Anal cancer in on the rise and there is very little being said about it. It has become the cancer no one likes to talk about. However, nearly 40 million people are infected with the human papilloma virus (HPV), which is believed to cause anal and rectal cancer in people who engage in rectal intercourse, especially men who have sex with men (MSM).
But here is reality. As people with HIV grow older, due to the better control of their HIV infection with anti-retroviral and other therapies, the more common diseases of aging are becoming evident. In the era of effective highly active anti-retroviral therapy (HAART), other clinical issues may be being overlooked. It now seems pretty clear that HAART alone is not the answer for living well with HIV disease. One of the most surprising pieces of news about acquiring HPV infection is that the human papilloma virus is not necessarily prevented by condom use.1 HPV can penetrate certain types of condomsÑespecially non-latex condoms. So even if people are correctly and consistently practicing safe sex, they can still be at risk for HPV and possible anal cancer. However, before abandoning condom use, it is important to consider several factors.
The number of sexual partners over a lifetime is a major risk indicatorÑthe higher the number, the greater the risk. This is as true for HPV as for any other sexually transmitted disease (STD). Also, if there is a history of one or more STDs, the risk increases. This is especially troubling because the rates of syphilis and gonorrhea are on the increase in some major epicenters of the epidemic, like San Francisco and New York. Epidemiologists have been tracking these two STDs for decades and know that they very accurate indicators of other diseases.
Other risk factors include receptive anal intercourse, cigarette smoking, and advanced suppression of the immune system. Finally, another risk factor for developing anal cancer is the use of recreational drugs anally ("booty bumps"). Inserting crystal meth or ecstasy into the rectum can lead to higher rates of anal cancer.
What are the symptoms of HPV infection? Unfortunately, they may be minor or even absent, and this is what makes this disease a "silent killer." Patients may not know they even have it. Some people may experience some bleeding, irritation, and itching in the rectal area. Others may actually feel a lesion or growth. It is always important to have any lesion examined by a healthcare professional.2
One of the major problems in dealing with rectal HPV infection is that there is no clear consensus about how to screen for it or treat it. The need to develop clinical guidelines is critical. Many clinicians simply do not even bother to check for anal HPV infection due to this lack of clarity.3
However, medical confusion has never been a reason for inaction. With the lack of consensus on HPV disease, it would be wise to gather more than one opinion before deciding on treatment. Anal pap smears have yet to become standard general practice. However, many clinicians feel they should be. Some clinicians are recommending yearly anal pap smears.
Treatment Options
The treatment of rectal cancer is guided by the degree of seriousness of the lesions (See Table 1). Interventions include topical medications and gels such as podofilox, podophyllum, trichloroacetic acid, and imiquimod. In general, these treatments have been shown to be 30% to 80% effective in reducing wart size. Cryotherapy uses liquid nitrogen to freeze warts or other abnormal cell patches. Laser treatment is more aggressive than cryotherapy and uses a high-powered light beam to burn and remove abnormal anal or cervical tissue. More advanced surgical interventions include loop electrical excision procedure (LEEP) and cold knife biopsy.
For more advanced cancers, the combination treatment of radiation and chemotherapy is being studied. The anticancer drugs being used today include 5-fluroouracil, mitomycin and cisplatin. These agents are not without their side effects. Both mitomycin and cisplatin may lead to bone marrow suppression, and 5-fluorouracil may lower the white blood count. These side effects can be life threatening.
What to Do?
Anal cancer is highly treatable and controllable. Talk to your primary healthcare provider about it. An AIDS-savvy primary care clinician is going to be up on the latest research and expert opinions. Living well HIV is a complex and forever-evolving challenge.
The National Cancer Institute has developed a grading system to help classify the different degrees of anal cancer. Cancers staged at a higher number are more serious than those at lower numbers. Treatment options are determined based on the stage of the disease.
Richard S. Ferri, Ph.D., ANP, ACRN, FAAN is a HIV/AIDS nurse practitioner specializing in pain and symptom management in Provincetown, MA. Dr. Ferri is also freelance writer and journalist and the associate editor of Numedx.
References
1. Walboomers, JM, Jacobs, MV, Manos, MM, et al. Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathology. 1999;189:12-19.
2. Goldie, SJ, Kuntz, KM, Weinstien, MC, et al., The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. JAMA. 1999; 281: 1822-29.
3. Goedert JJ, Cote TR, Virgo P, et al. Spectrum of AIDS-associated malignant disorders. Lancet. 1998;351:.