Anal Paps for Everyone!

Although we haven't made it official, making anal Pap smear testing routine for everyone is becoming more and more important. Data from several studies in 2007 and 2008 showed (shockingly!) that heterosexuals get anal HPV just like men who have sex with men do. There are a handful of patients with whom I've dealt in-house who had abdominoperineal resection (APRs) or pelvic exenterations for advanced-stage anorectal carcinomas that could have been avoided with screening.

UCSF has sort of pioneered the "new" science of screening for cancer of the anus, and their website is I think the reference for how to do it: http://www.analcancerinfo.ucsf.edu/screening/philosophy.html . Take a quick look at their anatomy page, too, just to refresh your memory: http://www.analcancerinfo.ucsf.edu/screening/anatomy.html .

I think (and probably most of the attendings would agree) that at the very least, all sexually active men who have sex with men should have annual or every-other-year screening, a la sexually active women getting Pap smears. The British HIV Association in 2008 published guidelines for cancer screening that included a bit about anal cancer, but the USPSTF and DHHS haven't weighed in yet on things. The BHIVA's guidelines are a little wishy-washy about how to screen, and UCSF's clinic actually does anoscopy (akin to a colposcopy) on their patients, with acetic acid prep and biopsy for diagnosis - rather than cytology.

Our clinic's as-yet-unpublished chewing-gum-and-paper-clips guidelines go something like this:

• Open and nonjudgemental discussion with male and female patients about sexual risks on a routine basis, including having receptive anal sex with or without condoms
• Annual or biennial (QOY) screening with female cervical Pap kit's cytobrush inserted into the anal canal and then sent to Pathology in the supplied fixative
• If no dysplasia is identified, then likely can fall into an algorithm along the lines of female Paps, with spacing-out of tests if a couple of negative tests are obtained and patient is in a monogamous relationship
• For any dysplasia, referral to general surgery for consideration of anoscopy with biopsy for staging and additional management (just like sending to Gyn for a colpo with ASCUS, LSIL, or HSIL)

It's unclear whether or not insurance carriers will cover the Pap testing, but as with other tests we do, I think that good medicine shouldn't be impaired by the billing department. Lynda Bell and others in the clinic are working on trying to sort out those issues.

The younger guys will balk at this, and probably many women will, too. Also be aware that in the Latino community, there's a significant and well-described social desirability bias that keeps women (and sometimes men) from owning up to having anal sex. In a perfect clinic setting (which we're not), all male and female patients would be screened. Just like with your residency continuity clinics, it's difficult sometimes to work in primary and secondary prevention into visits where the patients are sick as stink or come in with specific complaints. Just do your best! :)

– Christopher Hurt