Anal Cancer Screening in Men Who Have Sex With Men
Anal Cancer Screening in Men Who Have Sex With Men
Objectives. We investigated attitudes about and acceptance of anal Papanicolaou (Pap) screening among men who have sex with men (MSM).
Methods. Free anal Pap screening (cytology) was offered to 1742 MSM in the Multicenter AIDS Cohort Study, who reported history of, attitudes about, and experience with screening. We explored predictors of declining screening with multivariate logistic regression.
Results. A history of anal Pap screening was uncommon among non– HIV-infected MSM, but more common among HIV-infected MSM (10% vs 39%; P < .001). Most participants expressed moderate or strong interest in screening (86%), no anxiety about screening (66%), and a strong belief in the utility of screening (65%). Acceptance of screening during this study was high (85%) across all 4 US sites. Among those screened, most reported it was "not a big deal" or "not as bad as expected," and 3% reported that it was "scary." Declining to have screening was associated with Black race, anxiety about screening, and low interest, but not age or HIV status.
Conclusions. This study demonstrated high acceptance of anal Pap screening among both HIV-infected and non–HIV-infected MSM across 4 US sites.
In the past 3 decades, anal cancer incidence has increased 39% in women and 96% in men in the United States. In the general US population, anal cancer incidence remains higher among women than men (1.8 vs 1.4 cases per100 000 annually), but the incidence is especially high among men who have sex with men (MSM; 35 per 100 000). Indeed, data suggest that anal cancer incidence among MSM may be similar to or higher than incidence of cervical cancer among US women before the introduction of cervical cytology screening in the mid-1950s. Incidence estimates for HIV-infected MSM are even higher and vary from 45.9 per 100 000 person-years in meta-analyses to 78.2 per 100 000 person-years for US AIDS Surveillance Epidemiology and End Results data.
Human papillomavirus (HPV) infection is the major cause of anal cancer. Consistent with the increased anal cancer incidence among MSM, anal HPV prevalence and incidence are elevated among MSM compared with the general population. HIV-infected MSM have even higher anal HPV prevalence, compared with non–HIV-infected MSM (98% vs 57%). As effective antiretroviral therapy (ART, also referred to as HAART) helps HIV-infected individuals live longer, more may now develop anal cancer. On the basis of initial studies, it is unclear whether ART use reduces risk of anal intraepithelial neoplasia (AIN2/3, precancer) or anal cancer, although low CD4-cell count does appear to increase risk of anal cancer.
Recent research suggests that anal Papanicolaou (Pap) screening may have utility in preventing anal cancer and is a costeffective screening method for anal cancer prevention among MSM. Like cervical dysplasia, anal dysplasia is slow-growing and treatable, and studies suggest that anal Pap tests can detect dysplasia with similar sensitivity and specificity to cervical Pap tests. On the basis of these data and the success of cervical Pap screening in reducing cervical cancer incidence, some have proposed routine anal Pap cytology (referred to as anal Pap screening hereafter) among MSM. However, these guidelines remain preliminary as researchers have not yet conducted a randomized trial to establish whether anal Pap screening reduces anal cancer deaths. Furthermore, recent studies have suggested that anal precancers (AIN2+) are relatively common among unscreened non–HIV-infected (∼4%) and HIV-infected (15%–30%) MSM, much higher than anal cancer rates, so other researchers have suggested that closer examination of the relative harms and benefits of treating all AIN 2/3 in MSM is first needed.
Despite the high incidence of anal cancer among MSM and recommendations, by some, for screening,MSM currently have low awareness of, access to, and use of anal Pap screening. Indeed, in our previous research, we observed a low reported prevalence of ever having anal Pap screening among MSM. We have expanded on these previous findings by examining acceptance of screening when offered for free. We also examined attitudes about anal Pap screening, experience with screening, and reasons for declining to have an anal Pap test.
Abstract and Introduction
Abstract
Objectives. We investigated attitudes about and acceptance of anal Papanicolaou (Pap) screening among men who have sex with men (MSM).
Methods. Free anal Pap screening (cytology) was offered to 1742 MSM in the Multicenter AIDS Cohort Study, who reported history of, attitudes about, and experience with screening. We explored predictors of declining screening with multivariate logistic regression.
Results. A history of anal Pap screening was uncommon among non– HIV-infected MSM, but more common among HIV-infected MSM (10% vs 39%; P < .001). Most participants expressed moderate or strong interest in screening (86%), no anxiety about screening (66%), and a strong belief in the utility of screening (65%). Acceptance of screening during this study was high (85%) across all 4 US sites. Among those screened, most reported it was "not a big deal" or "not as bad as expected," and 3% reported that it was "scary." Declining to have screening was associated with Black race, anxiety about screening, and low interest, but not age or HIV status.
Conclusions. This study demonstrated high acceptance of anal Pap screening among both HIV-infected and non–HIV-infected MSM across 4 US sites.
Introduction
In the past 3 decades, anal cancer incidence has increased 39% in women and 96% in men in the United States. In the general US population, anal cancer incidence remains higher among women than men (1.8 vs 1.4 cases per100 000 annually), but the incidence is especially high among men who have sex with men (MSM; 35 per 100 000). Indeed, data suggest that anal cancer incidence among MSM may be similar to or higher than incidence of cervical cancer among US women before the introduction of cervical cytology screening in the mid-1950s. Incidence estimates for HIV-infected MSM are even higher and vary from 45.9 per 100 000 person-years in meta-analyses to 78.2 per 100 000 person-years for US AIDS Surveillance Epidemiology and End Results data.
Human papillomavirus (HPV) infection is the major cause of anal cancer. Consistent with the increased anal cancer incidence among MSM, anal HPV prevalence and incidence are elevated among MSM compared with the general population. HIV-infected MSM have even higher anal HPV prevalence, compared with non–HIV-infected MSM (98% vs 57%). As effective antiretroviral therapy (ART, also referred to as HAART) helps HIV-infected individuals live longer, more may now develop anal cancer. On the basis of initial studies, it is unclear whether ART use reduces risk of anal intraepithelial neoplasia (AIN2/3, precancer) or anal cancer, although low CD4-cell count does appear to increase risk of anal cancer.
Recent research suggests that anal Papanicolaou (Pap) screening may have utility in preventing anal cancer and is a costeffective screening method for anal cancer prevention among MSM. Like cervical dysplasia, anal dysplasia is slow-growing and treatable, and studies suggest that anal Pap tests can detect dysplasia with similar sensitivity and specificity to cervical Pap tests. On the basis of these data and the success of cervical Pap screening in reducing cervical cancer incidence, some have proposed routine anal Pap cytology (referred to as anal Pap screening hereafter) among MSM. However, these guidelines remain preliminary as researchers have not yet conducted a randomized trial to establish whether anal Pap screening reduces anal cancer deaths. Furthermore, recent studies have suggested that anal precancers (AIN2+) are relatively common among unscreened non–HIV-infected (∼4%) and HIV-infected (15%–30%) MSM, much higher than anal cancer rates, so other researchers have suggested that closer examination of the relative harms and benefits of treating all AIN 2/3 in MSM is first needed.
Despite the high incidence of anal cancer among MSM and recommendations, by some, for screening,MSM currently have low awareness of, access to, and use of anal Pap screening. Indeed, in our previous research, we observed a low reported prevalence of ever having anal Pap screening among MSM. We have expanded on these previous findings by examining acceptance of screening when offered for free. We also examined attitudes about anal Pap screening, experience with screening, and reasons for declining to have an anal Pap test.
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