Routine anal Pap smear testing gains ground.
The role of routine anal Pap smear screening is controversial in part because a clear link between anal intraepithelial neoplasia (AIN) and anal cancer has long been assumed, but never demonstrated in prospective trials. Other factors may be that clinicians are unfamiliar or uncomfortable with the disease, programmatic considerations, and the lack of clear guidelines for screening and treating various manifestations of anal neoplasia.
Advocates note that cytology is as effective in detecting anal disease as it is in cervical disease, and that cost-effective studies suggest that anal Pap screening is a viable option.
Skeptics contend that treatments for AIN often fail and there is no data that early diagnosis leads to improved survival, function, or quality of life in patients with anal cancer.
The issue has taken on new urgency with a recent change in New York's HIV Clinical Guidelines stipulating that in order to receive state or federal HIV funding, health centers must perform routine anal cytology in HIV-infected individuals who belong to one of the following categories: men who have sex with men, any patient with a history of anogenital condylomas, and women with abnormal cervical and/or vulvar histology. Many health centers serving homosexual men are already providing the service, said Dr. Wright, a professor of pathology and director of gynecologic and obstetric pathology at Columbia University, New York.
"They are getting a lot of 'abnormals,' and the internists are calling us as people who specialize in gynecologic disease, and asking, 'What do I do with them?'" Dr. Wright said. "You are going to be seeing a lot more of this, and anal exams are going to become important to you."
Dr. Wright acknowledged that anoscopy is much more difficult than colposcopy to perform because of the smaller, confined space and the tendency of the anus to move. In addition, anal mucosa frequently reacts to acetic acid, which makes the differential diagnosis difficult; hypertrophic papillae can mimic warts; and biopsy sites frequently bleed.
"It makes you much more worried to do these procedures than it does colposcopy," he said. "I hate telling patients they are probably going to be bleeding for a day or two."
AIN appears as flat red areas that react strongly to acetic acid, and can have prominent vascular features including extensive coarse mosaicism or punctuation. AIN occurs most frequently at the anal squamocolumnar junction, although it can occur in the anal canal below the dentate line. It also can be contiguous with perianal intraepithelial neoplasia, Dr. Wright said.
Currently, neither the U.S. Centers for Disease Control, the U.S. Preventative Services Task Force, the American Cancer Society, or the Infectious Diseases Society of the United States recommend routine anal cytologic screening, Dr. Wright said at the conference sponsored by the American Society for Colposcopy and Cervical Pathology (ASCCP).
ASCCP president Dr. Mark Spitzer said in an interview that the organization doesn't have guidelines on routine anal cytologic screening because there is not yet sufficient scientific evidence to show that anal cytology and high-resolution anoscopy work to reduce the incidence of anal cancer.
"Current practice merely extrapolates from our very successful experience with cervical cytology and colposcopy of the cervix, vagina, and vulva," Dr. Spitzer said.
Both Dr. Spitzer and Dr. Wright said there needs to be training for pathologists on the interpretation of anal cytology and for clinical practitioners on the obtaining of specimens.
"Routine screening doesn't make sense until a specific group of professionals are trained in how to deal with positives," Dr. Wright said in an interview.
In the meantime, the New York mandate is not yet on the radar screen of some physicians, while anal screening has been underway for about a year at the Montefiore Medical Center's HIV Clinic and Jacobi Medical Center, which serve 1.4 million women in the Bronx, N.Y, and a large HIV population. The centers screen not only HIV-infected men and women, but also women with other human papillomavirus (HPV)-associated precancerous lesions, said Dr. Mark Einstein, a gynecologic oncologist and director of clinical research for the Division of Gynecologic Oncology at Montefiore Medical Center.
"The mandate coming down is a fantastic thing, and it's about time," Dr. Einstein said in an interview. "The biggest issue, even in the era of HAART [highly active antiretroviral treatment] and antiretroviral HIV therapies, is that the incidence of anal disease and anal cancer continues to increase as opposed to all other AIDS-associated diseases and malignancies that are on the decline in this country. This is a disturbing trend."
Having recognized this trend, the National Cancer Institute's AIDS Malignancy Consortium requires baseline anal Pap screening and anoscopy as part of all its trial protocols, said Dr. Einstein, a member of the consortium's HPV working group.
Dr. Einstein agrees that part of the problem with anal disease is the lack of trained professionals to perform the testing and treatments necessary for these patients. And he called on a variety of stakeholders in women's health such as ob.gyns., gastroenterologists, and family physicians to provide input on how to broaden professional training.
As more states adopt these mandates, state officials are also going to have to participate in regulation, a process for which New York officials are already preparing, Dr. Einstein said.
BY PATRICE WENDLING
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|Title Annotation:||Women's Health|
|Publication:||Internal Medicine News|
|Date:||Feb 1, 2008|
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