Response to: “Anal cancer screening”

Abstract

To the Editor: We would like to thank Drs Kreuter, Esser, and Wieland for their thoughtful response to our article. We also appreciate reading a European perspective on the treatment and management of anal intraepithelial neoplasia (AIN). Regarding treatment options for AIN, we opted to give a cursory overview of treatment options to thoroughly discuss the indications and limitations of screening for anal dysplasia. Therefore, we commend the excellent and succinct summary provided in the authors' letter. Although we do agree there are no published studies on the use of cryotherapy for treating anal dysplasia, the US Department of Veterans Affairs and the University of California at San Francisco's anal neoplasia clinic both endorse it as a treatment option.1US Department of Veterans Affairs, Office of Clinical Public Health Programs for the Public Health Strategic Health Care Group. Primary care of veterans with HIV. 1st ed. Department of Veteran Affairs; 2009.Google Scholar, 2Chin-Hong P.V. Palefsky J.M. Natural history and clinical management of anal human papillomavirus disease in men and women infected with human immunodeficiency virus.Clin Infect Dis. 2002; 35: 1127-1134Crossref PubMed Scopus (249) Google Scholar, 3Berry J.M. Jay N. Cranston R.D. et al.Progression of anal high-grade squamous intraepithelial lesions to invasive anal cancer among HIV-infected men who have sex with men.Int J Cancer. 2014; 134: 1147-1155Crossref PubMed Scopus (140) Google Scholar Furthermore, cryotherapy is an acceptable treatment option for cervical dysplasia,4American College of Obstetricians and GynecologistsACOG practice bulletin no. 99: management of abnormal cervical cytology and histology.Obstet Gynecol. 2008; 112: 1419-1444Crossref PubMed Scopus (84) Google Scholar it is inexpensive, and it is readily available in most dermatology practices. Ultimately, data on its usefulness in treating AIN are needed. Regarding treatment of high-grade anal dysplasia, although the recommendations of the New York Department of Public Health and the Austrian and German AIDS Societies are not without merit, they do not substitute for consensus guidelines from a national government health care agency. Although the 2 new studies the authors mention do suggest that treating AIN2 and AIN3 in HIV-positive patients is merited,3Berry J.M. Jay N. Cranston R.D. et al.Progression of anal high-grade squamous intraepithelial lesions to invasive anal cancer among HIV-infected men who have sex with men.Int J Cancer. 2014; 134: 1147-1155Crossref PubMed Scopus (140) Google Scholar, 5Dalla Pria A. Alfa-Wali M. Fox P. et al.High-resolution anoscopy screening of HIV-positive MSM: longitudinal results from a pilot study.AIDS. 2014; 28: 861-867Crossref PubMed Scopus (48) Google Scholar a Cochrane Review from 20126Macaya A. Muñoz-Santos C. Balaguer A. Barberà M.J. Interventions for anal canal intraepithelial neoplasia.Cochrane Database Syst Rev. 2012; 12: CD009244PubMed Google Scholar and a meta-analysis by Machalek et al7Machalek D.A. Poynten M. Jin F. et al.Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis.Lancet Oncol. 2012; 13: 487-500Abstract Full Text Full Text PDF PubMed Scopus (678) Google Scholar found insufficient evidence to support the treatment of AIN. Machalek et al7Machalek D.A. Poynten M. Jin F. et al.Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis.Lancet Oncol. 2012; 13: 487-500Abstract Full Text Full Text PDF PubMed Scopus (678) Google Scholar also argue that progression of anal dysplasia to invasive cancer is lower than it is for comparative grades of cervical dysplasia. Without recommendations from national health care organizations or from a peer-reviewed meta-analysis, we believe it would be imprudent to formally recommend or reject treating AIN. Instead, we believe the decision to treat or not treat anal dysplasia is a conversation that physicians should have with their patients on a case-by-case basis. Anal cancer screeningJournal of the American Academy of DermatologyVol. 72Issue 2PreviewTo the Editor: We read with great interest the review article of Liszewski et al1 about anal Pap smears as a screening tool for anal cancer. The authors provide an overview of the current knowledge of anal intraepithelial neoplasia (AIN) and anal cancer prevention in high-risk populations such as HIV-positive men who have sex with men (HIV+MSM). It is important to bring attention to this relevant issue of modern HIV medicine, but we are concerned about some aspects of the article. Full-Text PDF