Anal Cancer Prevention in HIV -Infected Men and Women

38 Pages·2013·1.18 MB·English

Slide #1
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Timothy Wilkin, MD, MPH
Associate Professor of Medicine
Weill-Cornell Medical College
Slide #2
Case #1
• Bob is a 42 year-old HIV-infected man
– Diagnosed 3 years ago with a CD4 of 250
– On efavirenz/tenofovir/emtricitabine
– Current CD4 455 cells/mm3
– HIV-RNA <40 copies/mL
– Sex with men only, 3 receptive anal sex partners
in the past 6 months, uses condoms with HIV-
uninfected partners
• History of perianal warts 10 years ago
treated with cryotherapy
• No history of anal cancer screening
Slide #3
Case #1 Question #1
What proportion of your HIV-infected
patients have been screened for anal
cancer?
1. Do not offer anal cancer screening
2. <10%
3. 10-25%
4. 26-50%
5. >50%
Slide #4
Epidemiology of Cervical Cancer
United States
16
Incidence
14
Mortality
n
12
o
i
t
a
l 10
r u
e
p
p
o
e P 8
t
a 0
R 0
0 6
,
0
0
1 4
2
0
1975 1980 1985 1990 1995 2000
• Although US cervical cancer incidence and mortality rates have
declined, there were still an estimated 3710 deaths in 20052
1. Ries LAG, Eisner MP, Kosary CL, et al, eds. SEER Cancer Statistics Review, 1975–2002, National Cancer Institute.
Bethesda, Md; 2005. 2. American Cancer Society. Atlanta, Ga: American Cancer Society; 2005:1–60.
Slide #5
Anal Cancer, United States
Cancer Incidence 2008
250
s 215.02
d
n 200 184.45
a
s
u 150
o
108.07
h
T 100
62.48
50
11.07
5.07
0
ast ng on m a cal nal
Bre Lu Col no rvi A
a e
el C
M
60% of U.S. anal cancer cases are in women
Source: American Cancer Society
Slide #6
Anal Cancer in MSM
Anal Cancer Incidence
160
144
137
140
120 HIV-neg
s
r
a
e
y
- 100 92 HIV-pos pre-HAART
t
n
e
ti 78.2
a 80
p HIV-pos post-HAART

0
0
0
0, 60
0 49
1
r 40 NA-ACCORD estimates
Pe 40 35 35 30 3% of HIV-infected
19
adults will have anal
20 14
11
cancer by age 601
1.4 1
0
US Gen US MSM London US US San French
Pop 1982 HIV+ MACS Cohort Diego Cohort
MSM Cohort Cohort
1Silverberg M, Abstract 758 CROI 2010
Slide #7
Anal Cancer in MSM
Anal Cancer Incidence
160
144
137
140
120 HIV-neg
s
r
a
e
y
- 100 92 HIV-pos pre-HAART
t
n
e
ti 78.2
a 80
p HIV-pos post-HAART

0
0
0
0, 60
0 49
1
r 40
Pe 40 35 35 30 cervical cancer rate prior to PAP
19
20 14
11
current cervical cancer rate
1.4 1
0
US Gen US MSM London US US San French
Pop 1982 HIV+ MACS Cohort Diego Cohort
MSM Cohort Cohort
Slide #8
Case #1- continued
• Bob elects to be screened for anal cancer
• His provider uses a rayon (or Dacron)
swab to collect anal cells
• ASCUS
Slide #9
Case #1 – Question #2
What is the next step?
1. Repeat anal cytology in 6 months
2. Send HPV testing
3. Anoscopy
4. High resolution anoscopy
5. Referral to colorectal surgery for exam
under anesthesia and biopsies
Slide #10
HRA