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Anal Health Screening
I. Screening for Anal Carcinoma
Rationale: Anal cancer is an unusual cancer with an incidence rate of 2/100,000 in the general population but up to 35/100,000 in HIV negative MSM; a rate comparable to that of cervical cancer prior to widespread screening programs. Among HIV infected patients, added risk factors for anal cancer include a history of receptive anal intercourse, a history of having > 10 sexual partners, a history of anal warts (RR 11.5) and cigarette smoking (RR 1.9 to 5.2) while CD4 < 500 is a risk factor for HSIL (RR 7.5). The incidence of anal cancer does not appear to be decreasing in the HAART era.
Unfortunately, at this time screening tests such as anal Pap smears or high-resolution anal colposcopy have not been shown to improve the detection or outcome of anal cancer. Until validated screening and treatment methodologies for anal cancer are established we propose the following protocol for the care of patients at special risk of anal cancer:
II. Management of Anal Warts
Rationale: The evaluation and treatment of anal warts pose special problems given
1) their association with the development of anal cancer,
2) their possible location within the anal canal and
3) their high recurrence rate.
There are several proven therapies for anal warts including liquid nitrogen, 5% imiquimod (Aldara) cream, laser and electrocautery and surgical excision. Choosing between treatments needs to be individualized and may follow the following recommendations:
1. HPV Screening & Anal Cancer in HIV-infected Patients. Joel Palefsky, June 21 2008.
2. Holly EA, et. al. Anal cancer incidence: genital warts, anal fissure or fistula, hemorrhoids, and smoking. J Natl Cancer Inst 1989 Nov 15;81(22):1726-31.
3. D'Souza G, Wiley DJ, Li X, Chmiel JS, Margolick JB, Cranston RD, Jacobson LP.
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