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• W2331379944 abstract "Arthur C. Clarke, the science fiction writer, stated that “information is not knowledge, knowledge is not wisdom, and wisdom is not foresight. Each grows out of the other, and we need them all.”1 What we have learned over the last century about the prevention of human papillomavirus (HPV)–associated cancers is truly amazing, beginning with the development of colposcopy, in which a microscope and application of acetic acid were used to identify lesions. This was followed by the development and implementation of secondary cervical cancer prevention methods including cytology as a screening tool and colposcopy to identify and eradicate the precancerous lesions. Subsequently, zur Hausen identified HPV as the cause of cervical cancer, and more recently, based on this knowledge, an effective prophylactic HPV vaccine has been licensed.2–4 Persistent oncogenic HPV infection can lead to squamous cell carcinomas not only of the cervix but also of the oropharynx, vulva, and anus. Anal cancer is increasing worldwide; epidemiologically, HIV-infected persons are at greatest risk.5 Information about HPV has been applied to successfully prevent cervical cancer: primary prevention by vaccinating women before exposure and secondary prevention by screening for and eradicating the precancerous lesions known as high-grade squamous intraepithelial lesions (HSILs). Clinicians and clinical investigators have had the foresight to prevent cervical cancer. The same types of HPV and HSIL found in the cervix can be found in the anus of those at risk for anal cancer, but the evidence-based knowledge required that eradication of HSIL prevents anal cancer is still accumulating. In the 1990s, the University of California San Francisco (UCSF), Anal Neoplasia Clinic was established to detect and treat anal HSIL in an effort to reduce the incidence of anal cancer, similar to the model used to prevent cervical cancer. High-grade squamous intraepithelial lesions were identified using high-resolution anoscopy, a unique term used to describe visualization of the anal canal and perianus with a colposcope to provide magnification after applying acetic acid and Lugol solution, which makes otherwise invisible lesions apparent.6,7 Progression of biopsy-proven anal HSIL to cancer in a group of 27 HIV-infected men who have sex with men followed at UCSF has been recently reported.8 These data are the first to conclusively demonstrate that individual HSIL lesions can progress to cancer and included 4 cancers that were not palpable and presumably would not otherwise have been identified if high-resolution anoscopy (HRA) had not been performed. From November 22–24, 2013, the inaugural scientific meeting of the International Anal Neoplasia Society was held in San Francisco and included an oral presentation titled “Establishing competency in diagnosis and treatment of anal squamous intraepithelial lesions.”9 The talk engendered collegial discussion of how this might best be accomplished. Although there are no universally accepted standards for performing HRA, consensus is emerging regarding the importance of acetic acid and adequate magnification. It is also clear that adequate training and experience performing HRA are necessary to maximally detect and treat HSIL. How HRA is performed in clinical trials will need to be standardized. It is anticipated that recommendations for assessment of proficiency and competency will be developed and posted on the society’s Web site. In this issue, Factor et al.10 surveyed the membership of the American Society of Colon and Rectal Surgeons (ASCRS), the specialists to whom most providers would likely refer their patients with anal problems and ask the question: Are colon and rectal surgeons ready to screen for anal squamous intraepithelial lesions (dysplasia)? The answer unfortunately but not surprisingly is no. The authors describe the pathogenesis of anal cancer and the particular role that HRA plays in diagnosing HSIL. High-resolution anoscopy is defined, and the differences in viewing the anal canal without application of acetic acid or using magnification are illustrated in figures in the article. Experience with colposcopy has taught us that there is a long learning curve to becoming proficient. This is even truer for HRA because of the unique features of anal anatomy. Formal courses providing training in HRA only began in 2005, and thus, it is not surprising that there is a paucity of experienced and trained providers. However, colorectal surgeons are the specialists to whom most patients with extensive or clinically worrisome lesions would be referred. Between January and March 2012, 290 (18%) of 1655 ASCRS members asked to participate completed the qualifying survey questions. Their responses to the survey questions are somewhat concerning. Most respondents were well informed regarding anal HSIL: they had either read relevant literature or attended a lecture, were able to identify risk factors, treated patients who were HIV infected, and most, specifically treated patients with anal condylomata, dysplasia, and anal cancer. However, when asked about their anal HSIL screening practices, only 96 (33%) performed an anal cytology, 99 (33%) performed HRA, and only 10% performed HRA in the office. Of the 99 who performed HRA, only 46 (46%) had been formally trained in HRA. Of the 48 of 53 who had not been trained were queried about future training, only 17 (35%) planned on becoming trained. More disturbingly, 80% of this group indicated that if asked about their training, they tell their patients they were never trained but still perform HRA and 4% of those not trained indicated that HRA is not necessary. Although most evaluate patients for anal dysplasia in the operating room, only 31% used acetic acid with magnification; the remainder use unaided visual inspection only, acetic acid without magnification, or no special technique. As pointed out in the discussion, there may be serious consequences from inadequately examining someone at risk for anal cancer, such as missing lesions that may progress or providing a false sense of security to patients. If providers want their patients examined with HRA, they need to be aware of the exact training and experience in HRA when referring their patients to colorectal surgeons and whether patients can be examined in the office or only in the operating room. It is important to emphasize that most HSIL is not palpable and not visible without application of acetic acid or magnification.11 However, most anal cancers can be felt and colorectal surgeons are the most experienced specialists to take these patients to the operating room and perform necessary biopsies to diagnose anal cancer. They are highly knowledgeable about the anal sphincter and how to biopsy and treat lesions without causing incontinence. So why aren’t most colorectal surgeons who responded to this survey ready to screen for anal HSIL? Although colorectal surgeons are the specialists who will care for most patients with anal lesions, they may not be ideally suited to perform primary screening because they are generally not primary care providers. It is our hope that some colorectal surgeons will incorporate screening into their practice because they see patients at risk presenting with anal symptoms and those with chronic inflammatory diseases. And more importantly, that those who manage anal neoplasia will understand the critical role that HRA plays in managing these patients. Multiple articles demonstrating the usefulness of HRA in detecting HSIL and guiding eradication of HSIL have been published.12–16 Most studies demonstrate that patients who have their HSIL treated are less likely to progress to cancer, but these data were collected from small numbers of patients, were retrospective, and are not considered definitive evidence.13,17–19 Although anal cancer is theoretically preventable, that has yet to proven. Recently, the National Cancer Institute has funded a study to demonstrate that identification and eradication of HSIL in HIV-infected persons prevents anal cancer, known as the ANal Cancer-HSIL Outcomes Research (ANCHOR) anal cancer prevention study. Data should be forthcoming in the next 5 to 8 years, as approximately 5100 participants with biopsy-proven HSIL are enrolled and then randomized to treatment or active monitoring without treatment. The UCSF Anal Neoplasia Clinic successfully uses an alternative screening model in which primary care providers including HIV, sexually transmitted disease specialists, and sexual health physicians perform anal cytology screening and refer those patients with abnormal cytology results or abnormal digital anorectal examination results for HRA. Most patients are managed in the clinic; HRA with biopsies of abnormal lesions is performed and used to guide ablation. Patients who have extensive lesions or who cannot be appropriately assessed in the office are referred to the colorectal surgeons for an examination under anesthesia with HRA provided in the operating room by one of the Anal Neoplasia Clinic providers. It is clear that we in the field of anal neoplasia have our work cut out for us to better educate, inform, and train more providers to perform HRA and, ultimately, demonstrate if anal cancer can be prevented, the goal of the soon-to-be-initiated ANCHOR study. And just as importantly, as more providers perform HRA, it is necessary that procedures are put in place to document proficiency and competency in performing HRA. The ASCRS Practice Parameters Committee has recently published evidence-based guidelines on management of anal squamous neoplasms indicating that anal cytological examination may be useful in the detection and follow-up of HSIL and targeted destruction (using HRA) and close clinical follow-up is appropriate therapy for HSIL. Anal cytology screening and HRA-guided targeted destruction were both given strong recommendations; however, these were based on low-quality evidence.20 The practice parameters state that although mapping was once considered routine, it is generally not required. Mapping refers to a procedure described by Strauss and Fazio21 in 1979 in which systematic biopsies are taken from all 4 quadrants of the anal canal, verge, and perianus and from any visualized lesions (without the aid of acetic acid or magnification). In a second procedure, areas containing dysplasia or cancer can be excised, which often requires skin grafts. Targeted destruction guided by HRA is effective and less morbid than wide local excision. Although not stated, mapping is not required because of the ability of HRA to readily identify lesions targeting treatment and, thus, rarely requires skin grafts. However although inferred, given the value of HRA in identifying HSIL, future guidelines should emphasize the inclusion of this technique in managing patients with anal lesions, which might persuade more colorectal surgeons to become trained in HRA. Basic information about HPV has led to knowledge about how best to detect and eradicate HSIL, which has led to the development of treatment algorithms that will be used the ANCHOR study. This is what is needed to move forward with wisdom and foresight, an effective, evidence-based approach to anal cancer prevention. Based on current knowledge, it seems likely that it will be one in which all providers who care for patients at risk for anal cancer will either examine them using HRA or refer them for HRA when appropriate." @default.
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• W2331379944 title "Who Is Ready to Screen for Anal Squamous Intraepithelial Lesions and Why Should They Perform High-Resolution Anoscopy?" @default.
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