Over the past few decades, there has been a steady increase in anal cancer worldwide. While this is a relatively uncommon type of cancer, one of the key features is it affects certain groups of people much more than the general population. Gay and bisexual men are at particularly high risk of anal cancer, and experience rates that are at least 20 times higher than rates among heterosexual men. For all people living with HIV, anal cancer can be up to 30 times higher. Gay and bisexual men living with HIV are the most affected groups of people, with up to 100 times higher rates of anal cancer than heterosexual men.
The main risk factor of anal cancer is exposure to human papillomavirus (HPV). HPV is the most common sexually transmitted infection (STI). The strong link between anal HPV infection and cancer means anal cancer is potentially preventable by HPV vaccination, especially if the vaccine is given before people become sexually active. In 2013, the addition of HPV vaccination of school-aged boys to the female vaccination program in Australia means future generations of Australian men and women will be protected from the HPV types that cause most anal cancer. However, for the next 30-50 years, alternative strategies will be required to reduce rates of anal cancer.
One potential strategy to reduce the impact of anal cancer in the community involves screening for early detection of anal cancer. The benefit of early detection of early stage anal cancer, while the cancer is still small and has not spread, means treatment may be less aggressive, and is often associated with much greater survival rates than treatment at later stages. Unfortunately, a diagnosis of anal cancer is also associated with embarrassment and stigma. Many people are uncomfortable discussing their anal symptoms and signs, which means diagnosis tends to occur late. Greater awareness and education about anal cancer can reduce community discomfort and embarrassment and increase early diagnosis of this cancer.
Starting in September 2010, the Study of the Prevention of Anal Cancer (SPANC) is an ongoing, three-year research study into anal HPV infection and anal pre-cancer lesions in gay and bisexual men in Sydney. A total of 617 men have been recruited into the study, which will contribute to understanding anal HPV and pre-cancer. Results will be used to develop guidelines for implementing anal cancer screening programs. One unplanned but very productive consequence of SPANC has been the creation of the Anal Cancer Advocacy Group in late 2013. This group is now made up of members from Positive Life NSW, ACON, AFAO, the Kirby Institute UNSW Australia, Cancer Council NSW, Australasian Society for HIV Medicine (ASHM), NAPWHA, sexual health specialists and oncologists and a member of the affected community.
The group has developed an advocacy plan for better anal cancer prevention and treatment in NSW, with a focus on four main priority areas. Some of the work completed in Sydney so far includes:
1. Generating greater community awareness of anal cancer and testing options within communities at heightened risk of anal cancer
AFAO launched its nation-wide campaign The Bottom Line in October 2014 and the Cancer Council NSW conducted a webinar on anal cancer in gay and bisexual men in July 2015. In 2016, Positive Life NSW created a Factsheet on HPV and anal cancer and has conducted an online survey.
2. Raising doctors’ awareness of best practice anal cancer prevention and treatment through guidelines to support improved practice among doctors
In October 2015, ASHM hosted a webinar on anal cancer and HIV and the group’s community member wrote an article on anal cancer awareness and diagnosis for the medical journal, Australian Family Physician. ASHM has commissioned a subcommittee to investigate the role of screening for anal cancers in men living with HIV and a multidisciplinary symposium on anal cancer to be held at the annual ASHM and Australian Sexual Health conferences in November 2016.
3. Encouraging expanded HPV vaccination programs
There is a strong case on equity and public health grounds to maximise HPV vaccine coverage for men who have sex with men (MSM) aged 26 years or less, and a proposal was developed that HPV vaccine be offered to all unvaccinated MSM less than 26, attending publicly funded sexual health clinics. A report was created by a senior health economist and a submission was prepared by members of the group. This was submitted in late 2015 by the Kirby Institute UNSW Australia to NSW Health and by leading sexual health specialists in Victoria and Queensland to their respective health departments. Letters of support from community groups accompanied these submissions. There is yet to be a response.
4. Promoting greater access to high resolution anoscopy (HRA) referral services for early diagnosis of anal cancer
HRA is a medical procedure where a small tube (anoscope) is inserted into the anus, to pick up anal cancer as early as possible. The Dysplasia and Anal Cancer Services (DACS) clinic at St Vincent’s Hospital is currently the only HRA service available in NSW, for people concerned that they may have anal cancer or severe dysplasia. A submission to St Vincent’s by ACON and Positive Life NSW resulted in increased services from one clinic per month to six clinics per month at St Vincent’s Hospital. A similar submission to Royal Prince Alfred Hospitals is awaiting a response.
The Anal Cancer Advocacy Group shows what can be done when community groups, researchers and clinicians combine their resources, skills and expertise to achieve better health outcomes and equity in health care. If you are an older gay or bisexual man, please talk to your GP about having an annual digital anorectal examination (DARE). If you have symptoms such as a lump, unusual bleeding or a sense of anal fullness and your GP has any concerns that you might have signs or symptoms of anal cancer, your GP can write you a referral to the DACS clinic at St Vincent’s Hospital for further examination and follow-up. Early detection of anal cancer means early treatment, and this can offer you the best outcomes from this disease. Digital Ano-Rectal Examination (DARE)
Dr Mary Poynten
Dr Mary Poynten is a Senior Lecturer and clinical epidemiologist at The Kirby Institute (UNSW) since 2008. She is project leader of the Study of the Prevention of Anal Cancer (SPANC).