IDSA: HIV Patients Face Early Anal Cancer Risk

By Ed Susman, Contributing Writer, MedPage Today
Published: October 25, 2011

BOSTON -- Anal intraepithelial neoplasia seems to develop during in the first year of HIV infection, according to the results of a cross-sectional study.

Among 82 patients in the study group, 32.4% were diagnosed with high-grade anal intraepithelial neoplasia and 35.4% were diagnosed with low-grade disease, said John Lough, a medical student at Rush Memorial College in Chicago, in his presentation at the annual meeting of the Infectious Diseases Society of America. In addition, 3.7% were observed with atypia and 18% of the group had normal pathology.

Action Points  

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• Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
• Explain that anal intraepithelial neoplasia seems to develop during the first year of HIV infection, according to the results of a cross-sectional study.
• Note that individuals who had more than one unprotected receptive anal sex partner during the past six months had a 4.53-fold increased risk of developing high-grade anal intraepithelial neoplasia.

"Intervention with early treatment and possibly vaccination may be able to prevent the future development of anal cancer in this high-risk population," Lough said. He noted that high-grade anal intraepithelial neoplasia is considered a direct precursor of anal cancer.
Lough and colleagues recruited the 82 men (average age 36 years) from the Options Project, an NIH study of individuals with confirmed, primary HIV infection within the previous year. Nearly 70% of the patients in the cohort were white and about 16% were Hispanic.
About 32% of the men admitted to use of drugs, such as amphetamines, while 30% were tobacco smokers at the time of the study. Additionally, 40% of the patients were on highly active antiretroviral therapy. The median CD4-positive cell count was about 550 cells/mm³.
The patients underwent a comprehensive clinical examination, an external visual examination, and biopsies of visible anal lesions with high-resolution anoscopy. The researchers used logistic regression to find risk factors for the development of high-grade anal intraepithelial neoplasia.
The authors found that patients who had been infected with HIV for longer than six months had 5.91-fold risk of developing high-grade anal intraepithelial neoplasia when compared with patients who had been diagnosed for less than six months (P=0.01).
He said that 22% of the patients diagnosed with HIV infection for less than six months tested positive for high-grade anal intraepithelial neoplasia compared with 51.6% of patients who had been infected for more than six months (P<0.01).
Individuals who had more than one unprotected receptive anal sex partner during the past six months had a 4.53-fold increased risk of developing high-grade anal intraepithelial neoplasia (P=0.06).
"High-grade anal intraepithelial neoplasia likely develops in the later part of early HIV infection," Lough suggested. He said that CD4-positive cells counts were not particularly helpful in determining the lesion grade.
"There is a need to continue to build capacity for screening for anal cancer especially among HIV-infected men who have sex with men," Lough concluded.
Screening patients for anal intraepithelial neoplasia is controversial, commented IDSA session moderator Joel Gallant, MD, from Johns Hopkins University in Baltimore.
"Many of us assume we should be screening for this because of what we know about cervical cancer which is such a similar disease," he told MedPage Today. "We extrapolate from cervical cancer that we should be doing this screening."
But there is currently no evidence that screening can help prevent anal cancer, Gallant said, pointing out that some professional guidelines recommend it while others do not. One problem with anal cancer screening is that high-resolution anoscopy requires special training and equipment that may not be widely available, he added.

Primary source: Infectious Diseases Society of America
Source reference:
Lough J, et al "Prevalence of high-grade anal intraepithelial neoplasia increases further in early HIV infection" IDSA 2011; Abstract 1391.  

HIV and HPV - Short Lecture on What You Should Know to Prevent Anal Cancer

There are no guidelines currently set about anal cancer diagnosis. But many doctors are referring their patients to colon-rectal surgeons every two years or so to get high resolution anoscopies. Others just use anal pap smears as a first step to determine if an anoscopy is justified. These simple tests can detect precancerous tissue before they may become a problem. They are removed with infrared coagulation. Biopsies are usually taken prior to the removal of the suspect tissue to determine it is low grade or high grade dysplasia.
Wkipedia has a good explanation for dysplasia:
"Dysplasia is the earliest form of pre-cancerous lesion recognizable in a pap smear or in a biopsy by a pathologist. Dysplasia can be low grade or high grade (see "Carcinoma in situ," below). The risk of low grade dysplasia transforming into high grade dysplasia, and eventually cancer, is low. Treatment is usually straightforward.
High grade dysplasia represents a more advanced progression towards malignant transformation.
Carcinoma in situ, meaning "cancer in place," represents the transformation of a neoplastic lesion to one in which cells undergo essentially no maturation, and thus may be considered cancer-like. In this state, epithelial cells have lost their tissue identity and have reverted back to a primitive cell form that grows rapidly and without regulation. However, this form of cancer remains localized, and has not invaded past the basement membrane into tissues below the surface.
Invasive carcinoma is the final step in this sequence. It is a cancer which has invaded beyond the basement membrane and has potential to metastasize (spread to other parts of the body). Invasive carcinoma can usually be treated, but not always successfully. However, if it is left untreated, it is almost always fatal."
The American Cancer Society says that a great deal of research is now under way to learn how HPV might cause anal cancer. There is good evidence that HPV causes many anal squamous cell carcinomas. But the role of this virus in causing anal adenocarcinomas is less certain. More than 100 subtypes of HPV have been found. The subtype known as HPV-16 is often found in squamous cell carcinoma and is also found in some anal warts. Another type, HPV-18, is found less often. Most anal warts are caused by HPV-6 and HPV-11. Warts containing HPV-6 or HPV-11 are much less likely to become cancerous than those containing HPV-16.
The HPV tests on the market are only used to help screen for cervical cancer. There is no general test for men or women to check one's overall "HPV status," nor is there an HPV test to find HPV on the genitals or in the mouth or throat. But HPV usually goes away on its own, without causing health problems. So an HPV infection that is found today will most likely not be there a year or two from now.
I tell HIV+ long term survivors not to neglect their anal area ( tops or bottoms, women or men). Although anal cancer is a disease that progresses slowly, it is better to be proactive about it than waiting until it needs chemotherapy.

I posted a list of doctors in a previous answer on this subject. I live in Houston and used to travel to New York once a year for an anoscopy, but gladly there is now a physician trained in my city. If you live in a place where there is no colon rectal doctors who perform this procedure, have your doctor contact local physicians to see if any of them is interested in being trained at the University of California- San Francisco. They provide a two day training session. Their web site is http://www.ucsfhealth.org/adult/special/d/12748.html
Doctors that are trained on this issue will be better equipped to help people as they age with HIV, so it is a good thing to do right now while we wait for more data that will support future guidelines on this important cancer that is showing up as one of the highest incidence in HIV.

Nelson's lecture in Chicago addresses aging with HIV

COH talk addresses aging and HIV/AIDS

by MATT SIMONETTE on Jun 5, 2011 • 10:05 am0 Comments and 0 Reactions

CHICAGO – A long-time AIDS activist and author spoke May 31 at Center on Halsted, 3656 N. Halsted, about recent breakthroughs in research and potential issues persons with HIV/AIDS might face as they get older.

Matt Simonette

Long-time AIDS activist and author Nelson Vergel

Nelson Vergel, who lives in Houston, said that he has lived with HIV for 27 years at the beginning of his talk, “Promising Advances in HIV Cures and Healthy Aging Research,” which was sponsored by Test Positive Aware Network.

Even as the GLBT community observes a rather grim milestone, the 30th anniversary of the CDC publishing its first reports of AIDS on June 5, 1981, Vergel said much still needs to be understood about the infection, especially its implications for the aging process.

“We’re all getting older and there are things that are showing up in all of us,” Vergel said.

Vergel, a former chemical engineer, opened by discussing the state of current research on vaccines and cures for the infection. He lamented that many pharmaceutical companies, not having made tremendous profits in recent years with HIV/AIDS drugs in America, have ratcheted back investment in that area.

“When it comes to potent new drugs, we’re getting drier and drier,” Vergel said. “Unfortunately, it is market driven.” He did add, however, that some companies have been preparing new one-pill-a-day treatments that might eventually replace more complex treatments.

“I tell people, if you take one vitamin a day, you’ll get used to this,” Vergel said.

He also discussed Timothy Ray Brown, also known as “the Berlin Patient,” who seems to have had the AIDS virus completely wiped clear from his body thanks to a stem cell bone marrow transplant.

“It’s not until now that people are using the ‘c-word,’” Vergel said.

But while Brown’s story should inspire hope—Vergel’s own mother was ready to begin a fundraiser for him so he could have the same treatment—a great deal of research and testing must take place before Brown’s situation can be duplicated.

New studies in the wake of Brown’s case “are asking for a lot from people,” according to Vergel. Subjects are expected to get off HIV meds and undergo extremely invasive testing procedures, among other requirements.

Another consideration is that chemotherapy played so heavily into Brown’s treatment. “What are we going to do with the healthy (men and women) who don’t have leukemia?” Vergel asked.

By 2015, over 50 percent of persons with HIV/AIDS will be over the age of 50. As such, both medical professionals and the government will have to rethink standard treatments for people who are aging and have the infection.
“We’re going to live longer, but what’s our quality of life going to be?” Vergel asked.

Many infected individuals, for example, must contend with facial wasting. But Medicare usually refuses to pay for treatments unless a physician marks in the patient’s file that the person is suffering from a depression brought about by the wasting.

“Most people just want to get their face back, but you have to have ‘depression’ on your chart in order to have anything done about it,” Vergel said, adding that community activists need to start advocating on behalf of physicians as well as patients.

“Many doctors are refusing (to see Medicare patients) because Medicare doesn’t want to pay enough,” he said.

Vergel suggested that persons with HIV/AIDS be extra vigilant in guarding against afflictions beguiling older Americans. Bone density scans, exercise and vitamin D, for example can help stave off osteoporosis.

HPV infections were another condition to be concerned with. Vergel said the condition was common—“We’re not talking top or bottom, men or women,” he said—and concerned individuals should not be afraid to ask their physician about having an anuscopy done to check for anal warts if they think they might need it.

Doctors are rarely proactive about that particular procedure, Vergel said, adding that it was not the same thing as a colonoscopy, which usually is probing for gastro-intestinal issues.

Infected individuals are often “more frail by about 15 years,” Virgil suggested, so he said good overall advice is to be sure to take plenty of exercise.

“Exercise is the best therapy for most health problems,” Vergel said.

How to Fight Insurance Companies that Refuse to Pay for Anal Cancer Procedures

Question:

I am looking for any peer-reviewed articles regarding anal cancer screening studies, even with preliminary results, which substantiate the effectiveness of preventive screenings as relates to anal cancer.

My insurance will pay for some "emerging or experimental" treatments in areas such as cancer, etc, which look promising but may not yet have produced concrete recommendations or generally-accepted treatment guidelines.  I'd like to find some peer-reviewed articles I can submit with my claim, to get them to call this "preventive", and so fully paid-for.  Does anyone have any links to such articles published in any medical journals?  Thanks!


Answer from Nelson:

There is nothing better anywhere in the world than this info on anal cancer guidelines. NY State is the only place worldwide where they recommend high resolution anoscopies and infrared coagulation (IRC).  The info has all the references you need for a doctor to write a good letter to fight the insurance company.

There is a study that may or may not be approved to follow people for 7 years with and without IRC to prove to insurance companies that (and if) IRC works to prevent people from progressing into anal cancer. But many companies (and Medicare) are paying for this now.  The key is finding a doctor who is willing to write a good medical necessity letter if you get denied, like it sounds you did.

http://www.hivguidelines.org/clinical-guidelines/adults/neoplastic-complications-of-hiv-infection/#V. ANAL DYSPLASIA AND CANCER