Rising Anal Cancer Incidence Parallels HPV, AIDS

SAN FRANCISCO — The HIV epidemic has brought to light evidence that men who have sex with men now have a rate of anal cancer as high as the incidence rate of cervical cancer in women prior to Pap smear.

The incidence rate in women also has risen, Dr. Joel Palefsky said at a meeting on HIV management sponsored by the University of California, San Francisco.

The incidence rate of cervical cancer prior to Pap smear screening was 40–50 cases per 100,000 females. The present rate of anal cancer in HIV-negative men who have sex with men is 35 per 100,000, and the rate for HIV-positive men is probably twice as high, said Dr. Palefsky, a professor of medicine and the director of the Anal Dysplasia Clinic at the UCSF Cancer Center.

Both anal dysplasia and cervical cancer are related to human papillomavirus (HPV) infection. The incidence rate in HIV-positive men appears to be rising for a few reasons. Highly active antiretroviral therapy (HAART) is prolonging the life of HIV-infected individuals long enough for cancer to develop. HIV infection itself accelerates the process, said Dr. Palefsky, who is part of group urging anal Pap smear screening for at-risk individuals. “If you are HIV positive, you have anal HPV infection,” he said.

Studies he conducted in the pre-HAART era found abnormal anal cytology in 80% of HIV-infected men with CD4 T-cell levels less than 200 cells/mcL, Dr. Palefsky said. Since then, studies have shown that HPV-infected persons develop intraepithelial neoplasia regularly and rapidly, and that HAART may not lower the incidence (Clin. Infect. Dis. 2002;35:1127–34).

Women too have high rates of anal HPV infection, and it is not just HIV-positive women, he said. In the Women's Interagency HIV Study, they found a high prevalence of HPV infection. In fact, anal HPV was more common than cervical infection in both 251 HIV-positive women (79% vs. 53%) and in 68 HIV-negative women (43% vs. 24%) (J. Infect. Dis. 2001;183:383–91).

Surveys he did in Planned Parenthood clinics and a cervical dysplasia clinic also suggest that anal HPV infection is as least as common as cervical HPV in women.

Evidence that anal cancer is becoming more common is less certain, Dr. Palefsky said. Data from the Surveillance, Epidemiology, and End Results survey suggest that squamous cell carcinoma of the anus has increased perhaps 96% in men and 39% in women over the past 40 years.

Much of anal HPV infection results from receptive anal intercourse, but not all. It has been found to be common in HIV-positive men who are injection drug users.

Data suggest that half of women in this country engage in anal intercourse at least once in their lifetime, and, “as we know from the cervix, it doesn't take too many exposures to get HPV,” he noted.

Dr. Palefsky said he examines for anal dysplasia the same way one does for cervical dysplasia. He inserts a water-moistened Dacron swab into the anus and rubs the swab around the wall of the canal. The material obtained is graded according to the Bethesda System like a cervical sample.

A digital rectal exam, done after the swabbing, requires lubricant. “You will feel things with your finger that you'll not see either on a Pap smear or through the anoscope because a lot of the cancers are subcutaneous at that point,” he said.

Patients with a positive Pap smear undergo examination with a cervical colposcope. A gauze pad is soaked in a vinegar solution (2:1 vinegar to water), then wrapped around a swab and inserted through an anoscope. The anoscope is then removed, and the gauze is left in place for 1 minute. Once the gauze is removed, the anoscope is reinserted and examination is done with the colposcope.

The same signs used for the cervix have been validated in the anal canal, he said.

Small lesions can be treated with trichlor-oacetic acid, and larger lesions can be treated with infrared coagulation, which is being shown to be successful, he added.

Squamous cell carcinoma of the anus has increased perhaps 96% in men and 39% in women over the past 40 years. DR. PALEFSKY

SAN FRANCISCO — The HIV epidemic has brought to light evidence that men who have sex with men now have a rate of anal cancer as high as the incidence rate of cervical cancer in women prior to Pap smear.

The incidence rate in women also has risen, Dr. Joel Palefsky said at a meeting on HIV management sponsored by the University of California, San Francisco.

The incidence rate of cervical cancer prior to Pap smear screening was 40–50 cases per 100,000 females. The present rate of anal cancer in HIV-negative men who have sex with men is 35 per 100,000, and the rate for HIV-positive men is probably twice as high, said Dr. Palefsky, a professor of medicine and the director of the Anal Dysplasia Clinic at the UCSF Cancer Center.

Both anal dysplasia and cervical cancer are related to human papillomavirus (HPV) infection. The incidence rate in HIV-positive men appears to be rising for a few reasons. Highly active antiretroviral therapy (HAART) is prolonging the life of HIV-infected individuals long enough for cancer to develop. HIV infection itself accelerates the process, said Dr. Palefsky, who is part of group urging anal Pap smear screening for at-risk individuals. “If you are HIV positive, you have anal HPV infection,” he said.

Studies he conducted in the pre-HAART era found abnormal anal cytology in 80% of HIV-infected men with CD4 T-cell levels less than 200 cells/mcL, Dr. Palefsky said. Since then, studies have shown that HPV-infected persons develop intraepithelial neoplasia regularly and rapidly, and that HAART may not lower the incidence (Clin. Infect. Dis. 2002;35:1127–34).

Women too have high rates of anal HPV infection, and it is not just HIV-positive women, he said. In the Women's Interagency HIV Study, they found a high prevalence of HPV infection. In fact, anal HPV was more common than cervical infection in both 251 HIV-positive women (79% vs. 53%) and in 68 HIV-negative women (43% vs. 24%) (J. Infect. Dis. 2001;183:383–91).

Surveys he did in Planned Parenthood clinics and a cervical dysplasia clinic also suggest that anal HPV infection is as least as common as cervical HPV in women.

Evidence that anal cancer is becoming more common is less certain, Dr. Palefsky said. Data from the Surveillance, Epidemiology, and End Results survey suggest that squamous cell carcinoma of the anus has increased perhaps 96% in men and 39% in women over the past 40 years.

Much of anal HPV infection results from receptive anal intercourse, but not all. It has been found to be common in HIV-positive men who are injection drug users.

Data suggest that half of women in this country engage in anal intercourse at least once in their lifetime, and, “as we know from the cervix, it doesn't take too many exposures to get HPV,” he noted.

Dr. Palefsky said he examines for anal dysplasia the same way one does for cervical dysplasia. He inserts a water-moistened Dacron swab into the anus and rubs the swab around the wall of the canal. The material obtained is graded according to the Bethesda System like a cervical sample.

A digital rectal exam, done after the swabbing, requires lubricant. “You will feel things with your finger that you'll not see either on a Pap smear or through the anoscope because a lot of the cancers are subcutaneous at that point,” he said.

Patients with a positive Pap smear undergo examination with a cervical colposcope. A gauze pad is soaked in a vinegar solution (2:1 vinegar to water), then wrapped around a swab and inserted through an anoscope. The anoscope is then removed, and the gauze is left in place for 1 minute. Once the gauze is removed, the anoscope is reinserted and examination is done with the colposcope.

The same signs used for the cervix have been validated in the anal canal, he said.

Small lesions can be treated with trichlor-oacetic acid, and larger lesions can be treated with infrared coagulation, which is being shown to be successful, he added.

Squamous cell carcinoma of the anus has increased perhaps 96% in men and 39% in women over the past 40 years. DR. PALEFSKY

SAN FRANCISCO — The HIV epidemic has brought to light evidence that men who have sex with men now have a rate of anal cancer as high as the incidence rate of cervical cancer in women prior to Pap smear.

The incidence rate in women also has risen, Dr. Joel Palefsky said at a meeting on HIV management sponsored by the University of California, San Francisco.

The incidence rate of cervical cancer prior to Pap smear screening was 40–50 cases per 100,000 females. The present rate of anal cancer in HIV-negative men who have sex with men is 35 per 100,000, and the rate for HIV-positive men is probably twice as high, said Dr. Palefsky, a professor of medicine and the director of the Anal Dysplasia Clinic at the UCSF Cancer Center.

Both anal dysplasia and cervical cancer are related to human papillomavirus (HPV) infection. The incidence rate in HIV-positive men appears to be rising for a few reasons. Highly active antiretroviral therapy (HAART) is prolonging the life of HIV-infected individuals long enough for cancer to develop. HIV infection itself accelerates the process, said Dr. Palefsky, who is part of group urging anal Pap smear screening for at-risk individuals. “If you are HIV positive, you have anal HPV infection,” he said.

Studies he conducted in the pre-HAART era found abnormal anal cytology in 80% of HIV-infected men with CD4 T-cell levels less than 200 cells/mcL, Dr. Palefsky said. Since then, studies have shown that HPV-infected persons develop intraepithelial neoplasia regularly and rapidly, and that HAART may not lower the incidence (Clin. Infect. Dis. 2002;35:1127–34).

Women too have high rates of anal HPV infection, and it is not just HIV-positive women, he said. In the Women's Interagency HIV Study, they found a high prevalence of HPV infection. In fact, anal HPV was more common than cervical infection in both 251 HIV-positive women (79% vs. 53%) and in 68 HIV-negative women (43% vs. 24%) (J. Infect. Dis. 2001;183:383–91).

Surveys he did in Planned Parenthood clinics and a cervical dysplasia clinic also suggest that anal HPV infection is as least as common as cervical HPV in women.

Evidence that anal cancer is becoming more common is less certain, Dr. Palefsky said. Data from the Surveillance, Epidemiology, and End Results survey suggest that squamous cell carcinoma of the anus has increased perhaps 96% in men and 39% in women over the past 40 years.

Much of anal HPV infection results from receptive anal intercourse, but not all. It has been found to be common in HIV-positive men who are injection drug users.

Data suggest that half of women in this country engage in anal intercourse at least once in their lifetime, and, “as we know from the cervix, it doesn't take too many exposures to get HPV,” he noted.

Dr. Palefsky said he examines for anal dysplasia the same way one does for cervical dysplasia. He inserts a water-moistened Dacron swab into the anus and rubs the swab around the wall of the canal. The material obtained is graded according to the Bethesda System like a cervical sample.

A digital rectal exam, done after the swabbing, requires lubricant. “You will feel things with your finger that you'll not see either on a Pap smear or through the anoscope because a lot of the cancers are subcutaneous at that point,” he said.

Patients with a positive Pap smear undergo examination with a cervical colposcope. A gauze pad is soaked in a vinegar solution (2:1 vinegar to water), then wrapped around a swab and inserted through an anoscope. The anoscope is then removed, and the gauze is left in place for 1 minute. Once the gauze is removed, the anoscope is reinserted and examination is done with the colposcope.

The same signs used for the cervix have been validated in the anal canal, he said.

Small lesions can be treated with trichlor-oacetic acid, and larger lesions can be treated with infrared coagulation, which is being shown to be successful, he added.

Squamous cell carcinoma of the anus has increased perhaps 96% in men and 39% in women over the past 40 years. DR. PALEFSKY