Stier et al bring focus to the growing incidence of squamous cell cancer of the anus (SCCA) in women over the last 4 decades, which has doubled from 1975 through 2008. Moreover, human papillomavirus (HPV) has been detected in 80–90% of SCCA with types 16 and 18 found in 80% of anal cancers. The current increase in the incidence of SCCA among women dictates that more attention is needed on women’s risk factors and the mechanism of transmission of SCCA.

Stier et al proposes that, while a reported history of anal intercourse among women was not a consistent risk factor for acquiring anal HPV, there is a “field effect” on the lower genital tract in women. However, we suggest that the prevalence of anal intercourse may be underreported in this study. Receptive anal intercourse among heterosexual partners has become common in the United States. There is less condom use during heterosexual anal intercourse (HAI) than reported with vaginal intercourse. In a study of 10,463 sexually active heterosexual women, Benson et al reported that 13.2% and 36.3% study participants had a recent or lifetime HAI experience, respectively. It is postulated that women of all ages and ethnicities are engaging in more HAI than providers may have previously realized and the prevalence of HAI has steadily increased since the early 1990s. Further, it may be helpful to report the percentage of women in the study that were vaccinated against HPV strains 16 and 18 and still acquired SCCA.

If receptive HAI is a risk factor for SCCA, there is clearly a need to develop and distribute targeted education for patients and health care professionals. Increasing awareness by all stakeholders may be particularly important as reports indicate decreased condom use during HAI.