In Journal Watch AIDS Clinical Care, we published a simple case: Clinically stable HIV+ gay man, on HIV treatment; anal pap comes back with “atypical squamous cells of undetermined significance” (ASCUS).
What to do with this result? Two experts weighed in, Howard Libman and Joel Gallant. In Howard’s thoughtful response, he acknowledges the limitations of the data thus far, but said he would refer the patient for high-resolution anoscopy (HRA) and biopsy — which is what most of our readers said as well.
But Joel acknowledges that, despite an institutional protocol to refer all such patients, he wavers a bit for those with ASCUS:
I have been bending the rules in patients with ASCUS and monitoring them with yearly Pap smears rather than referring them for HRA. I do this with the understanding that the Pap smear provides an imprecise measurement of the true grade of dysplasia and that those with ASCUS could have higher grades on biopsy. However, I have to weigh that risk with the fact that my patients don’t enjoy going through HRA, biopsy, and ablation, that the parallels between anal and cervical dysplasia aren’t perfect, and that the protocols around anal Pap smear are written without much evidence backing them up.
It’s safe to say that we don’t really know yet what to do — not in this situation, nor in multiple other scenarios involving anal cancer screening.
Just a few questions to ponder: How frequently (if at all) should anal paps be done? If the sensitivity is so poor, why not refer all gay men for HRA/biopsy, skip the pap? Or should it be limited to those with a history of condyloma?
Or should those patients go right to biopsy? Should HPV testing be done in all patients? What anal cancer screening should be done in HIV-infected women? Or should this just be done in women with cervical disease?
If the evidence were stronger, clearly the guidelines would recommend a standard screening protocol.
But until then, one hears the voice of Joel Palefsky — owner of the “World’s Worst Science Job” — as he highlights the benefits of preventing a common, potentially life-threatening and disfiguring cancer. In response to his work, a diverse range of practitioners out there (PCPs, ID docs, gynecologists, dermatologists, surgeons) now offer high-resolution anoscopy with biopsy for this indication.
But is screening for cancer always the right thing to do?
Paul Sax is the Clinical Director of Infectious Diseases at Brigham and Women’s Hospital. His blog HIV and ID Observations, is part of Journal Watch, where he is Editor of Journal Watch AIDS Clinical Care.
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