{"id":11603,"date":"2025-08-16T12:58:07","date_gmt":"2025-08-16T16:58:07","guid":{"rendered":"https:\/\/blogs.nejm.org\/hiv-id-observations\/?p=11603"},"modified":"2025-08-16T14:46:02","modified_gmt":"2025-08-16T18:46:02","slug":"anal-cancer-screening-in-hiv-when-guidelines-get-ahead-of-the-evidence","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/anal-cancer-screening-in-hiv-when-guidelines-get-ahead-of-the-evidence\/2025\/08\/16\/","title":{"rendered":"Anal Cancer Screening in HIV: When Guidelines Get Ahead of the Evidence"},"content":{"rendered":"

\"\"Should every person with HIV over age 35 (if MSM or transgender woman) or 45 (everyone else) have an anal Pap smear, a digital anal rectal exam (DARE), and possibly a high-resolution anoscopy every 1\u20132 years? According to recent guidelines, yes. But here\u2019s the problem: we don\u2019t know if this screening effort actually prevents cancer.<\/p>\n

First, some facts:<\/p>\n

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  1. Human papillomavirus (HPV) infection is necessary, but not sufficient, for the development of anal cancer.<\/li>\n
  2. Both HPV prevalence and anal cancer incidence are higher in PWH than in those without HIV.<\/li>\n
  3. The natural history of HPV leading to anal cancer is similar to cervical cancer.<\/li>\n
  4. Cervical cancer screening programs have reduced incidence of that disease.<\/li>\n
  5. In the ANCHOR trial<\/a>, treatment of biopsy-confirmed, high-grade squamous intraepithelial lesions (HSIL) in PWH reduced the risk of anal cancer.<\/li>\n<\/ol>\n

    So far, so good.<\/p>\n

    The temptation, therefore, is to apply our cervical-cancer-prevention model directly to anal cancer, and that’s an approach many have advocated for years. But here\u2019s the problem — there\u2019s no proof this works. As Dr. Hayden Andrews wrote in a recent State-of-the-Art review<\/a> in Clinical Infectious Diseases <\/em>(Note: I am currently editor-in-chief of this journal):<\/p>\n

    To date, no trial has been conducted to determine if anal cancer screening among PWH decreases anal cancer incidence.<\/p><\/blockquote>\n

    And if you think about it for a nanosecond, that\u2019s not surprising! Demonstrating that cancer screening improves outcomes is notoriously hard. Just ask anyone who studies breast, prostate, lung, or colorectal screening — and those cancers are far<\/em> more common than anal cancer, and have been far more widely studied.<\/p>\n

    This gets to the core of why I believe the International Anal Neoplasia Society guidelines<\/a> — later reinforced by the Department of Health and Human Services HIV guidelines<\/a> — are premature and overly aggressive. They’re posted in our clinic workroom, so I’m constantly reminded of just how broad they are. The recommendations show up in this Bluesky post of mine, along with my incredulous query:<\/p>\n

    \n

    Calling all HIV\/ID providers: How many are able to do this screening for anal cancer according to IANS? Including the HRA and repeat screening every 1-2 years (!!) for normal results? Wow, that's a lot of screening tests in a lot of people! #IDSky #HIVsky onlinelibrary.wiley.com\/doi\/10.1002\/…<\/p>\n

    — Paul Sax (@paulsaxmd.bsky.social)<\/a> 2025-08-15T17:39:22.614Z<\/a><\/p><\/blockquote>\n