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?

Introduction

In 2011, an estimated 5820 cases of anal cancer and 770 disease-related deaths occurred in the United States. As with cervical cancer, human papillomavirus (HPV) has been strongly implicated in its development. But while evidence-based screening guidelines exist for cervical cancer, research into prevention of anal cancer has been limited by its rarity and a deficit of researchers trained to do high resolution anoscopy (HRA). A new study examined the incidence and prevalence of anal cytologic abnormalities and the factors linked with abnormalities in HIV-positive women, a population whose estimated risk is 7-14 times that of HIV-negative women.

Denise M.S. Willers, MD and George A. Macones, MD, MSCE, Associate Editor

Introduction

In 2011, an estimated 5820 cases of anal cancer and 770 disease-related deaths occurred in the United States. As with cervical cancer, human papillomavirus (HPV) has been strongly implicated in its development. But while evidence-based screening guidelines exist for cervical cancer, research into prevention of anal cancer has been limited by its rarity and a deficit of researchers trained to do high resolution anoscopy (HRA). A new study examined the incidence and prevalence of anal cytologic abnormalities and the factors linked with abnormalities in HIV-positive women, a population whose estimated risk is 7-14 times that of HIV-negative women.

Denise M.S. Willers, MD and George A. Macones, MD, MSCE, Associate Editor

Study Design

Willers: Why is this study question important?

Kizer: Anal cancer is as important a health issue for HIV-infected women as are other cancers, and its diagnosis carries devastating consequences; both emotional and physical. Anal cancer receives minimal attention by the medical community, and little data exist to guide health care providers in the screening and management of anal dysplasia. This, in turn, leads to less patient education and thus, minimal public awareness. Baranoski and colleagues addressed the fact that the pathogenesis of anal cancer appears to follow a similar pattern to that of cervical cancer, with the existence of a precursor lesion—anal intraepithelial neoplasia (AIN). The authors investigated current anal screening protocols to further understand the clinical significance of abnormal anal cytology and anal HPV detection in a high-risk population. Ultimately, these efforts will help to prevent anal cancer among women with HIV.

Willers: What was the study design?

Keegan: This was a prospective observational study designed to assess the incidence of and risk factors for abnormal anal cytology and AIN 2 (moderate dysplasia) and AIN 3 (high-grade dysplasia) in HIV-infected women.

Willers: How well did the study design address the research question?

Keegan : Prospective observational studies are appropriate for assessment of exposures or risk factors. By following patients over a specific period of time, researchers can examine whether patients develop a specific outcome or disease. 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. The risk factors or exposures evaluated were collected at the initiation of the study from chart review and patient reports. The specific outcome evaluated was abnormal anal cytology or AIN 2-3. A statistical analysis identified which data points conveyed risks for abnormal anal cytology. The authors assessed prevalence and incidence of abnormal cytology but not AIN 2-3. Many patients refused HRA, resulting in possible underdiagnosis and an inaccurate incidence of AIN 2-3.