017. Of these, 12.0% were stage 1, 22.8% stage 2, 33.0% stage 3 and 8.5% stage 4; 23.8% were unknown or unstageable. There was a statistically significant difference in the proportion of early (i.e. stage 1) HRA-detected cancers between HANS and national statistics (P < 0.001). Our results suggest that surveillance and examination within an HRA programme may lead to the detection of aSCC at an earlier stage, allowing for less morbid treatment and potentially lower mortality.

Prevalence, Incidence and Predictors of Anal HPV Infection and HPV-Related Squamous Intraepithelial Lesions in a Cohort of People Living with HIV

Background: Anal HPV infection can cause squamous intraepithelial lesions (SILs), which are precursors of anal squamous cell carcinoma (SCC). The early detection of HPV infections and improvement of effective screening programmes are, therefore, essential to prevent progression from pre-cancerous lesions to SCC, especially in people living with HIV (PLWH), who represent a population at higher risk of HPV infection and associated lesions. Among prevention strategies, HPV vaccination is relevant too, but its efficacy in persons already infected by HPV is still debated. Methods: This is a retrospective single-center study on a cohort of PLWH who performed longitudinal screening for anal dysplasia and HPV infection. The screening included cytological and molecular analyses. Results: A total of 110 PLWH performed at least one anal HPV screening, with an overall prevalence of HPV infection of 86.4% [23.6% low risk (LR)-HPV and 62.7% high risk (HR)-HPV genotypes]. Abnormal cytology was demonstrated in 39.1% of subjects, of whom ASCUS 6.4%, LSIL 30.9% and HSIL 1.8%. In total, 80 patients (72.7%) had an available longitudinal screening. No patient developed SCC during follow-up. However, a high incidence of new cytological abnormalities and new HPV infections was observed. On the other side, clearance of some HPV genotypes was also frequent, confirming that HPV infection is a dynamic process. A CD4 cell count > 500/mmc was an independent predictor of HPV clearance. HPV vaccination was performed on 30.9% of patients. A trend toward an increased clearance of HPV genotypes included in 9-valent vaccine was observed in vaccinated patients (40.6% versus 30.8% in unvaccinated, p = 0.079). Conclusions: A high prevalence of HPV infection and SILs was observed in our cohort of PLWH. A high incidence of new HPV infections and HPV-associated lesions was also observed in the longitudinal cohort, highlighting the need of strengthening immunization programs and continuous screening for anal HPV infection. Whether HPV vaccination may be efficacious in patients already infected by HPV remains to be determined.

Self- versus clinician-collected swabs in anal cancer screening: A clinical trial

BACKGROUND

Risk of anal cancer is high in certain populations and screening involves collection of anal swabs for HPV DNA and/or cytology testing. However, barriers exist, such as the need for an intimate examination, and stigma around HIV status, sexual orientation, and sexual practices. Self-collected anal swabs (SCA) are a proposed alternative to clinician-collected swabs (CCA) to overcome these barriers.

METHODS

Participants were order-randomised to undergo SCA or CCA first, with a second swab taken immediately afterwards. Sample adequacy was assessed for HPV DNA and cytology testing. CCA was used as the gold standard to calculate sensitivity and specificity of SCA for cytology and HPV results. Acceptability of swab collection was assessed following the procedure.

RESULTS

There was no significant difference in sample validity for HPV DNA testing between SCA and CCA (p = 0.564). Concordance was >90% for detection of any HR-HPV and HPV16. There was no significant difference in cellular adequacy for cytological testing between SCA and CCA, (p = 0.162). Concordance for cytologic prediction was 88.2% for any cytologic abnormality. Almost half (48.5%) of participants expressed no preference for SCA versus CCA; 15.2% preferred SCA and 35.4% CCA.

CONCLUSIONS

SCA may be an acceptable and feasible alternative to CCA for detecting HPV and cytological abnormalities in a clinic population.

Utilization of Anal Cytology Screening among Sexual and Gender Minority Populations in Pennsylvania

BACKGROUND

Despite the risk of anal cancer in sexual and gender minority (SGM) populations, anal cancer screening remains infrequent and inconsistent in these populations. The objective of this analysis was to identify factors associated with anal cancer screenings among SGM populations using the Andersen's behavioral model of health services use.

METHODS

Secondary analyses of two cross-sectional surveys from the 2020 (N = 1,125) and 2022 (N = 630) Pennsylvania LGBTQ Health Needs Assessment. Multiple logistic regression analyses were used to identify correlates of anal cytology screening.

RESULTS

Average age was 37.7 (SD = 13.3) and 39.7 (SD = 13.6) in 2020 and 2022, respectively. Approximately 16% to 18% reported living with human immunodeficiency virus (HIV). A minority of respondents reported past year screening (14.0%, 2020 and 13.6%, 2022). Enabling and need-based factors consistently associated with screening included sexually transmitted infection treatment, living with HIV, preexposure prophylaxis use, and multiple sex partners. Robust factors associated with ever being screened were age and living with HIV.

CONCLUSIONS

Anal cytology screening is being done in Pennsylvania at a small but not insignificant rate. In accordance with existing guidelines, SGM populations living with HIV were most likely to be screened, but still at a low rate. Predictive factors associated with screening in this study can inform future interventions to implement guideline-specific anal cancer prevention.

IMPACT

Factors that reflect consistent connection to healthcare are associated with increased rates of screening via anal cytology testing, indicating there are opportunities to implement anal cancer screening as part of a larger, more comprehensive SGM-focused care pathway.

[Translated article] Retrospective Study of Risk Markers for Developing High-Grade Anal Intraepithelial Neoplasm in Men Who Have Sex With Men Living With HIV

BACKGROUND

High-grade anal intraepithelial squamous lesion is significantly prevalent among men who have sex with men and are infected with the human immunodeficiency virus (HIV). This condition-the precursor to anal cancer-significantly increases the risk of developing it. Conversely, low-grade anal intraepithelial squamous typically follow a benign course and usually regress spontaneously.

MATERIALS AND METHODS

To describe a population of men who have sex with men living with HIV followed in a specialized anal cancer screening unit we conducted an observational, retrospective, and single-center study.

RESULTS

Ninety-four patients were analyzed, with a mean age of 39±9 years, and a 87% positivity rate for high-risk human papillomavirus (HR-HPV). At the initial visit, 47% presented with low-grade squamous intraepithelial lesions. The progression rate to high-grade squamous intraepithelial lesion was 37.2 per 100,000 patients/year. None of the patients developed anal cancer. Tobacco and alcohol consumption were associated with this progression.

DISCUSSION

In this series, longer duration of HIV infection, tobacco and alcohol use and the presence of HR-HPV were significantly associated with the occurrence of high-grade intraepithelial lesions. A lower risk of progression was seen in patients with higher education.

CONCLUSION

In men who have sex with men living with HIV, the association of factors such as smoking, alcohol, the presence of HR-HPV and an increased burden of human papillomavirus disease makes these patients more susceptible to develop high-grade anal squamous lesions.

Predictors of Resolution and Recurrence of Anal High-Grade Squamous Intraepithelial Lesions in People With HIV

OBJECTIVE

High-resolution anoscopy (HRA) with ablation of high-grade squamous intraepithelial lesions (HSIL) can prevent the development of anal cancer in people with HIV (PWH). The authors sought to characterize factors associated with successful HSIL resolution or local or metachronous recurrence.

METHODS

The authors conducted a retrospective study of 62 PWH who underwent HRAs from December 1, 2017, to July 1, 2022. Participants were ≥30 years old with ≥2 HRAs and ≥1 HSIL lesions. Poisson and logistic regressions were used to assess factors associated with HSIL resolution and local or metachronous recurrence of HSIL.

RESULTS

Of 62 PWH, 85.5% had resolution of at least 1 HSIL. Undergoing ≥5 HRAs with thermoablation was associated with HSIL resolution (adjusted rate ratio [aRR] = 2.82) (confidence interval [CI] = 1.55-5.15), p < .001). Tobacco use was negatively associated with resolution (aRR = 0.62 (CI = 0.43-0.90), p = .01). Of this cohort, 58.1% had HSIL recurrence. Having more HRAs (adjusted odds ratio [aOR] = 2.77 (CI = 1.27-6.06), p = .01) and female sex (aOR = 9.66 (CI = 1.14-81.85), p = .04) were associated with recurrence. Non-White race was negatively associated with recurrence (aOR = 0.12 (CI = 0.02-0.68), p = .04). This study was primarily limited by its retrospective nature and small sample size.

CONCLUSION

This study supports the utility of HRA/ablation for HSIL treatment with >85% of participants experiencing resolution of at least 1 HSIL. The authors found that having more HRAs was associated with a higher likelihood of resolution. However, the high rate of recurrence and progression to HSIL highlights the need for continued surveillance after treatment.

Trends in Cervical and Anal Cancer Incidence and Mortality in the United States

OBJECTIVES

This article describe trends in the incidence and mortality of cervical (CC) and anal (AC) cancers by race and neighborhood socioeconomic status.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to construct a cohort of CC and AC cases from 2006 to 2018. Incidence rates and survival were calculated by race and neighborhood socioeconomic status (nSES). Annual percent change (APC) in incidence was calculated using linear regression, and 5-year overall survival (OS) by the Kaplan-Meier method.

RESULTS

Of the cases, 33,487 CC and 16,018 AC cases were identified. Women of low nSES were nearly 4 times more likely to be diagnosed with cervical cancer than those of high nSES. Cervical cancer incidence declined marginally in all groups except for low nSES women who are White (APC 0.0). Women who are Black had lower 5-year OS than their nSES counterparts of other races (most notably for Black women of low nSES 53% vs White 63%). Similarly, the low nSES AC cohort contained nearly 3 times the number of diagnoses as the high nSES cohort. AC incidence increased most in women who are White (APC 1.8 and 2.2 for low and high nSES) and men who are Black and low nSES (APC 3.3). Five-year OS was lowest for men who are Asian American and Pacific Islander (40% and 50% for low and high nSES, respectively).

CONCLUSIONS

These data suggest a strong correlation between nSES, race, and their interaction on the incidence and survival trends of HPV-related disease and highlight inconsistent effects between cervical and anal cancers.

Health Disparities and Anal Cancer

Health disparities are preventable differences in health outcomes that are experienced by disadvantaged patient populations. Disparities in prevention, incidence, treatment, and mortality exist among patients with anal cancer. Factors contributing to these disparities are found at the patient, provider, health system, and public policy levels. Future multilevel interventions targeted at each of these levels will provide opportunities to reduce these disparity gaps and improve anal cancer care for all patient populations.

Anal cancer prevention: A field in need of scientific Advancement

Despite the availability of several human papillomavirus (HPV) vaccines, the incidence of HPV-associated anal cancer is growing at a rate of 2.2% each year. As shown in results from the recent Phase III ANCHOR study, the treatment of high-grade anal lesions in people living with HIV (PLWH) can significantly reduce rates of anal cancer development compared to active surveillance alone. As a result, screening programs to identify and treat patients with anal precancers are recommended by recent guidelines. Intense resources are needed to perform screening tests and follow-up abnormal results. The lack of effective and well-tolerated therapies, the lack of understanding regarding therapeutic targets, the paucity of preclinical models to test therapies, and the lack of biomarkers to determine which patients will develop cancer or respond to therapies are the issues that need to be addressed. We provide an overview of cutting-edge research and propose additional research that is needed to help move the field of anal cancer prevention forward. This review highlights the most significant current areas of research, as defined by the authors, and is by no means comprehensive of all anal dysplasia/cancer research.

Surgical protocols for oral leukoplakia and precancerous lesions across three different anatomic sites

OBJECTIVE

This systematic review and meta-analysis aimed to compare the risk of recurrence and cancer progression after surgical treatment for oral potentially malignant disorders (OPMD) and precancerous lesions in different anatomical sites.

MATERIALS AND METHODS

A comprehensive search was conducted in nine databases and grey literature. We included randomized controlled trials assessing surgical treatment efficacy for OPMD and precancerous lesions of cervical, vaginal, anal, and penile sites. Excision or ablation surgical treatments were considered.

RESULTS

Overall, 12 studies met the eligibility criteria for oral leukoplakia (OL), proliferative verrucous leukoplakia, cervical intraepithelial neoplasia (CIN), vaginal intraepithelial neoplasia, and anal intraepithelial neoplasia (AIN). In qualitative analysis of surgical protocols, the lack of margin description impacts the clinical outcomes of OL and AIN, and the ablative protocols were heterogeneous in both OPMD and precancerous lesions. No significant difference in OL (risk ratio 0.82 [95% CI: 0.59-1.15]) and CIN (risk ratio 0.31 [95% CI: 0.09-1.09]) for recurrence was observed when cold-knife was compared with ablative protocols. OL exhibited higher recurrence and cancer progression rates compared to CIN and AIN.

CONCLUSION

There is no difference in recurrence risk post-surgical treatment for OL and CIN. Surgical protocols for oral leukoplakia and CIN/AIN lack standardized approaches.

Using Anal Cytology and Human Papillomavirus DNA and E6/E7 mRNA Detection to Optimize High-Resolution Anoscopy Referrals in Men Who Have Sex With Men With HIV

Background

This study was conducted to evaluate screening procedures for anal high-grade squamous intraepithelial lesions (HSILs) with anal liquid-based cytology (aLBC) and biomarkers to identify candidates for high-resolution anoscopy (HRA).

Methods

This cross-sectional study included men who have sex with men with HIV. Participants underwent HRA, aLBC, and biomarker testing. Three screening procedures were compared with aLBC: biomarker alone, cytology and biomarker in all, and cytology and reflex biomarkers (biomarkers applied if aLBC results were atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion). Biomarkers included Linear Array (LA), LA for 14 high-risk human papillomavirus (LA 14 HR-HPV) genotypes, LA HPV-16, Hybrid Capture 2 (HC2), E6/E7 mRNA, and E6/E7 mRNA HPV-16.

Results

Of 354 participants, 179 (50.6%) had atypical squamous cells of undetermined significance or worse, requiring HRA (sensitivity, 80%; specificity, 57.3%; area under the curve, 0.687; reference, biopsy-proven HSIL). Cytology and reflex biomarkers per E6/E7 mRNA, LA 14 HR-HPV, and HC2 and the biomarker-alone procedure with HC2 showed comparable accuracy (sensitivities: 71.6%, 78.8%, 73.1%, 75.7%; specificities: 73.5%, 67.9%, 76.1%, 65.5%; areas under the curve: 0.726, 0.734, 0.746, 0.706) with fewer HRA referrals (number needed to diagnose: 2.2, 2.1, 2, 2.4).

Conclusions

Our findings suggest that E6/E7 mRNA, LA 14 HR-HPV, and HC2 in the cytology and reflex biomarkers procedure, as well as HC2 in the biomarker-alone procedure, can improve anal HSIL screening effectiveness.

Future Research Directions in Anal Cancer

While anal cancer is somewhat rare, it is increasing in incidence despite improving screening and the human papillomavirus vaccine. Given this, there is growing research into the management of high-grade squamous intraepithelial lesion as well as how to optimize screening approaches. This includes increased study of biomarkers to improve screening sensitivity as well as strategies to improve access and reduce loss to follow-up. Additionally, there is an ongoing research into the role of the microbiome in oncogenesis and research to adapt other treatments to anal cancer.

Considerations for the Treatment of Sexual and Gender Minority Individuals in Colon and Rectal Surgery

Sexual and gender minorities (SGMs) experience critical barriers to health care access and have unique health care needs that are often overlooked. Given the rise in individuals identifying as lesbian, gay, bisexual, transgender, and queer, colorectal surgeons are likely to care for increasing numbers of such individuals. Here, we discuss key barriers to health care access and research among SGM populations and outline approaches to address these barriers in clinical practice. We also highlight two specific topics relevant to SGM populations that colorectal surgeons should be familiar with: current approaches to anal cancer screening among men who have sex with men, and transgender individuals, as well as the management of recto-neovaginal fistula in transfeminine individuals.

Pathophysiology of Anal Cancer

The pathophysiology of the development of anal cancer is thought to be linked to chronic inflammation, a possible consequence of infections with human papillomavirus (HPV) or HIV, or inflammation from inflammatory bowel disease. Anal HPV-induced carcinogenesis bears similarities to its cervical counterpart via viral integration into the host genome and the development of precursor lesions termed anal intraepithelial neoplasia. HPV-16 and -18 are the most common HPV genotypes associated with anal cancer. Other risk factors for the development of anal cancer include chronic immunosuppression, sexual activity and sexually transmitted diseases, female gender, history of anogenital dysplasia, and smoking.

Prevention of Anal Cancer

Anal cancer, though rare, is witnessing an annual increase in incidence, predominantly of squamous cell carcinoma (SCC). Prevention strategies revolve around reducing risk factors such as human papillomavirus (HPV) infection, human immunodeficiency virus/acquired immunodeficiency syndrome, immunosuppression, smoking, and high-risk sexual practices, while advocating for HPV vaccination. The Anal Cancer-HSIL Outcomes Research trial validates treating anal high-grade squamous intraepithelial lesion to curb SCC development. Screening methods include digital anal rectal examination, anal Papanicolaou smear, HPV testing, and high-resolution anoscopy. However, standardized screening guidelines are lacking, necessitating future efforts to streamline protocols and enhance public awareness of anal cancer.

Retrospective Study of Risk Markers for Developing High-Grade Anal Intraepithelial Neoplasm in Men Who Have Sex With Men Living With HIV

BACKGROUND

High-grade anal intraepithelial squamous lesion is significantly prevalent among men who have sex with men and are infected with the human immunodeficiency virus (HIV). This condition-the precursor to anal cancer-significantly increases the risk of developing it. Conversely, low-grade anal intraepithelial squamous typically follow a benign course and usually regress spontaneously.

MATERIALS AND METHODS

To describe a population of men who have sex with men living with HIV followed in a specialized anal cancer screening unit we conducted an observational, retrospective, and single-center study.

RESULTS

Ninety-four patients were analyzed, with a mean age of 39±9 years, and a 87% positivity rate for high-risk human papillomavirus (HR-HPV). At the initial visit, 47% presented with low-grade squamous intraepithelial lesions. The progression rate to high-grade squamous intraepithelial lesion was 37.2 per 100,000 patients/year. None of the patients developed anal cancer. Tobacco and alcohol consumption were associated with this progression.

DISCUSSION

In this series, longer duration of HIV infection, tobacco and alcohol use and the presence of HR-HPV were significantly associated with the occurrence of high-grade intraepithelial lesions. A lower risk of progression was seen in patients with higher education.

CONCLUSION

In men who have sex with men living with HIV, the association of factors such as smoking, alcohol, the presence of HR-HPV and an increased burden of human papillomavirus disease makes these patients more susceptible to develop high-grade anal squamous lesions.

'Does human papillomavirus (HPV) cause cancer?' - A cross-sectional study of HPV awareness among sexual minority men in Nigeria

Background Human papillomavirus (HPV)-associated cancers are a global concern, particularly for sexual minority men (SMM). Understanding awareness and the determinants of these beliefs is crucial for developing educational programs to reduce HPV-associated cancers. This study explored awareness and determinants of beliefs about HPV's carcinogenicity among SMM living with and without HIV in Nigeria. Methods Participants were recruited through secure social media platforms in Abuja, Nigeria. REDCap surveys captured demographics, sexual practices and participants' beliefs regarding HPV's role in cancer. Multivariable logistic regression modeling was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the relationships between individual characteristics and belief levels stratified by those living with and without HIV. Results Of 982 participants, the median age was 29years (interquartile range: 26-34); 64.1% were living with HIV, and 9.7% believed HPV causes cancer. Awareness was highest for anal (82.1%) and penile cancers (15.8%) and less so for oropharyngeal and female HPV-associated cancers (range: 3-7%). Anogenital warts increased the odds of awareness for SMM living with HIV (aOR: 6.4, CI: 3.0-13.6) and for individuals without HIV (aOR: 4.8, CI: 1.6-14.2). Living with HIV for over 6years was independently associated with a two-fold increased knowledge about HPV's carcinogenicity (aOR: 2.1, CI: 1.1-4.1). Conclusions Awareness of HPV's carcinogenicity was low; however, those who were aware were more likely to identify male HPV-associated cancers relevant to their own cancer risk. Formalizing targeted education in HIV care settings may promote knowledge and advocacy for prevention strategies.

Diagnosis of Anal Cancer: Symptoms, Imaging, and Endoscopy

Anal cancer is an uncommon disease in a sensitive region of the body that benefits from early and systematic workup and treatment. Main modalities for workup include history, physical examination, and MRI. PET scan and computed tomography scan are helpful in assessing spread of disease. High-resolution anoscopy may be useful in identifying precancerous lesions but come with a high-learning curve.

Epidemiology of Anal Cancer

Anal cancer is a rare disease, accounting for only 2% of all gastrointestinal tract malignancies. While individuals with advanced age (>50 years) and female sex have an increased risk of anal cancer, there has been a trend toward diagnosis at a younger age particularly among men who have sex with men, irrespective of their human immunodeficiency virus status. Histologically, approximately 85% of anal cancers are squamous cell carcinomas (ASCC). However, while more than 90% of ASCC is associated with oncogenic human papillomavirus, the temporal trends of anal cancer incidence modeled on national databases represent an unmet need for primary prevention.