The other side of screening: predictors of treatment and follow-up for anal precancers in a large health system

Abstract

Background: Anal cancer disproportionately affects people with HIV (PWH). Highgrade squamous intraepithelial lesions (HSIL) are cancer precursors and treating them might prevent anal cancer. Data on adherence to HSIL treatment and surveillance is limited but needed to identify deficiencies of screening strategies.Methods: We collected data on high-resolution anoscopy (HRA) attendance and outcomes from 2009 to 2019 in a large urban anal cancer-screening program. Patients with an initial HSIL diagnosis were followed for return for HSIL electrocautery ablation within 6 months of index HSIL diagnosis, and follow-up HRA within 18 months of index HSIL diagnosis. We also evaluated predictors of these outcomes in univariable and multivariable analyses.Results: One thousand one hundred and seventy-nine unique patients with an anal HSIL diagnosis were identified and 684 (58%) returned for electrocautery ablation. Of those treated, only 174 (25%) and only 9% of untreated HSIL patients (47 of 495) underwent surveillance HRA within 18 months of index HSIL diagnosis. In multivariable analyses, black patients and PWH regardless of virologic control were less likely to undergo HSIL ablation within 6 months of HSIL diagnosis whereas patients with commercial insurance were more likely to be treated within 6 months of diagnosis. Among treated HSIL patients, PWH with viremia had a lower likelihood of engaging in post-treatment surveillance within 18 months of HSIL diagnosis.Discussion: Even in large specialized anal cancer screening programs adherence to HSIL treatment and surveillance is low. Psychosocial and economic determinants of health may impact retention in care. Addressing both personal and structural barriers to patient engagement may improve the effectiveness of anal cancer screening.

Évaluer les nouveaux tests de dépistage

“…Nous avons effectué une recherche documentaire sur chacun des sujets pour trouver des revues récentes qui présentent des données probantes sur la question de savoir si le dépistage est approprié chez les patients décrits dans les cas. Au Tableau 1, chacune des situations dans les exemples ont été évaluées en fonction des critères du dépistage 20,21,[29][30][31][32][33][34][35][36]…”

Editorial commentary on ‘the other side of screening: predictors of treatment and follow-up for anal precancers in a large health system’

“…The care provided was consistent with current practice, despite not being standardized [6]. It would be interesting to see whether the metrics in Table 1 by Silvera et al [4] changed over the study period since the time their Program began until present day, with the understanding that interruptions related to COVID-19 circa 2020-2021 would be expected. For example, whether patients would need anal Pap prior to HRA vs. either anal Pap or HRA, as this might add additional visits and less engagement.…”

“…HRA is a newer procedure compared to anal Pap smear, and its use is not mutually exclusive of anal Pap. The first public HRA training was offered by American Society for Colposcopy and Cervical Pathology (ASCCP) in 2005 (presentation by Dr J. Michael Berry-Lawhorn, ASCCP2016), 4 years before the start of the study period in Silvera et al [4]. However, the Mount Sinai Anal Dysplasia Program is a well established centre with a successful track record [5].…”

“…PWHA are at an increased risk of developing anal cancer [2,3]. In this context, Silvera et al [4] add to an important growing body of literature on anticipating the needs of PWHA with respect to their increased risk of anal cancer. Silvera et al [4] completed a 10-year retrospective chart review of a cohort of mostly MSM with high HIV burden who underwent high-resolution anoscopy (HRA) to screen for precancerous anal high-grade squamous intraepithelial lesions (HSIL), precursors for anal cancers such as squamous cell carcinoma of the anus (SCCA).…”

“…In this context, Silvera et al [4] add to an important growing body of literature on anticipating the needs of PWHA with respect to their increased risk of anal cancer. Silvera et al [4] completed a 10-year retrospective chart review of a cohort of mostly MSM with high HIV burden who underwent high-resolution anoscopy (HRA) to screen for precancerous anal high-grade squamous intraepithelial lesions (HSIL), precursors for anal cancers such as squamous cell carcinoma of the anus (SCCA). They evaluated whether patients diagnosed with HSIL by HRA returned for therapeutic electrocautery ablation within 6 months of HSIL diagnosis and whether they followed up after HSIL diagnosis and/or treatment within 18 months of diagnosis.…”