Anal cancer screening among women with HIV: provider experiences and system-level challenges

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 ).

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 .

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.

The Impact of Human Immunodeficiency Virus on Women in the United States

Substantial improvements have been made in reducing HIV incidence rates among women in the United States. However, numerous disparities affect women's risk of HIV acquisition, in addition to affecting treatment outcomes for women living with HIV. As people with HIV continue to live longer due to antiretroviral therapy, clinicians must be cognizant of various health, financial, and social implications that can affect HIV self-management. Successfully ending the HIV epidemic will require more targeted approaches on prevention, linkage to care, and treatment while also addressing underlying factors that affect women's engagement in HIV-related services across the HIV care continuum.

A Qualitative Study of Barriers to Anal Cancer Screenings in US Veterans Living with HIV

People living with human immunodeficiency virus (HIV) are at high risk for anal cancer. Anal cancer screenings are recommended annually for US veterans with HIV. Screenings can identify treatable precursor lesions and prevent cancer development. In a previous study, we found screening rate to be only 15%. Semistructured interviews were conducted with Veterans Affairs (VA) providers who treat veterans living with HIV. Participants described their experiences with anal cancer screenings. Researchers developed a codebook based on Theoretical Domains Framework (TDF) and coded data using thematic analysis to identify barriers to anal cancer screenings. Twenty-three interviews were conducted with VA providers representing 10 regions. Barriers identified corresponded with five targetable TDF domains: Knowledge, Skills, Environmental Context/Resources, Professional Roles/Identities, and Social Influence. Many providers lacked knowledge of screening protocols. Knowledgeable providers often lacked needed resources, including swabs, clinic space, reliable pathology, access to high-resolution anoscopy, or leadership support to implement a screening program. Providers mentioned competing priorities in the care of veterans with HIV infection and lack of skilled/trained personnel to perform the tests. It was often unclear which provider specialty should "own" screening responsibilities. Additional factors included patient discomfort with screening exams. Anal cancer screening protocols are recommended but not widely adopted in VA. There is a critical need to address barriers to anal cancer screenings in veterans. The TDF domains identified align with five intervention domains to target, including education, training, resource/environment, delineation of provider roles, and improved counseling efforts. Targeting these barriers may help improve the uptake of anal cancer screenings within VA.

Perspectives on preparing for long-acting injectable treatment for HIV among consumer, clinical and nonclinical stakeholders: A qualitative study exploring the anticipated challenges and opportunities for implementation in Los Angeles County

Long-acting injectable (LAI) antiretroviral therapy (ART) is a novel HIV treatment option for people with HIV. The first LAI ART regimen for HIV treatment received regulatory approval in the United States in January 2021. In February 2020, we collected qualitative data from 18 consumers and 23 clinical and non-clinical stakeholders to catalog anticipated individual-consumer, healthcare system, and structural levels barriers and facilitators to LAI ART implementation in Los Angeles County, California. Thematic analysis was guided by the CFIR implementation science model. CFIR constructs of intervention characteristics, individual characteristics, outer and inner setting, intervention characteristics, and implementation process emerged in analysis. Under intervention characteristics, anticipated facilitators included the relative advantage of LAI ART over pills for adherence and reduced treatment management burden and related anxiety; anticipated barriers included non-adherence to injection appointments, concerns of developing HIV resistance, discomfort with injection and cost. Anticipated facilitators based on individual characteristics included overall acceptability based on knowledge and positive beliefs about LAI ART. Participant noted several characteristics of the outer setting that could negatively impact implementation, such as medical mistrust, external policies, and LAI ART eligibility (i.e., to be virally suppressed prior to initiation). Participants were optimistic about the potential to decrease stigma but expressed that provider willingness for adoption could be hindered by challenges in organizational inner setting related to payment authorizations, increased staffing needs, medication procurement and storage, and provider and healthcare system readiness. Results from this pre-implementation study may inform rollout and scale-up of LAI ART in Los Angeles County.

Genome-wide host methylation profiling of anal and cervical carcinoma

HPV infection results in changes in host gene methylation which, in turn, are thought to contribute to the neoplastic progression of HPV-associated cancers. The objective of this study was to identify joint and disease-specific genome-wide methylation changes in anal and cervical cancer as well as changes in high-grade pre-neoplastic lesions. Formalin-fixed paraffin-embedded (FFPE) anal tissues (n = 143; 99% HPV+) and fresh frozen cervical tissues (n = 28; 100% HPV+) underwent microdissection, DNA extraction, HPV genotyping, bisulfite modification, DNA restoration (FFPE) and analysis by the Illumina HumanMethylation450 Array. Differentially methylated regions (DMR; t test q<0.01, 3 consecutive significant CpG probes and mean Δβ methylation value>0.3) were compared between normal and cancer specimens in partial least squares (PLS) models and then used to classify anal or cervical intraepithelial neoplasia-3 (AIN3/CIN3). In AC, an 84-gene PLS signature (355 significant probes) differentiated normal anal mucosa (NM; n = 9) from AC (n = 121) while a 36-gene PLS signature (173 significant probes) differentiated normal cervical epithelium (n = 10) from CC (n = 9). The CC progression signature was validated using three independent publicly available datasets (n = 424 cases). The AC and CC progression PLS signatures were interchangeable in segregating normal, AIN3/CIN3 and AC and CC and were found to include 17 common overlapping hypermethylated genes. Moreover, these signatures segregated AIN3/CIN3 lesions similarly into cancer-like and normal-like categories. Distinct methylation changes occur across the genome during the progression of AC and CC with overall similar profiles and add to the evidence suggesting that HPV-driven oncogenesis may result in similar non-random methylomic events. Our findings may lead to identification of potential epigenetic drivers of HPV-associated cancers and also, of potential markers to identify higher risk pre-cancerous lesions.