Many patients are aware of cervical cancer and its connection to the HPV virus. But few may know about anal cancer and what populations are at greater risk for the disease.
Though rare in the general population, anal cancer has higher incidence rates in individuals with HIV than even more common cancers that are routinely screened for in the general population. Anal cancer often appears without symptoms, so people may not be aware that they have it. It may be mistaken for hemorrhoids, and, by the time it is diagnosed, it may have spread to other parts of the body.
Assessment of cervical cancer is well established, with a colposcopy allowing for examination of the cervix. Providers should know there is an equivalent for the anus: a high-resolution anoscopy (HRA). HRA is like an anoscopy, but with magnification, allowing doctors to closely examine suspicious areas and remove precancerous lesions as needed.
In 2024, a panel of HIV experts put out the first federal guidelines to prevent anal cancer in at-risk individuals. They advised HRA as part of screening for men who have sex with men, trans women 35 years or older and all other people with HIV ages 45 and older.
Historically, patients with abnormal anal pap results had to go to the operating room for additional testing like HRA. This was more onerous and expensive, experts say.
“There's a whole cohort of patients who are eligible for this screening, following the guidelines, who would've had to go to the OR or an outside practice,” Jonathan Baker, a physician assistant in the Division of Colon and Rectal Surgery at NYU Langone Medical Associates, told Fierce Healthcare.
Since June, NYU Langone has offered HRAs in the outpatient setting, joining only a few organizations in New York City to do so. The reason this remains rare is because it requires specialized equipment and extensive training for providers. NYU Langone hopes to offer HRAs at three of its outpatient locations by the end of this year.
Anal cancer was established as higher risk in the 1990s as people were starting to survive with HIV, Baker explained. “A lot of people in various fields were starting to recognize that they were seeing patients developing anal cancer at higher rates than they expected,” Baker said. But providers were hesitant to remove precancerous cells without concrete data to support that doing so prevents cancer.
Then, a groundbreaking study. In 2014, the National Cancer Institute funded a large multisite clinical trial with more than 4,400 participants. The goal was to determine whether treating anal pre-cancer was indeed effective at reducing cancer risk.
Researchers recruited people 35 years or older with HIV who had anal precancerous cells and were randomly assigned to either receive treatment or active monitoring without treatment. All participants received HRAs every six months and biopsies as needed.
Ultimately, patients in the treatment group were 57% less likely to develop anal cancer than those in the active monitoring group. The results informed the 2024 federal guidelines. “Now that we know that, there’s a lot of movement toward people training on this,” Baker, who participated as a sub-investigator in the Anchor trial, said.
A growing number of trainees in colorectal surgery fellowships are familiar with HRA screenings: “They have a lot of exposure to this, whereas when this was a lot less common a decade or two ago some surgeons came out of fellowship totally unaware of this screening,” Baker said.
NYU Langone’s commitment to making HRAs more accessible comes at a time of diminishing access to healthcare for marginalized groups, Baker added.
“I’d be remiss if I didn't acknowledge that these are the very populations that a lot of health policies are working against right now,” Baker said. The Trump administration has taken aim at gender-affirming care, research of diseases affecting queer individuals and Medicaid coverage.
In Baker’s view, the federal guidelines on anal cancer screening were an important step toward normalizing the preventive treatment. "Having U.S. guidelines does put a big onus on healthcare institutions and providers to implement this screening,” he said.