San Francisco Chronicle - Tuesday, April 24, 2007
**Joel Palefsky, Jen Hecht, Jason Riggs, Michael Scarce

Most men and women who are sexually active acquire HPV at some point. Most HPV infections don't cause cancers, but some do. Rates of anal cancer among gay and bisexual men are 35 times greater than the general population -- comparable to rates of cervical cancer in women before routine Pap smear screening for cervical precancerous cells. HIV-positive men and women are even more susceptible, with HIV-positive men a staggering 80 times more at risk. Anal cancer rates have doubled in the last 10 years and are expected to continue rising. Black gay and bisexual men have seen the sharpest increase and have lower survival rates.

The National Cancer Institute estimates that 4,650 people in the United States will be diagnosed with anal cancer this year and 690 people will die from it.

Early detection of precancerous cells can save hundreds of lives each year and spare thousands of people from radiation therapy, chemotherapy and a lifetime of painful side effects.

The good news is that anal cancer is potentially preventable and highly curable. An anal Pap smear is an inexpensive and relatively painless screening procedure that can detect abnormal cells. A follow-up exam, which includes a high-resolution anoscopy, helps determine whether abnormal cells are precancerous. Specialists believe that treating anal precancerous cells, often through a simple in-office procedure, can prevent anal cancer.

Despite the experience of specialists, these potential preventive measures are not part of routine care for those at risk. One reason is a disturbing lack of large-scale studies and research funding on anal cancer prevention. Without these studies, policymakers and medical associations are hesitant to recommend preventive measures. In contrast, cervical Pap smears became part of women's health care before conclusive studies were published, yielding an 80 percent reduction in cervical cancer.

Another reason that preventive measures are not in place is the limited number of providers trained in high-resolution anoscopy (HRA). Further, if pre-cancers are detected through the procedure, no guidelines exist for optimal treatment.

This potentially preventable cancer is needlessly advancing among thousands of Americans each year. Some specialists are screening for and treating anal pre-cancers, but without randomized clinical studies, it hasn't been proven that these measures prevent anal cancer. Required studies are in the planning stages and will take years to conduct.

The STOP AIDS Project, a San Francisco-based community project that works to prevent the transmission of HIV among gay and bisexual men, supports evidence-based standards of care. However, until standards of care are implemented, something needs to be done. STOP AIDS advocates that policymakers and medical associations support and fund research on anal-cancer prevention, including the efficacy of HPV vaccines in males. In anticipation of published guidelines, a health-care infrastructure should be developed that includes provider training. Policymakers should also consider piloting screening programs to collect data and determine efficacy and feasibility.

Gay and bisexual men and those with HIV should talk with their health-care providers about their risk for anal cancer and HPV. Men can decrease their risk for HPV by using condoms. Those at risk should consider getting an anal Pap smear annually if they are HIV-positive or every two to three years if they are HIV-negative. At minimum, they should have a rectal exam to detect abnormal growths. Also, men at risk can lower their risk by stopping smoking, because smoking is a risk factor for developing anal cancer. Men at risk can advance prevention efforts by volunteering for clinical trials or advocating for research funding and health insurance coverage. Additionally, providers can seek training in preventive anal cancer procedures.

The San Francisco Department of Public Health STD Control Branch and STOP AIDS are convening an expert panel to evaluate existing data on anal cancer and develop recommendations. Last month, New York's AIDS Institute became the first Department of Public Health in the nation to publish such recommendations. Other organizations, counties and states should follow this lead.

**Dr. Joel Palefsky is a professor of medicine at the University of California, San Francisco. Jen Hecht, Jason Riggs and Michael Scarce are staff members of STOP AIDS Project, an HIV prevention and health promotion organization for gay, bisexual and transgender men. For more information visit www.stopaids.org and www.analcancerinfo.ucsf.edu/
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