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We are delighted to see that the topic of anal intraepithelial neoplasia and anal cancer has been highlighted in your journal1. However, one of the main challenges is the recognition of early lesions which are a precursor to invasive cancer. We were surprised therefore to see no mention of anal cytology and high-resolution anoscopy (HRA). HRA enables detection of anal intraepithelial neoplasia (AIN), analogous to cervical intraepithelial neoplasia (CIN) and uses the same colposcopic equipment. This has been applied most in HIV-positive populations, and in particular, HIV-positive men who have sex with men (MSM) who are at high risk for anal neoplasia2. Services caring for HIV positive people in the UK, as elsewhere, have been developing pathways to screen and treat patients with AIN, using a combination of anal cytology and HRA-directed biopsy. The accuracy of routine mapping biopsies can be improved by the use of HRA guidance. The importance of AIN is underlined by the fact that there is an increased incidence of anal cancer in HIV positive people, particularly now that long term survival is achievable, and by the fact that if anal cancer develops in this group their outcomes are poorer compared to HIV negative people3,4. Although the natural history is not as well defined, treatment strategies should mirror those of cervical intraepithelial neoplasia (CIN 2 and 3)5. The options include trichloroacetic acid application or 5% imiquimod as well as ablative treatments such as laser ablation or infra-red coagulation. These methods can be used for both internal AIN 2/3 disease, as well as external or perianal disease. These approaches have the potential to improve outcomes for both HIV positive and negative populations but will need close collaboration between services able to offer HRA and others in comprehensive cancer networks.
Mayura Nathan1, Michael Sheaff2, Paul Fox3, Peter Goon4, Richard Gilson5, Charles Lacey6
1 Consultant physician, Homerton University Hospital and Barts and the London NHS Trust, London
2 Consultant, Cellular Pathology, Barts and the London NHS Trust, London
3 Consultant physician, Chelsea & Westminster Hospital, London
4 Cancer Research, UK, Clinician Scientist, Department of Pathology, University of Cambridge
5 Director, Centre for Sexual Health and HIV Research, University college, London
6 Professor, Centre for Immunology and Infection, Hull York Medical School, University of York
References:
1 Simpson JAD, Scholefield JH. Diagnosis and management of anal intraepithelial neoplasia and anal cancer. BMJ 2011;343:1004-9.
2 Palefsky J. Anal cancer prevention in HIV-positive men and women. Curr Opin Oncol 2009;21:433-8.
3 Crum-Cianflone NF, Hullsiek KH, Marconi VC, Ganesan A, Weintrob A, Barthel RB et al. Anal cancers amongst HIV-infected persons: HAART is not slowing rising incidence. AIDS 2010;24:535-43.
4 Oehler-Jänne C, Huguet F, Provencher S, Seifert B, Negretti L, Riener M-O et al. HIV-specific differences in outcome of squamous cell carcinoma of anal canal: a multicentric cohort study of HIV-positive patients receiving highly active antiretroviral therapy. J Clin Oncol 2008;26:2550-7.
5 Pantanowitz L, Dezube BJ. The anal pap test as a screening tool. AIDS 2010;24: 463-5.
Competing interests:
No competing interests
23 November 2011
Mayura Nathan
Consultant Physician
Michael Sheaff, Paul Fox, Peter Goon, Richard Gilson, Charles Lacey
High prevalence of anal intraepithelial neoplasia and anal carcinoma and its relationship with human papilloma virus infection calls for holistic and preventive approach towards it's prevention. The great success story of HPV vaccine in preventing HPV caused cervical cancer is a reminder that the same success may be achieved in other types of HPV caused cancers including vaginal cancer, vulval cancer in women and anal cancer and laryngeal cancers in both men and women. Probably time has come to start HPV vaccine using suitable strains of HPV virus in both men and women to prevent anal cancer. Research should focus on this aspect of preventive epidemiology which will be cost effective in the long run as has happened with the success story of HPV vaccine in case of cervical cancer.
Competing interests:
No competing interests
19 November 2011
J. B. Sharma
Obstetrician and Gynaecologist
Additional Professor, Obst & Gynae
All India Institute of Medical Sciences, New Delhi 110029, India
Re: Diagnosis and management of anal intraepithelial neoplasia and anal cancer
Dear Sir,
We are delighted to see that the topic of anal intraepithelial neoplasia and anal cancer has been highlighted in your journal1. However, one of the main challenges is the recognition of early lesions which are a precursor to invasive cancer. We were surprised therefore to see no mention of anal cytology and high-resolution anoscopy (HRA). HRA enables detection of anal intraepithelial neoplasia (AIN), analogous to cervical intraepithelial neoplasia (CIN) and uses the same colposcopic equipment. This has been applied most in HIV-positive populations, and in particular, HIV-positive men who have sex with men (MSM) who are at high risk for anal neoplasia2. Services caring for HIV positive people in the UK, as elsewhere, have been developing pathways to screen and treat patients with AIN, using a combination of anal cytology and HRA-directed biopsy. The accuracy of routine mapping biopsies can be improved by the use of HRA guidance. The importance of AIN is underlined by the fact that there is an increased incidence of anal cancer in HIV positive people, particularly now that long term survival is achievable, and by the fact that if anal cancer develops in this group their outcomes are poorer compared to HIV negative people3,4. Although the natural history is not as well defined, treatment strategies should mirror those of cervical intraepithelial neoplasia (CIN 2 and 3)5. The options include trichloroacetic acid application or 5% imiquimod as well as ablative treatments such as laser ablation or infra-red coagulation. These methods can be used for both internal AIN 2/3 disease, as well as external or perianal disease. These approaches have the potential to improve outcomes for both HIV positive and negative populations but will need close collaboration between services able to offer HRA and others in comprehensive cancer networks.
Mayura Nathan1, Michael Sheaff2, Paul Fox3, Peter Goon4, Richard Gilson5, Charles Lacey6
1 Consultant physician, Homerton University Hospital and Barts and the London NHS Trust, London
2 Consultant, Cellular Pathology, Barts and the London NHS Trust, London
3 Consultant physician, Chelsea & Westminster Hospital, London
4 Cancer Research, UK, Clinician Scientist, Department of Pathology, University of Cambridge
5 Director, Centre for Sexual Health and HIV Research, University college, London
6 Professor, Centre for Immunology and Infection, Hull York Medical School, University of York
mayura.nathan@homerton.nhs.uk
References:
1 Simpson JAD, Scholefield JH. Diagnosis and management of anal intraepithelial neoplasia and anal cancer. BMJ 2011;343:1004-9.
2 Palefsky J. Anal cancer prevention in HIV-positive men and women. Curr Opin Oncol 2009;21:433-8.
3 Crum-Cianflone NF, Hullsiek KH, Marconi VC, Ganesan A, Weintrob A, Barthel RB et al. Anal cancers amongst HIV-infected persons: HAART is not slowing rising incidence. AIDS 2010;24:535-43.
4 Oehler-Jänne C, Huguet F, Provencher S, Seifert B, Negretti L, Riener M-O et al. HIV-specific differences in outcome of squamous cell carcinoma of anal canal: a multicentric cohort study of HIV-positive patients receiving highly active antiretroviral therapy. J Clin Oncol 2008;26:2550-7.
5 Pantanowitz L, Dezube BJ. The anal pap test as a screening tool. AIDS 2010;24: 463-5.
Competing interests: No competing interests