Amber D'Souza outlined the epidemiology of anal cancer pointing out the significantly elevated risks for HIV positive MSM. She found DARE acceptable to patients within a study of 327 men.

Dr Jason Ong posed the question "What should we be doing with our patients now?"

He gave compelling reasons to screen for anal cancer targetting the most at risk, that is HIV positive men > age 50 ideally with an annual digital rectal exam to try and detect anal cancer at an earlier stage than is currently achieved with reactive checks related to symptoms.

50% of anal cancers are visible externally ie just looking would make a huge difference and currently less than 10% of HIV positive MSM have annual anal exams.80-100% will be found with DARE.

It is a simple safe cost effective and acceptable practice and can lead to better outcomes.

The evidence for screening for precursor lesions seems less compelling. 

HSIL is present in 30-50% of HIV positive gay men however only 1/400 progress to cancer in HIV positive men and 1/4000 progress to cancer in HIV negative men. 

SPANC has greatly increased understanding of this process.?Highest risk to progression to anal cancer is seen in those with persisting HPV16.

It was also suggested by Jason and Dr David Templeton to consider HPV vaccination in this group as despite the lack of evidence for efficacy, it may work.

From positivelife NSW we learned that most PLHIV  thought their risk for anal cancer was the same or lower than the general population.

84% of respondants in that survey and 64% HIV respondants had never talked to thier doctor about anal HPV/cancer- we should clearly be doing better than this.

This year the HIV conference has been dominated by presentations on anal cancer in men who have sex with men, particularly those living with HIV.

A/Prof David Templeton presented the interim findings from the SPANC study, which assessed the utility of cytologic screening for anal cancer.

Dr Jason Ong presented an interesting overview of what clinicians can do currently to screen for anal cancer, given how little evidence we currently have on the usefulness of screening.

Dr Amber D'Souza presented on the epidemiology of anal cancer

Ben Wilcox and Lance Feeney presented on community perspectives and education on anal cancer.

Brad Atkins gave a moving presentation on his personal experience of anal cancer.

 

Perhaps the key messages are:

- Modelling has shown that anal cancer screening by a digital anorectal examination has shown it to be cost-effective only for HIV-positive MSM over the age of 25. In that scenario, it is currently recommended to perform anorectal examinations annually. However, an argument could be made to offer screening also to those MSM who are HIV-negative.

- Cytologic screening is problematic, in that it lacks sufficient specificity, resulting in a very large proportion of referrals to high-resolution anoscopy.

- We need to offer HPV vaccination to all MSM under the age of 25, and whilst there is no evidence of benefit over the age of 25 it would be reasonable to offer is to those MSM also (keeping in mind the cost to the patient).

- Much more work remains to be done to determine the best strategies to screen for anal cancer in MSM.