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Do You Understand the Anal Pap for HPV? An Editorial

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It is a well known fact that someone with cervical dysplasia resulting from HPV (human papillomavirus) has a high risk of developing anal dysplasia along with anal cancer.

It is unfortunate that the doctors that you would think would be most familiar with performing this type of testing--colorectal surgeons and/or gastroenterologists--more often than not have not heard of it nor do they perform it. I have spoken to dozens of women lamenting their struggles in attempting to find a doctor who would perform an anal Pap.

The purpose of the anal Pap is to determine the presence or absence of the HPV virus in this area. The majority of anal cancers are the result of HPV, and while many know that HPV can result in cervical cancer they are unaware that it can also result in anal cancer.

Before Farrah Fawcett passed away a couple of years ago after a long battle with anal cancer she released a documentary about her experiences with this disease. It was never mentioned that her anal cancer was caused by HPV, though the majority of them are, and many who advocate for those with HPV were outraged that no PSA (Public Service Announcement) was provided at the end to inform people that a vaccine existed to prevent anal cancer caused by certain strains of HPV.

For those who have had an ECC (endocervical curettage) for diagnostic purposes in testing the endocervical canal (the area which connects the vagina to the uterus) the anal Pap is quite similar.

As with an ECC, a small brush-like instrument much like a Q-tip is inserted into the anal canal. The brush is then rotated in a circular motion while it is moved in and out of the anal canal (it sounds a lot worse than it actually is). It is a very quick and relatively painless procedure, but one which can quickly identify whether or not you are harboring the virus within the perianal/anal canal area.

Despite the relative ease of performing such a test, it is very difficult, as mentioned previously, to find someone who will perform it. There are several doctors on either coast of the U.S., Dr. Stephen Goldstone in New York and Dr. Joel Palefsky in Calif., both of whom specialize in HPV related anal cancers.

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It is still important that patients contact these organizations and put pressure on them.
You may want to ask your OB if she is aware that there is a nearly 40 percent increased risk for AIN and anal cancer if you have previously had CIN? Not clear from this comment if you have had CIN however the unprotected anal sex is definitely reason even w/o CIN to have an anal pap. There is an excellent brochure, the best I've found so far that I am in the process of incorporating into my website which speaks to this. It was actually created by Dr. Stephen Goldstone, a colorectal surgeon who specializes in HPV induced anal cancer and infectious disease. If you would like to contact me via hpvsupportnetwk@aol.com I can forward you som additional information including a copy of this brochure as wll as additional information on the subject. The perception by doctors that it isn't really needd needs to change. Just how many cancers does HPV need to be responsible for before the medical community finally sees this virus as the significant threat that it is.

June 12, 2011 - 12:21pm

I'll talk with her about it again. She knows my concerns, and she is really good about listening and addressing my needs. She didn't seem to think I need one, but would so it, if i requested. I'll let you all know.

June 12, 2011 - 10:07am

You can also write to the American College of Obstetrics and Gynecology as well.

June 11, 2011 - 4:45pm

Midnight - You are quite right and good for you to not take no for an answer. Unfortunately what many doctors don't realize is that while it may not be the #1 cancer out there if you're the one who gets it, you don't much care how "rare" it's supposed to be. I say rare because the statistics for those individuals treated for high grade dysplasia (anal or otherwise) are not calculated into the risk factors. The only thing that is looked at and perpetuated is the number of those who actually got cancer.

With new technologies allowing for testing and procedures to treat these high risk often high grade precancerous lesions obviously this reduces the incidence of invasive cancer. It does not change the fact the thousands of people are still being treated before they get to that point which is great but it doesn't factor into the statistics that doctors or the public really hears about. Hopefully that will change.

With HPV now being responsible for more cases of oral cancer than cervical cancer perhaps the media will again get involved. Unfortunately, and as usual though, they typically drop the story like a hot potatoe once it's had it's shock value.

I would suggest you write to the American Society of Colon and Rectal Surgeons and inform them of your situation and your dissatisfaction in this regard. Perhaps if enough patients do this, they will be more proactive in educating their members on these procedures and in recommending the vaccine going forward. Every voice makes a difference!

June 11, 2011 - 4:44pm
EmpowHER Guest
Anonymous (reply to Bonnie Diraimondo RN)

While I appreciate that patients should be proactive and request things they think they need....I think it is a little unrealistic to make it sound like public opinion will make a screening more widely available or recommended. I have not researched the cost effectiveness of anal paps specifically- but if they are not widely used (like the pap test), then there is a good chance that they have not been proven to be cost effective in preventing disease or reducing mortality. Tests are not recommended just because they may help- they must be cost effective and proven or insurance will not cover them.

June 17, 2011 - 6:59pm
(reply to Anonymous)

You make a good point and obviously tests such as this need to show efficacy to be supported by the medical comnmunity. However cost effectiveness regarding the use of anal paps and efficacy in terms of reducing the number of invasive cancers has been done. Most of the research has been done with respect to anal paps, HRA's (high resolution anoscopy) and even the benefits of providing the Gardasil vaccine to men.
Unfortunately, the majority of these studies have not included women. They have been conducted with a patient population, usually encompassing the male homosexual and bisexual community.
It was just those studies regarding the benefits of the Gardasil vaccine which could easily be extrapolated regarding the female population and which was presented to the FDA prior to its decision to approve the use of the vaccine in boys and young men.
Those physicians focusing on infectious disease (primarily HPV) and specialize in colorectal involvement (Drs. Stephen Goldstone and Joel Palefsky for example) are dismayed with the medical professions lack of focus on this issue.
Given the fact that the majority of all anal cancers are attributed to HPV and that the perianal/anal tissue (like the oral mucosa) are relatively no different than that of the cervix this type of screening should be embraced just as the use of oral screening has now that HPV has been shown to exceed as the cause of oral cancers in non-smoking young men and exceeding the number of cases of cervical cancer, the unfortunate truth is that it has not.
Much of this still has to do with numbers, there are fewer cases of anal cancer than either cervical or oral cancers, and also that people are still uncomfortable discussing the anus. Ten years ago discussing colon cancer was not a comfortable subject matter either but time has changed that and hopefully will do the same with anal cancer in general. If you are one of those who develops anal cancer, the fact that 5,000 fewer cases are diagnosed in a year doesn't mean much. For women, it is a known fact that womn with prior cervical involvement have a significantly higher likelihood of developing anal cancer.
There already exists sufficient evidence from a medical standpoint to warrant anal pap screening. For those who are at higher risk it is especially important to have these services available and if a physician begins losing business as a result of not providing such a service I'm sure that would change very quickly. Unfortunately it should not take something like this for doctors to provide them.
The drumbeat for oral cancer screening can aleady be heard and the connection of these particular oral cancers to HPV is far more recent than that of anal cancers. Anal cancers have been on the rise for the past ten years. Women suffragettes have been around for a long time and there is power in numbers and in speaking out. Reformers in any arena recognize that things do not change over night but failing to speak up does nothing at all. Is it the sole determining factor, of course not, but no one should underestimate the power the exists in numbers when it comes to effectuating change.

June 17, 2011 - 8:41pm

I have talked with my OB about this twice. She has said that most DR's don't preform the anal pap,because there wasn't real need for it. i asked about anal cancer and HPV. I'm very concerned and ,frankly, scared. I am going to ask if she will preform it and if not for a refferal to a DR who will. I do have HPV, low grade, (yes, i have had unrpprotected anal sex on several occasions) and am trying to be calm and be proactive about my health. It seems like everyday there i snew info coming out that can send one into a tail spin.

June 11, 2011 - 11:10am
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