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HIV-positive men at high risk for anal cancer
by Matthew S. Bajko
Published 11/26/2009
Cancer researchers have found that since the introduction of highly active antiretroviral therapy HIV-positive men's chances of having human papillomavirus (HPV) related anal cancers have increased. Yet many are not only unaware of their heightened risk but also do not know to seek HPV screening.
The lack of attention paid to HPV infections among HIVers has led to an incidence rate of anal cancer among HIV-positive men that now exceeds the highest incidence of cervical cancer among women reported anywhere in the world, recent studies have found.
"The incidence of human papillomavirus-associated anal cancer is unacceptably high among HIV-positive men who have sex with men, and possibly in HIV-positive women. Unlike most other malignancies occurring in the HIV-positive population, anal cancer is potentially preventable, using methods similar to those used to prevent cervical cancer in women," wrote Dr. Joel M. Palefsky, the co-leader of the cancer and immunity program at the Helen Diller Family Comprehensive Cancer Center at the University of California, San Francisco, in an article this year in the medical journal Current Opinion in Oncology. "The high incidence of anal cancer among HIV-positive individuals must not be ignored, since it may be preventable."
In the United States, the rate for anal cancer in the general population is 1 case per 100,000 people; among HIV-negative men who have sex with men the rate increases to 35 cases per 100,000 people.
But in HIV-positive gay and bisexual men the rate is estimated to be between 75 to 115 cases per 100,000 people.
"That is a huge number. It is not just a San Francisco phenomenon, it is happening all over the world," said Dr. J. Michael Berry, associate clinical professor of medicine in the Department of Hematology Oncology and associate director for HPV-related clinical studies at UCSF. "When we look at HIV-positive men, almost all of them will have HPV virus if we look for it."
Berry estimated that 95 percent of HIV-positive men have HPV and that more than 50 percent will have "precancerous changes" due to the virus.
"A small percentage will go on to develop cancer," he said.
The problem, said Berry, is that no one is talking about this growing health risk for HIV-positive men.
"People don't want to talk about their butts," said Berry. "I am happy to do it."
Even those gay men who think they are well informed about the health risks they face often are unaware to talk to their doctors about HPV infections or ask to be screened for anal warts.
Rick Payne-BeLow thought he knew everything when it came to gay men's health issues. At age 59, he has been HIV-positive for three decades and runs a Web site called California Cleanse aimed at promoting holistic and natural approaches to health care.
For several years he has spoken to high school and college students throughout Sonoma, Marin, and Mendocino counties about HIV and other sexually transmitted diseases. In particular, the Santa Rosa resident has focused on HPV infections. Yet Payne-BeLow was shocked to learn this July that not only did he have HPV, he likely has been co-infected with HIV and HPV for 30 years.
"In 2007 I had a colonoscopy and the doctor said, 'You are fine. Come back in 10 years.' They are not looking for HPV," he said. "Men don't know they are co-infected with HPV. My brothers in particular who have had HIV 20-plus years now need to ask their doctors about being screened for HPV."
It was only after he noticed several black marks on his body this summer, which his doctor could not diagnose, that he saw Berry at UCSF who confirmed it was HPV. In September Berry removed the colony of anal warts near his rectum. "This is a life changer for me. I can't think about having anal cancer," said Payne-BeLow.
Dr. Marcus Conant, who has been treating HIV-positive patients since the 1980s, faults health professionals for the rise in HPV-related anal cancers. He said too many doctors do not think to check their patients for signs of anal warts. "An HIV-positive man with a history of anal warts should request their doctor take a Pap smear," he said.
Over the last eight years he said he has made it routine to take a male Pap smear, where he collects tissue from the rectum and has it tested for signs of anal cancer.
"Most doctors in town don't even think about the fact the guy needs a Pap smear of his butt," said Conant. "Some say most people don't get cancer so you don't need to be concerned about it; others say you need to get a check up every six months. If it were me, I would do it every six months."
UCSF 15 years ago created the first clinic devoted specifically to treating and preventing anal cancer among HIV-positive men. Berry said many times a simple rectal exam with a finger is all that is needed for an HPV diagnosis.
"I can't tell you how many people who come to see me where if their doctor had inserted a finger in their anus and examined it, they would have realized something is happening," he said. "Anal cancers can be detected by doing digital rectal examinations."
While HIV-positive people can undergo chemotherapy and radiation to treat their anal cancers, it can be incredibly invasive for the patient, said Berry. "They don't do quite as well," he said.
Berry said there are signs that health care providers are increasingly screening patients for HPV as the concerns about anal cancer among HIV-positive people becomes better known.
"We have been making progress, albeit slowly," he said.
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