Why Are We Not Screening for Anal Cancer Routinely

HIV Physicians' Perspectives on Anal Cancer and Its Screening in HIV-Positive Men Who Have Sex With Men: A Qualitative Study

Jason J Ong; Meredith Temple-Smith; Marcus Chen; Sandra Walker; Andrew Grulich; Jennifer Hoy; Christopher K Fairley

Disclosures

BMC Public Health. 2015;15(67) 

In This Article

Results

Of 22 physicians approached, two did not reply to the invitation email and one suggested another physician in their clinic. Demographics are summarized in Table 1. Illustrative quotes include gender, specialty and years in HIV practice of the participant (YiHP).

Physicians' Understanding of Anal Cancer

Participants had an excellent grasp of causation, risk groups and rates of anal cancer. Almost all spoke of increasing age, human papillomavirus and smoking as important risk factors. Anal cancer was seen by all as a disease of concern.

…a devastating infection (F, Sexual health, 15 YiHP)
…potentially very nasty (M, General Practice, 28 YiHP)
…the last 25 years the rates have almost doubled I guess in Australia and similar patterns have been seen around the world (M, Infectious Disease, 15 YiHP)

Virtually all HIV physicians specifically identified HIV-positive MSM as the most at-risk group for anal cancer. However some (especially general practitioners) expressed discrepancy between reported rates and their own personal practice:

…I suspect the numbers have increased a bit over the last five or 10 years but they haven't gone up like everyone was predicting where we were going to see an avalanche (M, General Practice, 28 YiHP).

Despite scepticism from some, the consensus from the group was that targeting screening for HIV-positive MSM was important. There was an underlying sense of urgency that something should be done.

…you've got a cancer that's 100 times more common [in HIV-positive MSM compared with the general population] then we should be trying to do something about it (M, Infectious Disease, 27 YiHP)

Views on Anal Cytology

The major theme expressed when discussing cytology screening for HGAIN was the lack of convincing evidence.

…still done on the basis of belief rather than evidence (M, Immunologist, 30 YiHP)

Issues of concern included the absence of evidence for screening using cytology in reducing morbidity and mortality from anal cancer; the high prevalence of AIN in HIV+ MSMs and thus the concern of subjecting large numbers of patients to unnecessary investigations; and the lack of availability for patients to have a high resolution anoscopy as follow up to an abnormal anal cytology. Participants noted the uncertainty around the natural history of AIN, the effectiveness of treatments and whether treating HGAIN would make a difference to anal cancer rates.

…just about all gay men with HIV will have abnormal cells and the natural history of those abnormal cells is still not understood enough really so we don't know what to do once we've found those abnormal cells (M, General Practice, 22 YiHP)

Reflected in this reluctance to initiate anal cancer screening was a very strong theme calling for more evidence or guidelines before such screening should be introduced for HIV patients.

…one of the problems is that the current guidelines that we have in Australia don't recommend any form of anal cancer screening (M, General Practice, 23 YiHP).
…screening tests require a much higher level of evidence than even treatment studies (M, Sexual Health, 34 YiHP)

Views on DARE

Given the reluctance of HIV physicians in Australia to implement anal cancer screening using anal cytology, further interviewing enquired about the possibility of implementing an early cancer detection program instead. This was proposed as an annual visual inspection of peri-anal region together with a digital ano-rectal examination(DARE) by the HIV physician. It was interesting that the initial response from the majority (across all specialties and years of HIV experience) were positive.

…probably best practice (M, Immunologist, 30 YiHP)
…reasonable thing to do (F, Infectious Disease, 23 YiHP)
…correct means by which we should be screening… should be embraced (M, General Practice, 30 YiHP)
…sensible, cheap and easy thing to do (F, Immunologist, 5 YiHP),
…it's going to pick up lumps that may well be early cancers and I guess that's where the efforts should be made, really (M, General practice, 22 YiHP)

But despite the enthusiasm for DARE, the majority of HIV physicians admitted to not doing this routinely for their population of HIV positive MSM.

…I do it very rarely unless someone has symptoms (M, Infectious Disease, 5 YiHP)

When asked to elaborate why there was this discrepancy between the idea that DARE is a good one with the actuality of implementing DARE into routine care, multiple barriers acting at three levels were identified: systems, health provider and patient. Table 2 provides a summary of major themes under each of these headings.

1) Systemic barriers

A strong theme that emerged was the absence of a clinical routine to incorporate DARE. Thus 'the main barrier is forgetting to do it' (F, Sexual health, 12 YiHP). Physicians stated they had lost the opportunity to offer a DARE during checks for sexually transmitted infections as the option for self-collected anal swabs had increased in recent years.

…now we're getting people to self-collect all of the specimens at sexual health screens which I think is terrible because it means that often nobody looks (M, General practice, 23 YiHP)

This was compounded by the need to manage the complexities and competing interests of multi-morbidity seen in an ageing HIV population. Many physicians talked about the difficulties in delivering what is recommended already in the guidelines(e.g. screening for cardiovascular complications) and it seemed that anal cancer was not always a priority.

…often when you're time poor and there's other more pressing issues that the patient wants to discuss… [DARE] may be something that gets missed (M, Sexual health, 15 YiHP)

The frustration over lack of time was almost palpable in some, whilst not an issue for others:

…it's just one more thing that needs to be done in too little amount of time (M, GP, 30 YiHP)
…it's only once a year. Your average consultation now with a HIV patient is nowhere near as cluttered as it was 10 years ago… so it [DARE] wouldn't be that big an intrusion. It would add a minute or two to the consultation (M, Sexual health, 34 YiHP)

Another frustration for some physicians was the lack of clarity around who should be conducting the screening and where to send patients presenting with symptoms of concern. It was noted that in Australia, HIV patients may be cared for by different specialists(Infectious Disease, Immunology, Sexual health physicians or General Practitioners(GP)) in various settings(hospital or sexual health centre or GP) and that some patients can be under the care of more than one specialist. A consequence of this can be the assumption that another doctor is doing the anal cancer screening.

…where does that responsibility - who does it lie with? I guess for some people they potentially would fall through the cracks in the system in that we'd say it was the GPs and the GP would say it was ours (F, Sexual health, 25 YiHP)

Some participants perceived that differences inherent in specialty training and care setting could be a barrier with the Infectious Diseases and Immunology trained physicians being less comfortable and their practice setting not readily set up for DARE.

…being a sexual health physician we don't mind looking at bums at all… That could be quite different in a hospital outpatient environment for instance… ID clinics, as you know, have always avoided going anywhere near the genitalia (M, Sexual health, 34 YiHP)

One hospital physician suggested that GPs who effectively run small businesses are incentivized by payment systems for shorter consultations, which could act as a barrier.

…GPs won't do it because there's no money in it… if you've got to spend two or three minutes getting somebody undressed and doing an exam and then explaining their result then that's time that the GPs won't want to spend (M, Immunologist, 24 YiHP)

2) Health provider barriers

At the health provider level, a prominent theme was the current lack of published evidence for DARE primarily to do with its effectiveness in detecting early anal cancer and the cost-effectiveness of implementing this into routine HIV care.

…everybody would need to be convinced that the evidence was strong enough (M, Immunologist, 24 YiHP)

Beyond the need for evidence, a small number of physicians expressed difficulties in initiating the topic of anal cancer screening with patients.

…I must admit it's not easy for me to bring that one up (F, General practice, 19 YiHP)
…feel awkward in raising the issue (M, Immunologist, 24 YiHP)

In terms of the procedure of DARE itself, it was predominantly the sexual health physicians who discussed doubts about their ability to pick up early cancers. But in general there was consensus by all participants regardless of their specialty, that they would benefit from more training in utilizing DARE for detection of anal cancer.

…given that it could be very small and you want to pick it up early otherwise you lose a lot of the benefit. So I don't think it's a very sensitive method. Also it's so user dependent and I can't see that I would feel confident in it (F, Sexual health, 15 YiHP)

Most of us learn it [rectal exams] on the wards as an intern for constipation and prostate checks… I think the actual checking for anal cancer is more detailed …and I don't have a good handle on exactly what to feel for, what to worry about, what not to worry about, all that kind of thing (F, Immunologist, 5 YiHP)

3) Patient barriers

At the patient level, two main themes emerged. Firstly, physicians reported that there may be a level of patient discomfort in receiving a DARE. This may be due to perceived patient embarrassment, patients not feeling prepared for the examination and potential issues with past history of sexual assault or fear of disclosing sexual orientation.

…people don't like to think and talk about it [anal cancer]… you have to wait until patients become symptomatic and not embarrassed to talk about it or show you before it can get diagnosed (F, Immunologist, 5 YiHP)
…A lot of patients feel it's a bit of an invasion (M, General practice, 30 YiHP)
…there have been a few patients where they've said 'oh look I haven't prepared for that sort of examination'… the patient had some fears about not being clean (M, General practice, 29 YiHP)

Furthermore several physicians discussed that having a female physician perform the DARE may be hampered by patients' view of regarding them as a maternal figure.

…there's kind of a relationship builds up which is - it kind of almost an intimate friendship to some extent… almost it's like being an aunt or an older sister… and you don't let aunts and older sisters examine your backside comfortably (F, Infectious disease, 23 YiHP)

The second main theme revolved around the perception that health literacy concerning anal cancer risk remained poor in HIV positive MSM populations.

…I think the vast majority wouldn't know that [anal cancer is] something that they're particularly at risk of (M, General practice, 22 YiHP)

Attitude Towards Early Cancer Detection Using Self- and Partner-examination

We also explored other potential methods for early cancer detection. A majority of HIV physicians believed that self-examination was already occurring amongst HIV-positive MSM.

…often patients do present because they've felt a lump (M, General Practice, 29 YiHP)
…quite a lot of patients I've looked after are quite adept at examining their perianal region (F, Infectious Disease, 23 YiHP)

Some discussed the positive aspects of self-examination as patients becoming more educated, aware and involved in their own health.

…it definitely gives the patient some responsibility for their own health which I think is definitely worth it (F, Sexual Health, 15 YiHP)
…it's probably a bit like breast cancer screening… that if they find a lump that's a good thing if they tell us about that before we find it in them (M, Infectious Disease, 5 YiHP)

However, it was not seen as a screening method that could be solely relied upon as there were issues regarding potential difficulties of the technique of performing a self-examination and the ad hoc nature it was being done.

…I don't think the majority would to do it regularly and actually report back findings… There's been campaigns to get men to do testicular self-examination. By and large not even that happens (M, Immunologist, 30 YiHP)
…[The anus is] not the easiest place to self-examine (M, Sexual Health, 22 YiHP)
…they don't know what they're feeling and they haven't had the chance to be trained (M, Immunologist, 24 YiHP)

There was also a common perception that partner-examination was already happening.

…plenty of boys do, as part of foreplay, stick their fingers in each other's butts and are probably fairly familiar with what they feel (M, General Practice, 30 YiHP)

Although it was seen as easier to do in comparison to self-examination, it was perceived that less patients would be willing to ask their partner to examine their anus for a medical reason. Concern was expressed over the changing role of the partner:

…putting the responsibility on to the partner for the screening. I don't think that's appropriate' (F, Sexual Health, 14 YiHP).

It was noted that there may be a blurring of the line between sexual pleasure and examination for abnormalities, partnerships may not last and partners who are not trained don't understand what to feel for. Physicians stated that the partner finding unusual lesions may increase anxiety unnecessarily for both the patient and their partner. There was also a risk that if the physician was out of the loop for screening that significant lesions may be missed.

…it's not very romantic to have your partner do it too often I think. Well you'd need a very good friend at least' (M, Sexual Health, 22 YiHP)

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