Pictured: Ronald Bleday, MD, colorectal surgeon at the Brigham; Julian Sanchez, MD, colorectal surgeon at Moffit Cancer Center; Dr. Yoo; Dr. Johnson; Sanghyun (Alex) Kim, MD, colorectal surgeon at the Mount Sinai Health System.
High-resolution anoscopy (HRA) can be a helpful tool for detecting precancerous lesions in the anal canal. However, colorectal fellows traditionally have not received training in the technique.
In 2020, colon and rectal surgeon James Yoo, MD, and infectious disease specialist Jennifer A. Johnson, MD, co-founded the HRA clinic at Brigham and Women’s Hospital. They subsequently teamed up to develop the first HRA course in the United States for colorectal surgery fellows. The course, held at Harvard Medical School in September 2022, drew 23 participants from around the country.
“There’s a learning curve in terms of how to incorporate anoscopy with the magnification that you need to see lesions,” Dr. Yoo says. “Then there’s knowing what you’re seeing. How do you determine that the lesion is something you should be worried about? Is it normal tissue, or should you biopsy it? Lesion identification is probably the steepest part of the learning curve.”
Study Clarifies Benefits of High-Resolution Anoscopy
For many years, Dr. Yoo notes, clinicians were hesitant to embrace HRA. The cost of the equipment and the time required to learn the technique were two key factors. Most importantly, the clinical benefits were unclear.
A study published in The New England Journal of Medicine in June 2022, however, shed light on the benefits of HRA in identifying high-grade squamous intraepithelial lesions (HSILs). “Among participants with biopsy-proven anal HSIL, the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring,” the authors of the phase 3 trial concluded. They also called for the “[e]xpansion of diagnostic and therapeutic training programs in the use of high-resolution anoscopy.”
“We now know there are many clinicians who should be providing this service, but they don’t know how to do it or even set it up,” Dr. Yoo says.
Blending Didactic Lectures With Hands-on Labs
The HRA course featured physicians from the Brigham as well as the Moffitt Cancer Center and the Mount Sinai Health System. Lectures covered the basics of human papillomavirus and the rationale for HRA, treatment principles, lesion identification, and setting up an HRA program. Two hands-on labs, which included expert guidance, allowed participants to gain practical experience on multiple platforms.
“Our goals were to give the fellows basic skills that are necessary to perform this technique properly and an understanding of how to establish a program, which, as Dr. Johnson and I know firsthand, requires managing a lot of moving parts,” Dr. Yoo says.
Dr. Yoo was pleased with the turnout for the course and the positive participant feedback. He and Dr. Johnson plan to offer the course again for colorectal fellows and to gauge interest in adapting the course for infectious disease specialists and for general and colorectal surgeons.
To learn about future HRA courses, please email Dr. Yoo.