by David Aboulafia, MD - Special to the SGN

Anal cancer is a subject most people would rather not talk about because of its anatomical location, along with an unfortunate stigma attached to the malignancy.

Although the situation was tragic, actress Farrah Fawcett's openness about her anal cancer diagnosis in 2006 helped create much-needed public awareness about the malady during her 11-year battle with the disease, which, unfortunately, she lost in 2009 at the age of 62.

Closer to home, a 51-year-old White Center resident by the name of Ed was impressed with Fawcett's openness and advocacy. He now feels very fortunate that he listened to his physician and decided to have an anal cytology smear (similar to a cervical Pap smear) following many years of HIV treatment and participation in a surveillance program. Despite having put off the screening for a few months, Ed knew that since he had HIV - and, as a result, a compromised immune system - he was at higher risk for human papillomavirus (HPV), lesions, and anal cancer.

The anal cytology test showed cells that were concerning for cancer, and a subsequent biopsy of a suspicious-looking lesion proved to be cancerous. After additional studies, Ed was diagnosed with early-stage anal cancer. The fortuitous discovery in October 2015 allowed him to forgo surgery and instead receive six weeks of chemotherapy and radiation. Although his treatment was challenging, the holidays and the month of January allowed Ed to rest and recover. In February 2016, he felt good enough to return to work and subsequently began following a vegan diet, exercising regularly, and better managing his diabetes and stress. Due to the clarity that accompanied his hardship, Ed said he almost feels lucky to have gone through this experience because of everything it taught him - especially the importance of educating yourself, finding a good care team, and learning to be your own best health advocate.

Anal cancer and HPV
Anal cancer occurs when skin cells grow out of control in the anus. The causes and location of anal cancer should not be confused with colon or rectal cancer, which are different.

According to the American Cancer Society, about 90% of anal cancers are caused by HPV. It is important to know that there are many strains or types of HPV and not all of them cause cancer. Most cancers of the cervix and anus are caused by HPV strains 16 and 18, while other HPV strains cause genital warts. HPV is the most common sexually transmitted disease, and most people are exposed to HPV numerous times over their lifetime. Thankfully, HPV infection usually becomes undetectable using currently available tests. However, when the immune system is damaged by HIV and other causes, including autoimmune diseases, HPV infection can last longer and cause changes to the skin inside the anus, which is called 'dysplasia.' Over time, some of these HPV-damaged cells - called 'high-grade squamous intraepithelial lesions,' or HSILs - can develop into cancer. Although HSILs are not the same as cancer, it is an indication that cancer may develop in that spot at a later date. Unfortunately, researchers do not currently know why some HSILs go away on their own while others worsen and become cancerous.

Who is at risk for anal cancer?
Anyone can get anal cancer, even people who have never had anal sex. However, it is much more common in people who are HIV positive. For perspective, in HIV-negative people the chance of developing anal cancer is one to two people per 100,000. In HIV-positive people, it is between 30 and 131 per 100,000. (The rate in HIV-positive women is lower than in men.) In fact, even HIV-positive people on successful antiretroviral therapy have a higher risk of anal cancer than HIV-negative people.

Risk factors
The most common risk factors for anal cancer include the following:

o infection with certain HPV types

o age, as risk increases with age

o having a low CD4+ T-cell lymphocyte count (CD4+, also called T-helper cells, are a type of white blood cell that fight infection)

o smoking

o a history of genital warts

o for women: a history of HPV-related cervical and vulvar dysplasia and/or cancers

Symptoms
Early stages of anal cancer are often not accompanied by symptoms, which means most people are unaware when they begin to develop it. In later stages, the most common symptom reported is pain, which can be felt constantly or only when having a bowel movement or anal sex. Other symptoms can include a lump or bleeding from the anus. Unfortunately, anal cancer is often misdiagnosed as a hemorrhoid. If you are having any of these symptoms, it's important to tell your doctor.

Treatments
Like most types of malignancies, the earlier anal cancer is found and treated, the fewer side effects people face from treatment. When caught early, anal cancer usually responds well to treatment. Some small cancers can be removed surgically. However, once the cancer spreads, treatment may require a combination of chemotherapy, radiation, and surgery. Removing the affected areas can 'cure' anal cancer, but there are often long-term side effects from surgery, radiation, and chemotherapy, like needing to go to the bathroom more often.

Research: Virginia Mason, Harborview, and the Polyclinic in national screening study
Thankfully, deaths from AIDS are way down. However, anal cancer among people living with HIV is on the rise. Although it may be possible to prevent anal cancer through routine screening and removal of precancerous cells, researchers do not yet know if this is true.

In an attempt to increase our knowledge about this question, researchers at Virginia Mason, Harborview, and the Polyclinic are participating in a national clinical trial called the ANCHOR Study (ANCHOR stands for 'Anal Cancer HSIL Outcomes Research'). This strategy has reduced cervical cancer rates by 80%. But to get health insurance companies to cover routine anal cancer screening and preventive treatment, researchers need to prove that this strategy prevents cancer. The best way to show that is to recruit people with HSILs into a study and assign them randomly to a treatment arm or a monitoring arm. Researchers will then follow everyone for five years or more to compare the rates of cancer in both study arms. At the end of the study, researchers will know whether screening and treatment of HSILs are effective strategies in preventing anal cancer. Researchers will also learn a lot about HPV and other risk factors and why these sometimes cause cancer.

If you have any questions about whether this study might be right for you, talk with your doctor and have your provider call a local study site with any questions. For more information about the ANCHOR Study, including the list of study sites and contact information, visit ANCHORStudy.org.

Words of wisdom
Although Ed is not a candidate for participation in the ANCHOR Study, he now understands the importance of screening for anal cancer, especially among people living with HIV. Despite needing to come to Virginia Mason twice a year to be checked to make sure the cancer doesn't grow back, Ed feels very thankful, and he encourages male and female friends who may be at risk to speak with their physicians about anal cytology. After all, knowledge is power.

For more information, visit:

o Cancer.gov/Types/Anal

o Cancer.org/Cancer/AnalCancer

o AnalCancerFoundation.org

o AnalCancerInfo.UCSF.edu

o VirginiaMason.org/AnalDysplasia

David M. Aboulafia, MD, is board certified in internal medicine. His subspecialties include medical oncology, hematology, and HIV clinical care. Dr. Aboulafia is principal investigator of the ANCHOR Study at Virginia Mason and medical co-director of Bailey-Boushay House. He practices at Virginia Mason Hospital and the Floyd & Delores Jones Cancer Institute (1100 Ninth Ave., Seattle, WA 98101; 206-223-6193).

Courtesy of Virginia Mason Hospital and Medical Center

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