Discussion Questions

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  Why is this study question important?

  
  
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  What was the study design?

  
  
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  How well did the design address the study question?

  
  
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  What were the study results?

  
  
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  What were the study’s strengths and limitations?

  
  
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  How can we apply this information?

Anal cancer is a rare malignancy. However, patients infected with human immunodeficiency virus (HIV) have increased susceptibility to the tumor, which has been tied to human papillomavirus (HPV) infection. Highly active antiretroviral therapy has not prevented the amplified risk for anal cancer noted in this population.

As with cervical cancer, squamous cell carcinoma of the anus seems to have a precursor lesion; dysplasia is classified as anal intraepithelial neoplasia (AIN), grade 1 (low-grade), 2 (moderate), or 3 (high-grade). But, evidence-based screening recommendations for anal dysplasia and cancer do not yet exist. Observational studies, such as the work discussed at this month’s Journal Club meeting, are important for defining risk factors for AIN 2 and 3. This study, conducted among HIV-positive women, also attempted to address the effectiveness of anal cytology and anal HPV testing with the Hybrid Capture 2 test as possible screening tests for detection of AIN 2 and 3.

An unexpected finding

Patients were enrolled between October 2006 and May 2007 and were followed through April 2010; ideally, they were to be seen every 6 months for a total of 3 visits. Baranoski and colleagues learned that anal cytologic abnormalities were associated with current CD4 counts of less than 200 cells/mm ³ , anal HPV infection, and a history of sexually-transmitted infections (STIs) other than HPV infection. While Journal Club members did not think these findings were particularly surprising, they were taken aback by the speed with which lesions developed in several women. Of the 99 women in the study, 47 had abnormal anal cytology, and 36 underwent high-resolution anoscopy (HRA), the anal equivalent of colposcopy for the cervix. Of these 36, one-third (12) had an eventual diagnosis of AIN 2 or 3. Four of these patients had at least 1 negative anal cytology test during the study period, and 2 of the 4 had a negative cytology and negative HPV test within 1 year of diagnosis of AIN 2 or 3. Eleven of the participants who were referred for HRA did not undergo the procedure. This is a limitation in this study, but it speaks to the lack of patient acceptance of the procedure, even in patients enrolled in a study at a research center specializing in HRA.