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


BMC Public Health. 2015;15(67) 

In This Article


This study is the first to report qualitative data from HIV physicians on current views about anal cancer and attitudes regarding anal cancer screening in HIV-positive MSM. It is clear that there is excellent awareness of the issue of anal cancer amongst HIV physicians from all specialties with varying years of experience. Consistent with quantitative studies, there was an urgency that action is needed.[9–11]

Regarding anal cytology, there were two major barriers highlighted by participants. Logistically, there is a mismatch between potentially high number of men with an abnormal result from screening and the paucity of physicians able to perform high resolution anoscopy to follow up these abnormalities. Currently in Australia, only a handful of physicians are trained in providing high resolution anoscopy and virtually all are conducted within a research setting. Secondly, there was a call for greater level of evidence to demonstrate that treatment of HGAIN reduces the incidence of anal cancer and the effectiveness of treatments of HGAIN to resolve these lesions. Until more high resolution anoscopists are trained, and anal cytology is reflected in HIV guidelines supported by a higher level of evidence than 'expert opinion', it seems unlikely that Australian physicians would utilize anal cytology as a means of screening.

Whilst the majority of literature is focused on anal cancer screening using cytology, this study provided detailed views of HIV physicians in implementing an early cancer detection model using an annual DARE. DARE is regarded as the principal cancer screening test compared with anal cytology, which is the principal precursor (HGAIN) screening test.[9] Some researchers consider that DARE should be performed in everyone who is at high risk of anal cancer.[11] However, these recommendations have not been widely reflected in regional or national HIV guidelines.[17] Although many physicians were supportive of early detection of anal cancer, they identified multiple potential barriers at the systems, provider and patient levels. This highlights that even though an annual DARE appears to be a relatively simple procedure, it may not necessarily be easy to implement.

At the systems level, participants discussed the need to set in place a clear system that is clinic-specific that makes DARE a routine part of HIV care. There may be value in utilizing the knowledge gained from system change literature[18] to mitigate barriers to implementation. For instance by having a clear system in place, a Canadian HIV clinic increased its anal cancer screening either by DARE and/or cytology from 10% to 44% of patients over 3 years.[19] Furthermore, the provision of incentives should be explored in different settings if DARE becomes widely recommended as a routine part of HIV care as providing incentives has been found to be important for increasing uptake of other screening tests such as pap tests and mammograms.[20]

Our study suggests that provider level factors must be addressed. A key barrier was even though DARE is recommended as a means of early detection of anal cancer in some guidelines,[21,22] the level of evidence provided is only by 'expert opinion'. Almost all physicians remained skeptical over incorporating DARE into routine care until stronger evidence was made available. To date, there has been no published data on the sensitivity and specificity for DARE to detect early anal cancer. However, anal cancers were detected with an average size of 2.9 cm at diagnosis in HIV-positive patients, and most were visible and/or palpable for some time before definitive diagnosis.[23] Although it is likely that regular DARE could improve detection of early anal cancer, no studies have been published to evaluate whether it is cost-effective and would lead to a reduction in morbidity and mortality from anal cancer. As physicians in this study highlighted, these data must be shown before DARE becomes widely adopted. Although participants were comfortable with performing a rectal examination for prostate cancer screening, using DARE for anal cancer screening was seen as a new skill that required extra training. Instead of bypassing the anal canal to examine the prostate, physicians now have to learn to feel the entirety of the anal canal and identify the presence of any lumps or ulcers that may potentially be anal cancer.

Physicians had a perception that patients may find DARE uncomfortable. This was not surprising and was consistent with other screening programs involving genital examination – cervical pap smears[24] and mammogram.[25] Physicians involved in an anal cancer study also expressed concern that some patients may worry about being clean for the examination.[26] Therefore, one strategy to increase the uptake of DARE may be to allow time for patients to prepare psychologically and physically for the examination. This may involve telling patients that a DARE is due at their next visit or give them the option to clean themselves before doing the DARE.

Self-examination and partner-examination are potentially novel ways of screening for anal cancer. Whilst there are data for self-examination for breast cancer,[27] skin cancer,[28] and testicular cancer,[29] this is the first published study exploring the views of HIV physicians regarding self- and partner-examination as modes for early anal cancer detection. Physicians were open to discuss the concept of these novel screening methods and if the issues raised in this paper can be addressed, they may prove to be a useful adjunct to anal cytology and/or DARE. For example, in addition to regular screening by a physician, patients may be educated in how to self-examine and/or recognize potential symptoms of anal cancer and be encouraged to present to the physician between their regular scheduled physician screening. However, as with DARE, more research is needed to test its efficacy and acceptability before this is recommended to patients.

Despite multiple barriers identified in this study, these are not insurmountable and can be addressed. For instance, at the systems level, having a clear reminder system, a clinic champion (to encourage screening) and clear referral pathways may help to facilitate more men being screened. At the health provider level, the provision of more research evidence and training may help physicians feel more confident in conducting screening. And at the patient level, strategies to improve their awareness of anal cancer risk and allowing adequate preparation time before screening may facilitate greater uptake of screening.

In common with all qualitative studies, the findings are context dependent. However the inclusion of HIV physicians with different backgrounds and work settings across Australia has offered a broad range of viewpoints. This study has provided detailed information about current issues that need to be addressed before anal cancer screening be implemented. It may be useful to explore how widely these views are held in a quantitative study of a larger number of HIV physicians. The other limitation pertains to the current Australian practice of not offering anal cancer screening outside a research setting. This meant that the vast majority of physicians interviewed were not participating in any anal cancer screening and thus influenced the tone of the study with multiple barriers identified. Future research to specifically include physicians from overseas who are actively screening may provide insights into facilitators of anal cancer screening.