A new threat to the LGBTQ+ community
"Anal cancer is relatively rare in the [general] population, except for a select group of people who have their immune system suppressed," explained Dr. Vlad "Val" Simianu, one of the leading researchers in the groundbreaking ANCHOR (Anal Cancer HSIL Outcomes Research) study.

While anal cancer is not very common among the heterosexual population, it is recurrent among the LGBTQ+ community, especially for AMAB (assigned male a birth) people who are HIV positive. Doctors now know that people living with HIV are more likely to develop anal cancer over time, and because they are living longer, this likelihood is increasing.

"It's probably the fourth most common cancer for people with HIV. In fact, in men living with HIV who have sex with other men, it's 11 times more likely than in the regular population, and 40 times more likely in women living with HIV," Dr. Simianu said.

Anal cancer is also on the rise, according to the American Cancer Society. One of the reasons doctors believe this cancer is increasing is due to its relationship with HPV. "Ninety-nine percent of cases of anal cancer are caused by the human papillomavirus," Dr. Simianu explained. "[HPV is] an extremely common sexually transmitted infection. On top of that, there are a number of risk factors. HIV and smoking, which are higher in [the LGBTQ+] community, are related to why people get anal cancer."

In recent decades, doctors have made tremendous progress in developing drugs and vaccines to prevent and treat HIV and HPV, but vaccinations are not enough to prevent anal cancer.

Just because someone has received the HPV vaccine does not mean they can't still catch the virus. "There's probably a hundred different types of this virus. Not all of them lead to cancer, and not all the vaccines cover all the types," Dr. Simianu said. "As the vaccines get better, we cover more [variations] of the virus. From data we have in kids, we think that getting the vaccine prevents the HPV infection."

HIV-positive people are more likely to develop anal cancer because the disease attacks the immune system. "[HIV is] a virus that affects our immune system and our ability to fight off viruses and cancer cells in particular," Dr. Simianu said. "Part of our immune system is to prevent cancer from ever arising in our bodies, so when the virus affects that, then people living with HIV are at higher risk of certain cancers that otherwise our immune systems would prevent, like anal cancers or cancers caused by the human papilloma virus."

Early detection
When detected early, anal cancer is treatable, although it usually requires radiation and chemotherapy. "We can treat and cure maybe 60—70% of anal cancer, as long as we catch it at an early stage. We used to do pretty aggressive surgery about three or four decades ago. We figured out that this cancer goes away almost completely with radiation, so about 90% of the time, radiation with a couple of doses of chemotherapy can make [it] go away," explained Dr. Simianu.

Even when caught early, anal cancer is still very hard on the body, and treatments like chemotherapy can be hard to undergo. In extreme cases, anal cancer can also require surgery to remove the anal canal, which leaves patients unable to have bowel movements and requires them to use an ostomy bag. It can also metastasize to other organs and the lymphatic system, which makes it much more difficult to treat.

For those who do not want to risk living with an ostomy bag, prevention is key. "Even though we are in the business of treating cancer, boy, we'd love to prevent it," Dr. Simianu said.

While vaccinating against HPV, taking medications like PrEP, and having open conversations with partners about sexual health and history are some of the best ways to prevent anal cancer, the number one thing doctors recommend is attending yearly screenings. "The key with prevention is you want to catch it before it becomes cancer or becomes symptomatic," Dr. Simianu added.

Just like how people should get a colonoscopy at age 45, doctors believe people should start screening for anal cancer once they're middle-aged. For some people, screenings should happen earlier than 45 and as frequently as once a year.

"For men and women living with HIV, they probably should start anal cancer screening right away. Even for men having sex with men who are not HIV positive, because of their risk for HPV, they should probably start in their forties," Dr. Siminu said.

A study cut short
Following the release of the new ANCHOR study, doctors have even more reasons to recommend early screenings for anal cancer. Once chronic, HPV causes precancerous growths to mature around the vaginal and anal canals. These growths, known as high-grade squamous intraepithelial lesions (HSILs), can develop into either cervical or anal cancer. Previously, doctors would monitor HSILs to see if they would eventually evolve into cancer. In people living with HIV, the likelihood of this was much greater.

In the ANCHOR study, doctors from across the United States studied two groups of HIV-positive patients. One group was the control and the other group had their HSILs removed. The doctors then monitored both groups to see how likely it was those who had their HSILs removed would develop anal cancer. "After seven years, the trial stopped early," Dr. Simianu said. "In the group of patients for whom we were treating the lesions versus watching them, we prevented so much more cancer."

The doctors discovered that removing the HSILs had a direct link to preventing anal cancer, and they felt it was cruel to prevent the control group from receiving the same care. The control group returned to participating treatment centers, where they also had their HSILs removed. Doctors will continue monitoring both groups but have confidence that this new treatment is the most effective way to prevent anal cancer in people with HIV and HPV.

Due to the overwhelming success of the study, doctors recommend this treatment be used in all immunocompromised people who have developed HSILs. While this first group was made up entirely of HIV-positive people, the results will be able to help others who are immunocompromised for a variety of reasons.

"Now we can hopefully expand to transplant patients and other immunosuppressed patients. We know it works, so it's not like we can not give those patients the treatment," Dr. Simianu said.

Spread the word!
The next step to preventing anal cancer is just getting the word out. Now that the study is out, doctors everywhere are aware of this medical breakthrough, but it is still up to patients to seek screenings and HSIL removal. HSIL removal is relatively noninvasive (it does not require surgery or anesthesia). The growths can be removed with freezing or heat techniques, like a mole or wart.

Dr. Simianu warns that just because this new procedure is an option for people to use in preventing anal cancer, early vaccination against HPV is still the primary way to go. Anyone who is HIV positive, especially anyone who has both HIV and HPV; people who have a personal history of cervical, vulva, or vaginal cancer; or AMAB people over the age of 45 who are also having sex with AMAB people are at the highest risk of developing anal cancer and should have a yearly high-resolution anoscopy to detect HSILs. If detected, patients can schedule the procedure to have them removed.

People Dr. Simianu classifies as "moderate risk" include AMAB people over the age of 30 who are having sex with AMAB people, people who have experienced precancerous changes to the cervix or vulva, patients five years out from an organ or marrow transplant, or people who have suppressed immune systems from conditions like colitis or lupus. These people should seek an anal pap as a precursor to an anoscopy.

Thanks to Dr. Simianu, and all the other doctors working tirelessly at Virginia Mason, the Polyclinic, and Harborview Medical Center, we are one step closer to preventing anal cancer altogether.

If you have concerns about cancerous HSIL growths or are at an increased risk for anal cancer, talk with your doctor about scheduling a screening today.