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Experimental NYC HIV Anal Cancer Screening Clinic
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following the first letter is a 2nd letter questioning the efficacy of an analcancer clinic and requesting outcomes from the Mt Sinai clinic.
Successful initiation of an anal cancer screening and treatment program at a New York City HIV clinic
AIDS:
24 April 2010
Correspondance
NYS Guidelines recommendations on anal pap smears
Click on "Clinical Guidelines" and you'll see current NYS DOH guidelines in ... multiple sexual partners, HPV infection, and receptive anal intercourse. ...
www.natap.org/2010/HIV/032510_01.htm
Tider, Diane S; Caprio, Gabriela Rodriguez; Gaisa, Michael; Klein, Robert S; Goldstone, Stephen E
Mount Sinai School of Medicine, New York, New York, USA.
We read with interest the correspondence by Shalev et al. [1]'s regarding new New York State AIDS Institute guidelines for anal cancer screening and treatment in HIV-positive persons. The authors assert that the guidelines would require almost 50% of their patients to undergo routine anal screening, which is a large figure considering the absence of Centers for Disease Control directives or national standards. They noted that such an endeavor takes time and resources, and questioned the justification of such expenditures, in advance of the creation of broader policy.
At Mount Sinai, we have spent the last year initiating an anal cancer screening and treatment program within our HIV clinic, in response to the New York State guidelines. On the basis of the proven reduction of morbidity and mortality with cervical Papanicolaou (Pap) testing, recommendations were extended in 2007 to include anal cancer screening with annual visual and digital anal exams for all HIV-positive adults, and annual anal Pap testing for men who have sex with men, women with prior abnormal cervicovaginal histology, and persons with prior anogenital condyloma. Those with abnormal findings require follow-up with high-resolution anoscopy (HRA), with biopsy and treatment when appropriate [2].
Human papillomavirus (HPV), an established carcinogen and causative factor in cervicovaginal [3-5] and anal cancers [6-14], is particularly virulent in HIV-positive persons [15]. Cervical cancer is an AIDS-defining malignancy [16], and HPV-related anal, gynecologic, penile, and oropharyngeal cancers have all been associated with HIV/AIDS [6]. Although rare in the general population [17], anal cancer is increasingly prevalent in HIV-positive persons on highly active antiretroviral therapy [18].
In 2008, we successfully applied for Ryan White Title III HIV Capacity Development funding for 1 year to initiate an anal screening and treatment program within our New York City HIV clinic. We identified an infectious diseases physician interested in HRA, and partnered with an expert in the field for training and oversight. We collaborated with our institution's colon and rectal surgery department to streamline the referral process for patients requiring surgery. Our overall goal was to diagnose and treat as many patients as possible in clinic, rather than in surgery, where anoscopy and ablation had been performed in the past.
We purchased equipment and supplies for anal Pap testing, HRA, and ablation, including swabs, cytobrushes, and Thin-Prep Pap Test collection kits, Baby Tischler biopsy punches, a universal power procedures examination table that converts to the knee-chest position, a state-of-the-art colposcope, and an infrared coagulator. A procedure room was identified and stocked in the clinic.
Primary care providers in the clinic were educated on the new guidelines and trained in performing anal Pap smears via literature and an instructional DVD from Johns Hopkins University. Anal Pap smears were added as annual visit quality indicators. We developed instruction sheets on the anal Pap smear technique and ordering, and adapted a referral algorithm to post in examination rooms. Finally, we developed a low health literacy brochure to help patients understand the purpose and significance of anal Pap smears, HRA, and the results obtained.
In a short period of time, providers integrated anal Pap testing into their practice. An initially high rate of inadequate specimens lead to discussions about technique and practice. After consulting with our pathologists, inconsistencies in cytology reporting were remedied, and providers were educated on the interpretation and implications of anal cytology results.
In just under a year, 212 patients (47% women) underwent anal Pap testing. Similar to the forecasted rates of Shalev et al. [1], 44% of adequate cytology specimens were abnormal and were scheduled for HRA. Patients with extensive disease on HRA are referred to colon and rectal surgery clinic. Patients with more limited disease are treated in-office with infrared coagulator ablation [19-21].
Although the initiation of our anal cancer screening program took substantial time, effort, and funding, over the last year, our team has built a successful and dynamic program to meet New York State AIDS Institute guidelines. We believe that the preliminary evidence justifying the need for this clinical service is convincing, even if it has not yet proven cost-effective in large multicenter clinical studies. Although further studies are warranted, epidemiologic data and anecdotal reports of substantial morbidity and mortality in young, HIV-infected persons from this treatable condition should not await definitive cost-benefit studies before action is taken. At Mount Sinai, we now provide a valuable clinical service to patients at high risk for anal dysplasia.
Targeted anal cancer screening in HIV-infected patients: prevalence of screening indicators
AIDS:
24 April 2010 6e9a1
Correspondance
Shalev, Noga; Olender, Susan A; Chiasson, Mary Ann
aDivision of Infectious Diseases, Columbia University Medical Center, USA
bPublic Health Solutions, New York, New York, USA.
We thank Tider et al. [1] for their response to our research letter. The incidence of anal cancer in HIV-infected individuals is far higher than the general population but the utility of screening has not been established [2]. As medical providers to HIV-infected patients, we share the respondents' concerns regarding the excessive morbidity and mortality associated with anal carcinoma. Tider et al. [1] provide a detailed description of anal cancer screening Ôscale upÕ in an HIV clinic. However, the authors do not share information about key outcomes, such as the number of patients referred to high-resolution anoscopy, the proportion referred who underwent the procedure, or the correlation between cytological and anoscopic findings. In addition, neither the proportion of patients undergoing treatment, nor treatment response data are presented. These data are essential for guiding clinician practice.
Our concerns about anal cancer screening rest on the fear that screening will result in unnecessary diagnostic work-up and treatment without decreasing morbidity and mortality. As was recently illustrated by the US Preventive Service Task Force's revised recommendations on the use of mammograms [3], the benefit of screening is far more nuanced than our desire to prevent illness.
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