Shining A Light on "Unmentionable" Cancer
Eisenhower's high-resolution anoscopy program
Anal cancer is arguably the last taboo in medicine, a topic that many doctors as well as patients are reluctant to discuss.
“But if it’s not discussed, patients will go unscreened, unexamined and untreated, and that can be deadly,” says Cari Sudmeier, MSN, RN, FNP-BC, who, together with Jon Colbert, MSN, FNP-BC, AAHIVS, runs Eisenhower Health’s High-Resolution Anoscopy (HRA) program.
This program — the only hospital-based program of its kind in the desert — screens patients who are at increased risk for anal dysplasia (a precancerous condition in which lesions have formed in or near the anal canal) and anal cancer. Anal cancer is a relatively uncommon malignancy that’s associated with human papillomavirus (HPV), the most common sexually transmitted infection.
Who is at increased risk for anal dysplasia and anal cancer?
There’s a perception that men who have sex with other men are at greatest risk of anal cancer, but in fact, of the estimated 9,000 new cases diagnosed in 2022, two-thirds were women. The disease claims about 1,400 lives a year, nearly 900 of them women.
“You don’t have to have anal intercourse to contract HPV, which is associated with over 90 percent of anal cancer cases,” Sudmeier explains, noting that anyone who has had sex — including vaginal and oral sex — can get HPV, even if it was with only one person. “Or you can simply have skin-to-skin contact with someone who has HPV. Or in women, the virus can be in the vagina and migrate on its own to the anal canal, or through front-to-back wiping after urination — just a normal function.”
Other risk factors for anal dysplasia and anal cancer include a history of anal warts (also caused by HPV), receptive anal sex (in men and women), being over age 50, having multiple sex partners, smoking, and lowered immunity (like people with HIV/AIDS or those taking immunosuppressive drugs after an organ transplant or to treat autoimmune disorders). Also, women who’ve had cancer of the cervix, vagina or vulva are at increased risk of anal cancer, likely because these cancers are also caused by HPV infection.
What are the symptoms of anal dysplasia and anal cancer?
Anal dysplasia often has no symptoms until it has progressed to anal cancer. When symptoms do occur, they can be similar to other common conditions such as hemorrhoids: pain, itching, bleeding, or a lump or growth near the anus. As a result, anal cancer is often misdiagnosed. In fact, in one recent study, primary care physicians misdiagnosed anal malignancies as hemorrhoids in 27 percent of first visits, delaying appropriate diagnosis and treatment.
“This underscores why screening high-risk individuals is so important,” says Colbert. “While this is generally a slow-growing cancer, if you let it go undetected and untreated, it may progress and metastasize to other areas of the body. And that can be fatal.” Actress Farrah Fawcett, who died of the disease in 2009, is a highly visible example of this.
What does screening involve?
Screening begins with a digital rectal exam and what’s called an anal Pap test (a simple swab of the anal canal). This is usually performed by a patient’s primary care provider to detect the presence of any abnormal cells and HPV infection. If the test finds any abnormal cells, the patient should be referred for a high-resolution anoscopy.
Anoscopy examines the anal canal and lower rectum using a device called an anoscope, a tube about five inches long and slightly wider than a finger that’s inserted about two inches into the anal canal. High-resolution anoscopy also uses a colposcope, a mobile microscope connected to a monitor that magnifies the images. This enables the anoscopist to more closely examine suspicious areas in the anal canal.
“If we identify abnormal tissue, we do a biopsy, send it to the lab, and pathology tells us what we’re dealing with,” Sudmeier says. Both she and Colbert are anoscopists.
She also notes that, unlike with colonoscopy, anoscopy requires no special preparation or sedation (topical numbing gel is applied to the scope for patient comfort). The entire procedure takes 20 to 30 minutes and is performed in the HRA clinic on Eisenhower’s Rancho Mirage campus. It’s covered by most insurance plans.
What if anal dysplasia is detected?
“When we find dysplasia, we can treat it right in the office with a simple ablation technique called electrocautery, which destroys lesions caused by HPV,” says Colbert. Patients are then advised to have HRA screening exams every six to 12 months.
“It’s like when you go to a dermatologist and they identify a precancerous lesion on your arm,” he continues. “They get rid of it, then tell you to come in regularly for surveillance. This is exactly the same thing — it’s just in an area that no one usually looks at.”
Can anal dysplasia and anal cancer be prevented?
There actually is a vaccine (Gardasil®) that can prevent more than 90 percent of cancers that are attributable to HPV including anal, vulvar, vaginal, cervical and penile cancers, as well as cancers of the oropharynx (back of the throat, including the base of the tongue and tonsils). It’s recommended that preteens receive the vaccine as early as age nine to protect them from HPV infections that can cause cancer later in life. In certain patients, the vaccine may be administered up until age 45.
“This is a vaccine that enables parents to protect their kids from getting cancer,” Colbert says. Yet, he notes, the uptake of Gardasil in the US is less than 50 percent.
What’s more, the incidence of anal cancer is on the rise in the U.S. Because it can take two decades or more for HPV infection to lead to cancer, authors of a 2019 study in the Journal of the National Cancer Institute suggest that cases of anal cancer being diagnosed today are related to HPV infections contracted in the 1990s or earlier — before a vaccine to prevent infection with cancer-causing HPV types was available.
“Even though it’s still a small number of people who get anal cancer, it’s a devastating cancer to have because people lose a primary bodily function,” Sudmeier says. “But by screening we can catch it in a precancerous state and halt the progression to cancer. As with any type of cancer, screening and early detection are key to survivability.
“And with vaccination, we can work to prevent HPV-related anal cancer altogether,” she adds.
“We have to remove the stigma about this disease among both patients and medical providers,” Colbert says. “Patients need to advocate for themselves and get screened if they know they’ve had some sort of contact through which they could contract HPV.
“And we shouldn’t judge,” he adds.
For more information about Eisenhower’s High-Resolution Anoscopy Program, call 760.837.8601, or visit EisenhowerHealth.org/Podcast.
