1. Shihabuddin, Courtney DuBois APRN-CNP, AAHIVS


Usually HPV related, the cancer is increasingly common in this population.


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Anal cancer is the fourth most common cancer among HIV-infected patients, behind Kaposi's sarcoma, non-Hodgkin's lymphoma, and lung cancer. Cancer is more common in HIV-infected patients owing to various risk factors, including viral coinfections such as human papillomavirus (HPV), which is strongly associated with anal cancer. Unfortunately, anal cancer is often detected at advanced stages because its symptoms are similar to those of benign rectal and perianal conditions such as hemorrhoids and anal fissures. For the HIV-infected population, initiating annual anal Pap tests, minimally invasive screening that can be performed by any qualified health care provider, can allow early detection and treatment of anal dysplasia and malignancy and decrease the incidence of anal cancers that are advanced at time of diagnosis.

Figure. Courtney DuB... - Click to enlarge in new window Courtney DuBois Shihabuddin

But barriers exist to instituting anal Pap screening. Unlike for cervical cancer, the U.S. Department of Health and Human Services' HIV treatment guidelines contain no recommendation for annual Pap screenings for anal cancer. And although studies have shown that anal cytology may be cost-effective and clinically beneficial in those with HIV infection, no randomized controlled trials have examined the advantages of screening this high-risk population. In the absence of strong supporting data, HIV guidelines have not been revised to include an annual anal Pap screening recommendation. Without such a recommendation, obtaining funding to perform this test in a federally funded clinic-such as ours-will continue to be challenging.


Out of 1,752 patients seen at our clinic last year, 144 (8.2%) had at least one of the following diagnoses, based on diagnostic codes: condyloma acuminatum (59%), genital warts (35%), dysplasia of anus (3%), or malignant neoplasm of anus (3%). In my own patient cohort, I have had five patients with well-controlled HIV develop invasive squamous cell anal carcinoma in the past year. This has resulted in surgical procedures and multiple rounds of chemotherapy and radiation therapy, contributing to a myriad of complications, including pancytopenia, neutropenic fever, severe sepsis, third-degree radiation burns, respiratory failure, and others. These previously stable patients have experienced rapidly declining CD4 cell counts requiring the addition of opportunistic infection prophylaxis.


The impact of anal cancer on HIV-infected patients extends beyond the patient to the overall cost of care. In our facility, which is currently without a screening program, the estimated cost of screening a person for anal dysplasia using anal cytology is approximately $89 per patient. It would cost approximately $133,500 to screen the 1,500 HIV-infected patients at our clinic each year. While screening these patients adds cost, Goldie and colleagues reported in JAMA (1999) that screening HIV-infected homosexual and bisexual men provided quality-adjusted life expectancy gains at a cost comparable to that reported for screening for colon cancer in the general population.


The true benefit of anal cancer screening, however, is reflected in a patient's quality of life. Multiple patients in my practice have been diagnosed with late-stage anal cancer because it was not discovered until they became symptomatic. Patients with HIV infection are already living with a life-threatening, chronic disease. When they develop cancer, they have to contend with yet another painful disease that severely affects their quality of life.


Further research is necessary to evaluate anal Pap tests as screening tools for malignancy, but the current literature on their use is promising. I encourage nurses to examine the existing data, discuss it with colleagues, and further the field by conducting their own research. We can also advocate for our patients to receive screening studies. HIV-infected patients are a vulnerable, high-risk population and they need our dedication and service.