An elephant in the room? Anal cancer and people with HIV

HIV Australia | Vol. 11 No. 2 | July 2013

JASON ONG explains that being alert to potential symptoms and having an annual check-up can minimise the risks of anal cancer.

The face of HIV is changing in Australia. There has been a definite shift within the last two decades, from the fear of developing AIDS to the optimism of living a full life with HIV.

But despite the many advances in HIV management and the marked improvement in the quality of life of someone with well-controlled HIV, there is an elephant in the room that needs urgent attention.

The elephant represents a word that no one likes to think or talk about. Yes, it is the ‘C’ word – CANCER.

Every country with good records of cancer of those living with HIV has observed that despite marked improvements in how we manage HIV, the rates of anal cancer are not declining as they have for other cancers.

Anal cancer is now the most common non-AIDS defining cancer in someone living with HIV in Australia.

What is anal cancer?

Anal cancer is a form of cancer affecting the anal canal (the last 3–4 cms of your bowel) and the surrounding skin around the anal opening.

While it is a rare cancer in the general population (1 in 100,000 people will develop the cancer per year in Australia), there is a subgroup of people that remains at highest risk. In men who have sex with men who are living with HIV, the rate has been noted to be as high as 1 in 1,000 people developing anal cancer each year.

This is as common as other cancers in Australia like bowel and prostate cancer. While there has been a lot of attention given to the management of bowel and prostate cancer, currently very little attention is given to anal cancer.

What causes anal cancer?

The cause of anal cancer is still being intensely researched. Multiple factors are believed to contribute to increasing a person’s risk of developing anal cancer:

Increasing age. Anal cancer has been detected as young as 35 but is more common in those who are older than 65 years old.
Receptive anal intercourse. Receptive anal intercourse in both men and women also increases the risk of anal cancer.
Having a low immunity. If your immune system is not working optimally this may increase your risk of anal cancer.
Human papillomavirus (HPV). This is a very common virus that is sexually transmitted. There are many different types of HPV; some cause anal warts and others can cause anal cancer. It is important to understand though, that only a small proportion of those who have infection with the cancer causing types of HPV actually develop anal cancer. Studies have found higher rates of HPV in those living with HIV. This may be due to an impaired immunity that prevents the body clearing the HPV infection.

Smoking. Being a current smoker increases one’s risk of anal cancer.

Can I prevent anal cancer?

There are currently two vaccines that can help protect against infection with HPV. However, for the vaccine to work best, it must be given before a person becomes exposed to the HPV type that causes anal cancer.

So the earlier in one’s sexual life that the vaccine is used, the more likely it is to work. In Australia, this is now a routine vaccine offered to school-aged boys and girls. If you are a smoker, stopping smoking may help reduce your risk of anal cancer.

I don’t smoke and I’ve had quite a few partners in my life (so the vaccine is unlikely to be of much help) … can I do anything else to protect myself?

The good news is that, like other cancers, the sooner we can detect anal cancer, the greater chance of a complete cure and lesser chance of needing more invasive treatment.

Studies have shown that if we can detect anal cancer when it is less than 1 cm, there is a very high chance of a complete cure. The problem is that currently, most cancers are detected when they are already more than 2 cms in size.

This means an increased chance of dying from anal cancer as well as the need for chemotherapy, radiation therapy or more invasive surgery. So, it is important to try and detect anal cancer early.

How about anal pap smears?

A number of investigators in Australia are looking into whether men should have anal pap smears, in the same way that women have cervical pap smears. But there are big differences between the cervix (neck of the womb) and anus and currently no national health organisations are recommending anal pap smears.

A number of studies are currently investigating this issue, such as the SPANC study in Sydney. (Click here for further discussion of this study.) The SPANC study is currently recruiting.

So what can I do now?

There are three As that may help you detect anal cancer early. Ask your doctor about anal cancer Be fully informed about what anal cancer is. Your doctor is the best person to talk to about this.

More information about anal cancer can also be found on the following authoritative websites:

Type in ‘anal cancer’ in their search box for more information.

Alerts for potential symptoms

One of the main reasons for anal cancer to be detected too late is because people often ignore their symptoms and don’t go see a doctor.

Anal cancer can cause:

anal bleeding
anal discomfort or pain
anal lump
anal ulcer that won’t go away.

It is important to remember that these symptoms are very common and in most cases do not mean you have anal cancer.

There are many other conditions that commonly cause these symptoms. However if you notice any of these symptoms it is better to see your doctor for a check-up.

Don’t dismiss your symptoms as ‘just haemorrhoids’ and present to your doctor too late. Remember that early detection increases your likelihood of a complete cure from anal cancer.

Your doctor will be able to examine you and reassure you in almost all cases, and put your mind at ease.

Annual anal check-up

Just like it is wise to get an annual health check even though you may be feeling well, it is also wise to get an annual anal health check even if you don’t feel any unusual symptoms around your anus. This ensures that if there is an early anal cancer, it may be detected very early.

What does an anal check-up involve? Firstly, the doctor will carefully examine the skin around the anal opening to look for any suspicious lesions.

Secondly, the doctor will insert a gloved finger into the anus to feel for abnormal lumps and ulcers. This procedure normally takes less than a minute to perform.

Although there are currently no official guidelines in Australia for an annual anal check-up, a number of health professionals recommend this examination once a year.

Currently there is an important study running in Victoria to gather data on the acceptability and usefulness of an annual anal check-up – the Anal Cancer Examination Study (ACEs) in HIV-positive men who have sex with men (i.e., the subgroup at highest risk for anal cancer).

This study aims to monitor patients who are undergoing an annual anal exam to see if this method of screening causes any undue harm or worry and to see if the annual check-up will detect anal cancers earlier.

The study involves one baseline questionnaire and a yearly short questionnaire after each anal exam to ask you about your experience of the anal check-up.

If you are interested in participating in the study, or finding out more information, please call 1800 082 820. You can also visit the website www.anal.org.au for more information.

Conclusion

Although anal cancer may be an uncomfortable discussion to have, we must no longer ignore this elephant in the room. Despite the many advances in caring for those with HIV in Australia, anal cancer continues to be an important issue for men who have sex with men who are living with HIV.

However there are simple steps that can be taken to minimise the impact of this cancer. Remember to Ask your doctor, be Alert to potential symptoms and consider getting your Annual anal check-up.

Jason Ong is a PhD Candidate at the Melbourne Sexual Health Centre.