Pathology slide of HSIL, courtesy of David Papke, MD, PhD.
Screening guidelines for cervical cancer have been recognized for decades. But for other cancers linked to human papillomavirus (HPV), including anal cancer, cancer screening guidelines are not well-developed.
Since 2020, a unique Brigham and Women’s Hospital clinic has offered high-resolution anoscopy (HRA) to screen for anal dysplasia in people at increased risk of anal cancer due to HPV infection, HIV status, and other factors. The clinic aims to reduce the incidence of anal cancer in high-risk populations.
“The value of treating anal dysplasia to prevent anal cancer for the highest-risk patient population has now been established and is still being studied for lower-risk groups,” says colorectal surgeon James Yoo, MD, one of the two founders of the HRA clinic. “The field is still evolving, and more data are needed to determine the best practices. But this is clearly an area where we can make an impact in cancer prevention, especially for patients at higher risk.”
“As an infectious disease doctor, I’m obviously interested in the different diseases and complications that affect HIV patients,” says Jennifer A. Johnson, MD, a clinician-educator and the clinic’s other co-founder. “We know that people with HIV are one of the highest-risk groups for the development of anal dysplasia and anal cancer, making this an important population to focus on.”
A Collaborative Approach to Patient Care
Results from the phase 3 Anal Cancer–HSIL Outcomes Research (ANCHOR) trial, published in The New England Journal of Medicine in June 2022, demonstrated for the first time that treatment for anal high-grade squamous intraepithelial lesions reduced the progression to anal cancer when compared with active monitoring. Drs. Yoo and Johnson note that this study’s findings help illustrate the value of the Brigham’s HRA clinic.
“HRA requires special equipment that’s not commonly available as well as special training to learn how to perform the procedure and to know what to look for,” Dr. Yoo says. “In terms of what our clinic can offer, it’s relatively special.”
In addition to Drs. Yoo and Johnson, colorectal surgeon Ronald Bleday, MD, also participates in the clinic.
The clinic’s collaborative approach produces significant benefits for patients. Follow-up care may consist of a range of actions depending on what is found during the HRA exam. These include annual anal Pap smears, HRA exams offered on an annual or semiannual basis, ablation of dysplastic lesions, and more extensive surgical procedures.
HRA Offered as Simple Office Procedure
When a patient is referred to the clinic, they can have their HRA exam performed on their first visit. This makes scheduling less burdensome.
“The HRA procedure is very similar to a cervical colposcopy,” Dr. Johnson notes. “It requires no anesthesia beyond sometimes a local anesthetic. It is minimally invasive, doesn’t require any specific preparation on the patient’s part, and doesn’t affect their activities for the rest of the day.”
Beyond those with HIV, patients taking immune-suppressing drugs to treat autoimmune diseases may also be at increased risk of developing lesions caused by HPV. The leaders of the HRA clinic provide consultations to physicians both inside and outside the Brigham to help them identify which patients may benefit from enrollment in the clinic’s programs. The clinic also provides opportunities to counsel patients on topics like HPV vaccination.
“These visits provide a good opportunity to make sure we’re paying attention to any concerns the patients have about minimizing their cancer risks,” Dr. Johnson says.
“We have a pipeline of patients who come to us because their providers are aware of the need to screen for anal dysplasia,” Dr. Yoo adds. “One of our continuing roles is to educate other doctors about which patients they should send to us for evaluation.”