Researchers have introduced the first screening and treatment recommendations to prevent anal cancer in patients with the human immunodeficiency virus (HIV), according to new guidelines based on the results of a 2022 study published by Palefsky et al in The New England Journal of Medicine.
Background
Although anal cancer is rare within the general population, cases have been rising, and among patients with HIV, it is the fourth most common cancer type. Because anal cancer may have no symptoms in its early stages, patients may mistake it for hemorrhoids. By the time it’s diagnosed, the disease may already have metastasized.
Among patients with the human papillomavirus (HPV)—a common sexually transmitted virus— coinfection with HIV can increase the risk of developing anal cancer.
2022 Study Findings
In the ANCHOR trial, researchers found that routine screening for and removal of precancerous anal lesions could significantly reduce the risk of developing anal cancer.
The study’s findings informed the first guidelines at the federal level in the United States to detect and treat anal cancer precursor lesions in patients with HIV.
Overview of New Guidelines
The guidelines were established by the U.S. Department of Health and Human Services’ Panel on the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV. The panel was a working group of the National Institutes of Health (NIH) Office of AIDS Research Advisory Council in collaboration with the U.S. Centers for Disease Control and Prevention, the HIV Medicine Association, and the Infectious Diseases Society of America.
“Men with HIV who have sex with men [as well as] transgender women with HIV are the groups at the highest risk of anal cancer,” noted the guideline authors.
The guidelines suggested that if high-resolution anoscopy is available, certain adults with HIV—including men and transgender women aged 35 years and older who have sex with men as well as men and women aged 45 years and older who don’t have sex with men—should undergo screening for anal cancer precursor lesions with laboratory testing of an anal swab sample and a digital anorectal examination to feel for changes that may indicate the presence of a tumor.
“The screening procedure is quite simple,” detailed lead study author Joel M. Palefsky, MD, Professor of Medicine at the University of California, San Francisco Infectious Disease Division. “If the screening test is positive, the next step of the evaluation is [high-resolution anoscopy]. If an anal cancer precursor lesion is found at [high-resolution anoscopy], it is then treated to reduce the risk of progressing to cancer,” he indicated.
If high-resolution anoscopy is not available, patients with HIV who are of screening age were still advised to undergo an annual rectal exam and be referred for standard anoscopy if the screen is positive. Those who have pain, bleeding, or masses; or show signs of anal cancer should undergo standard anoscopy. The researchers emphasized that symptomatic patients under 35 years of age with HIV should also undergo standard anoscopy.
Conclusions
“Anal cancer is a very bad disease, and we now have the tools to significantly reduce the risk. With [these] new recommendations, we hope that screening for anal cancer becomes a routine procedure in the care of [patients] with HIV,” highlighted Dr. Palefsky. “I strongly encourage [patients] with HIV to discuss anal cancer screening with their primary care providers,” he concluded.
To view the full guidelines, visit clinicalinfo.hiv.gov.
Disclosure: The ANCHOR study was funded by the National Cancer Institute of the NIH. For full disclosures of the 2022 study authors, visit nejm.org.
