Patient Symptomatology in Anal Dysplasia
Original Investigation Research
PLoS One. 2013;8(12):e84030. doi:10.1371/journal .pone.0084030.
men and are infected with HIV. Clin Infect Dis. 2011; 52(9):1174-1181.
homosexual and bisexual men. Am J Med. 2000; 108(8):634-641.
17. Wilkin TJ, Palmer S, Brudney KF, Chiasson MA, Wright TC. Anal intraepithelial neoplasia in heterosexual and homosexual HIV-positive men with access to antiretroviral therapy. J Infect Dis. 2004;190(9):1685-1691.
21. Dalla 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(6):861-867.
25. Goldie SJ, Kuntz KM, Weinstein MC, Freedberg KA, Welton ML, Palefsky JM. The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. JAMA. 1999;281(19):1822-1829.
18. Palefsky JM, Holly EA, Ralston ML, et al. Anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual and bisexual men: prevalence and risk factors. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17(4):320-326. 19. Chin-Hong PV, Vittinghoff E, Cranston RD, et al. Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study. J Natl Cancer Inst. 2005;97(12):896-905. 20. de Pokomandy A, Rouleau D, Ghattas G, et al. HAART and progression to high-grade anal intraepithelial neoplasia in men who have sex with
22. Tong WW, Jin F, McHugh LC, et al. Progression to and spontaneous regression of high-grade anal squamous intraepithelial lesions in HIV-infected and uninfected men. AIDS. 2013;27(14):2233-2243. 23. Chin-Hong PV, Palefsky JM. Natural history and clinical management of anal human papillomavirus disease in men and women infected with human immunodeficiency virus. Clin Infect Dis. 2002;35 (9):1127-1134. 24. Goldie SJ, Kuntz KM, Weinstein MC, Freedberg KA, Palefsky JM. Cost-effectiveness of screening for anal squamous intraepithelial lesions and anal cancer in human immunodeficiency virus-negative
26. Palefsky JM, Holly EA, Hogeboom CJ, Berry JM, Jay N, Darragh TM. Anal cytology as a screening tool for anal squamous intraepithelial lesions. J Acquir Immune Defic Syndr Hum Retrovirol. 1997; 14(5):415-422. 27. Sillman FH, Sentovich S, Shaffer D. Ano-genital neoplasia in renal transplant patients. Ann Transplant. 1997;2(4):59-66.
Invited Commentary
Considering Standards of Care for Anal Cancer James Fleshman, MD
High-resolution anoscopy (HRA) has become a term that induces fear and trepidation in the hearts of most colorectal surgeons. There is a certain sinking feeling when one considers the time and effort that will be expended, with little return, Related article page 563 when the standard of care becomes the routine use of HRA for all human immunodeficiency virus–positive patients. This time and effort are for a 0.131% risk of anal cancer in the highestrisk group—men having sex with men who have human immunodeficiency virus. In fact, colorectal surgeons observe most of these individuals on a regular basis in the office if they have condyloma or symptoms of anal disease. Anoscopy without high resolution actually reveals most anal lesions that cause symptoms. The time spent performing HRA compared with routine anoscopy may discourage most health care professionals from using HRA, except those focused on high-grade squamous intraepithelial lesions (HSIL) and human immunodeficiency as a specialty. ARTICLE INFORMATION Author Affiliations: Department of Surgery, Baylor University Medical Center, Dallas, Texas; Department of Surgery, Texas A&M Health Sciences College of Medicine, Dallas.
The study reported by Hicks et al1 in this issue emphasizes some of the controversies surrounding the overall problem of HSIL. As usual, there are more questions than answers. Can the authors tell us how many patients without symptoms, never having HRA but observed closely, will develop anal squamous cell cancer? Is there a reliable correlation between the presence of an anal lesion and anal pain and HSIL? Can routine follow-up with anoscopy and destruction of obvious anal lesions have the same protective effect as HRA on anal cancer? Can asymptomatic high-risk individuals be observed until they develop one of the symptoms associated with HSIL? What are the “findings consistent with dysplasia,” as mentioned by the authors? Only 29% of the patients referred had cytologic findings on anal Papanicolaou tests showing high-grade dysplasia. How helpful is the Papanicolaou test, if the test and HRA were consistent in only 66% of cases? Finally, if only 30% of the group referred by primary care physicians for rising concern about anal cancer had HSIL and none had anal cancer, why not start with follow-up routine regular anoscopy instead of HRA?
Corresponding Author: James Fleshman, MD, Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave, First Floor Roberts, Dallas, TX 75246 (james.fleshman@baylorhealth .edu). Published Online: April 15, 2015. doi:10.1001/jamasurg.2015.48.
jamasurgery.com
Conflict of Interest Disclosures: None reported. REFERENCE 1. Hicks CW, Wick EC, Leeds IL, et al. Patient symptomatology in anal dysplasia [published online April 15, 2015]. JAMA Surg. doi:10.1001/jamasurg .2015.28.
(Reprinted) JAMA Surgery June 2015 Volume 150, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Central Michigan University User on 10/13/2015
569
Original Investigation Research
PLoS One. 2013;8(12):e84030. doi:10.1371/journal .pone.0084030.
men and are infected with HIV. Clin Infect Dis. 2011; 52(9):1174-1181.
homosexual and bisexual men. Am J Med. 2000; 108(8):634-641.
17. Wilkin TJ, Palmer S, Brudney KF, Chiasson MA, Wright TC. Anal intraepithelial neoplasia in heterosexual and homosexual HIV-positive men with access to antiretroviral therapy. J Infect Dis. 2004;190(9):1685-1691.
21. Dalla 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(6):861-867.
25. Goldie SJ, Kuntz KM, Weinstein MC, Freedberg KA, Welton ML, Palefsky JM. The clinical effectiveness and cost-effectiveness of screening for anal squamous intraepithelial lesions in homosexual and bisexual HIV-positive men. JAMA. 1999;281(19):1822-1829.
18. Palefsky JM, Holly EA, Ralston ML, et al. Anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual and bisexual men: prevalence and risk factors. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17(4):320-326. 19. Chin-Hong PV, Vittinghoff E, Cranston RD, et al. Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study. J Natl Cancer Inst. 2005;97(12):896-905. 20. de Pokomandy A, Rouleau D, Ghattas G, et al. HAART and progression to high-grade anal intraepithelial neoplasia in men who have sex with
22. Tong WW, Jin F, McHugh LC, et al. Progression to and spontaneous regression of high-grade anal squamous intraepithelial lesions in HIV-infected and uninfected men. AIDS. 2013;27(14):2233-2243. 23. Chin-Hong PV, Palefsky JM. Natural history and clinical management of anal human papillomavirus disease in men and women infected with human immunodeficiency virus. Clin Infect Dis. 2002;35 (9):1127-1134. 24. Goldie SJ, Kuntz KM, Weinstein MC, Freedberg KA, Palefsky JM. Cost-effectiveness of screening for anal squamous intraepithelial lesions and anal cancer in human immunodeficiency virus-negative
26. Palefsky JM, Holly EA, Hogeboom CJ, Berry JM, Jay N, Darragh TM. Anal cytology as a screening tool for anal squamous intraepithelial lesions. J Acquir Immune Defic Syndr Hum Retrovirol. 1997; 14(5):415-422. 27. Sillman FH, Sentovich S, Shaffer D. Ano-genital neoplasia in renal transplant patients. Ann Transplant. 1997;2(4):59-66.
Invited Commentary
Considering Standards of Care for Anal Cancer James Fleshman, MD
High-resolution anoscopy (HRA) has become a term that induces fear and trepidation in the hearts of most colorectal surgeons. There is a certain sinking feeling when one considers the time and effort that will be expended, with little return, Related article page 563 when the standard of care becomes the routine use of HRA for all human immunodeficiency virus–positive patients. This time and effort are for a 0.131% risk of anal cancer in the highestrisk group—men having sex with men who have human immunodeficiency virus. In fact, colorectal surgeons observe most of these individuals on a regular basis in the office if they have condyloma or symptoms of anal disease. Anoscopy without high resolution actually reveals most anal lesions that cause symptoms. The time spent performing HRA compared with routine anoscopy may discourage most health care professionals from using HRA, except those focused on high-grade squamous intraepithelial lesions (HSIL) and human immunodeficiency as a specialty. ARTICLE INFORMATION Author Affiliations: Department of Surgery, Baylor University Medical Center, Dallas, Texas; Department of Surgery, Texas A&M Health Sciences College of Medicine, Dallas.
The study reported by Hicks et al1 in this issue emphasizes some of the controversies surrounding the overall problem of HSIL. As usual, there are more questions than answers. Can the authors tell us how many patients without symptoms, never having HRA but observed closely, will develop anal squamous cell cancer? Is there a reliable correlation between the presence of an anal lesion and anal pain and HSIL? Can routine follow-up with anoscopy and destruction of obvious anal lesions have the same protective effect as HRA on anal cancer? Can asymptomatic high-risk individuals be observed until they develop one of the symptoms associated with HSIL? What are the “findings consistent with dysplasia,” as mentioned by the authors? Only 29% of the patients referred had cytologic findings on anal Papanicolaou tests showing high-grade dysplasia. How helpful is the Papanicolaou test, if the test and HRA were consistent in only 66% of cases? Finally, if only 30% of the group referred by primary care physicians for rising concern about anal cancer had HSIL and none had anal cancer, why not start with follow-up routine regular anoscopy instead of HRA?
Corresponding Author: James Fleshman, MD, Department of Surgery, Baylor University Medical Center, 3500 Gaston Ave, First Floor Roberts, Dallas, TX 75246 (james.fleshman@baylorhealth .edu). Published Online: April 15, 2015. doi:10.1001/jamasurg.2015.48.
jamasurgery.com
Conflict of Interest Disclosures: None reported. REFERENCE 1. Hicks CW, Wick EC, Leeds IL, et al. Patient symptomatology in anal dysplasia [published online April 15, 2015]. JAMA Surg. doi:10.1001/jamasurg .2015.28.
(Reprinted) JAMA Surgery June 2015 Volume 150, Number 6
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archsurg.jamanetwork.com/ by a Central Michigan University User on 10/13/2015
569
