PALEFSKY ET AL. RESPOND

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We agree with Katz et al. that “no prospective studies have demonstrated that performance of anal screening reduces the incidence of invasive anal cancer or of death due to cancer.” We also strongly agree that such a study is needed. However, we stand by our statement that anal cancer screening by anal Papanicolau test has potential benefits for gay and bisexual men. Anal cancer and its precursors are very similar to cervical cancer and its precursors.1 Based on the success of treating high-grade cervical intraepithelial neoplasia to reduce the risk of cervical cancer, we have good reason to believe that treating high-grade anal intraepithelial neoplasia (AIN) will achieve a similar reduction in anal cancer.1 Performing the study that we all agree is needed will take time, and it will be many years before we have the data necessary to implement the best evidence-based approaches to prevention of anal cancer. A key question is what to do now about high-grade AIN in men and women at risk for anal cancer until we have those data. Doing nothing about high-grade AIN is not a reasonable option given the unacceptably high rate of anal cancer in gay and bisexual men, as well as other groups known to be at high risk.2 There are precedents for treating other potentially precancerous lesions to prevent cancer without the benefit of the kind of randomized controlled trial evidence that we all agree is necessary. For example, ductal carcinoma in situ of the breast is routinely treated, sometimes with considerable morbidity, without prospective evidence that doing so reduces the mortality from breast cancer.3 We believe the best approach is to follow this example for now and work to collect the randomized controlled trial data as quickly as possible. Finally, while it is certainly true that anal cytology testing induces some anxiety and discomfort, most of our patients tolerate these procedures well. Screening for any kind of cancer is anxiety-producing, but anxiety for people with normal results typically falls quickly to pretest levels4 unless there is a testing error5 or other abnormal finding that requires follow-up. In our experience, treatment of high-grade AIN has a low complication rate, and our clinic retention rate is high. A diagnosis of anal cancer and its treatment can yield substantial physical and psychological distress that should not be underestimated.