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Microscope
“Anal cancer is on the rise across the USA. But if you’re a person living with HIV, that risk can be up to 80% higher” reads a participant recruitment flyer for the Medical College of Wisconsin (MCW) Prevent Anal Cancer (PAC) Study.
Funded through the National Cancer Institute of the National Institutes of Health and under the local direction of Dr. Alan Nyitray, the study’s principal investigator, PAC is part of a national program whose partner cities include Houston and Chicago. Together they will recruit a total of 1,00 gay and bisexual men, other men who have sex with men (MSM) and transgender individuals who have sex with men as participants.
In Milwaukee, about half of the contingent has already been recruited with an additional 200 still needed. The study’s purpose is to follow up a national study that has proven that treatments for anal cancer work at preventing the disease. The ANCHOR Study used a procedure called High-Resolution Anoscopy (HRA) to find the pre-cancerous lesions that were then successfully treated. The issue now is to determine the best way to encourage at-risk populations to get tested.
Trying to Understand
“Human Papillomavirus causes cervical cancer, we’ve had screening for it since the mid-20th century. We’ve discovered it causes other cancers including anal cancer. But we don’t know how to screen for it. We’re focusing the study on gay and bisexual men because their chance of anal cancer is 10-80 times higher in that demographic than in the rest of the general population,” Nyitray said. “We are trying to understand what we can do to increase the likelihood men would screen. Men are really bad about getting screened for anything,” he added.
The challenge, according to Nyitray, is stigma. “It’s an anatomic site people are reluctant to talk about—whether patient or clinician talking about the anus is uncomfortable. The question is how we deal with that.”
The reality is the rate is higher among gay, bisexual and transgender persons. It’s for the same reason as cervical cancer. The penis transmits HPV to the anal canal. Sexual intercourse transmits both cervical and anal cancer. Nyitray notes that even without anal sex, anal cancers are caused by HPV but we don’t know why. It may be a reluctance to disclose one’s practice of anal sex or it may be another means of transmission. The answer remains unclear.
Best Methods
To establish the best screening method, the 400-member study group will be divided into two sections. One will self-test using a kit that requires a swab around the anal canal done at home to be sent to the MCW for processing. Here the method addresses stigma around anal sex. It’s one reason for the kit because it avoids a doctor visit. The other section will be asked to have the same test done by a clinician in a medical facility setting. This group will also receive a digital rectal exam. All anal cancers present with a tumor than can be felt, even if small, in an anal exam. Local partners include the Holton Street Clinic, Inclusion Health Clinic at Froedtert-MCW, Sixteenth Street Community Health Centers, Vivent Health, and the Anal Dysplasia Clinic at Froedtert-MCW.
The idea is to determine which method is more likely to achieve compliance. Each group will repeat the process one year later. All Recruits will then get a high resolution anoscopy. “With the swabbing, we look for HPV, human transmitted. Most gay men probably already have it. The initial screening will be recorded and a year later the screening could show persistent HPV which could indicate high risk. If a pre-cancer in the anal canal is found, it can be removed easily. Outcomes are usually very good,” Nyitray said.
Recruit eligibility is fairly broad. Participants 25 years and older are sought with a preference for recruits in the 50-year age range, the average age for diagnosis. Ideally, the study group will reflect Milwaukee’s ethnic demographic percentages. All participants receive $130.
Potential recruits may visit the PAC Study website mindyourbehind.org to determine eligibility and to access survey consent forms. Recruitment ends Aug. 31.
When the study is completed peer review articles in medical journals will follow. These will go worldwide with screening guidelines. Implementation? “If we decide to say there should be screening, what’s the evidence that it will be beneficial rather than cause harm? Once the study is published and the evidence studied, a recommendation can be made.” Nyitray said.
Above all, however, the key is detection. The best means to that end is what the PAC study is determined to find out.
