Ask the doctor: What is HIV-related anal cancer?
Every month on Black AIDS.org, HIV specialist Theresa Mack, M.D., M.P.H.--an associate medical director at St Luke's Medical Group in Harlem, N.Y.--answers readers' most pressing HIV/AIDS questions.
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ABOVE PHOTO: Theresa Mack, M.D., M.P.H.
The human papillomavirus (HPV) is the most common sexually transmitted infection. At some point at least 50 percent of sexually active adults will get one of HPV's 40-odd strains, which can infect men and women, usually in the genital region but also in the throat.
Ninety percent of the time the immune system fights off HPV within two years, which means that most people won't have any signs that the virus has even been present. But when the body is unable to clear the infection, HPV can cause a variety of symptoms, including genital warts and cancers of the cervix, vulva, vagina, penis, anus and back of the throat, tongue and tonsils.
The Danger of Dysplasia
HPV can also cause a condition called dysplasia, a general term describing abnormal cell growth. (There is anal dysplasia, cervical dysplasia, etc.) Dysplasia can be detected only by a Pap smear (also called a Pap test), used to screen for precancerous and cancerous cells. Dysplasia does not always lead to cancer, but it can indicate that cancer may develop in the future, so doctors pay very close attention to it.
There are two types of dysplasia: high grade, which almost always progresses to cancer, and low grade, which never progresses directly to cancer but can progress to high grade.
Therefore, when doctors discover dysplasia, they recommend that the patient obtain a biopsy, a medical procedure in which the health provider removes a sample of cells that are then sent to a lab and analyzed. The biopsy helps determine which type of dysplasia is present so that the doctor can determine how to treat it. (Go here to learn more about HPV treatments, including those for dysplasia.)
The Anal Cancer-HIV Connection
Anal cancer's risk is greater among people living with HIV/AIDS (PLWHA) and among men who have sex with men (MSM), who have a 20 times greater risk of developing anal cancer, whether or not they have HIV. And although cervical cancer is more common than anal cancer, among HIV-positive women, anal dysplasia occurs more often, putting them at greater risk of anal cancer than cervical cancer. Importantly, antiretroviral meds don't treat or prevent dysplasia, and even people with CD4 counts above 600 can get dysplasia again.
Risk factors for anal cancer include having multiple sex partners or unprotected anal intercourse; having HPV, genital warts or cervical dysplasia; being HIV positive, with a CD4-cell count of (typically) less than 200 and an HIV viral load of (typically) greater than 100,000; and smoking. Its signs and symptoms include pain during a bowel movement, pain with intercourse, and itching or bleeding from the anal region. Many people mistake these symptoms for more-common conditions, such as hemorrhoids.
No national anal-cancer screening guidelines exist for PLWHA. However, most HIV specialists recommend that PLWHA--particularly gay or bisexual men and people with a history of genital warts and/or an abnormal cervical Pap smear--get screened for anal dysplasia yearly because they may not otherwise have signs.
The anal-dysplasia screening consists of an anal Pap smear, in which a health provider inserts the tip of a cotton swab into the rectum so that rectal cells can be analyzed for abnormalities. However, the results can be difficult to interpret. PLWHA who receive an abnormal test result should see a specialist with a background in anal diseases.
If anal cancer is present, surgery, chemotherapy, radiation and/or laser treatment may be required. Once the cancer is removed, however, anal dysplasia may recur.
Preventing HPV, Dysplasia and Anal Cancer
Among those who have not already been infected with HPV, the HPV vaccination can prevent HPV, the main cause of dysplasia and anal cancer. (Pap smear results indicate whether HPV infection has already occurred.)
Many (but not all) 11- and 12-year-old girls and boys receive the HPV vaccine as part of their routine immunization process--the idea being that they (hopefully) will be immunized before they become sexually active. Parents should inquire whether this vaccine is required in their state or school system and/or consider at what age they want their son or daughter to be immunized, if they believe it's appropriate. People between the ages of 9 and 26 can be vaccinated against HPV if they haven't already been infected. The HPV vaccine is believed safe for HIV patients, although no studies have proved it.
Condoms can also help curb the spread of HPV; however, the virus can be transmitted whether or not condoms are used.
As told to Tomika Anderson, a freelance writer based in Brooklyn, N.Y.
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