The Cancer That Dare Not Speak Its Name

Risk Factors

HPV-Associated Cancer in the U.S. (2011)
Type of Cancer	New Cases	Deaths	% From HPV
Cervical	12,710	4,290	Almost All
Anal	5,820	770	95%
Vaginal	2,570	780	65%
Vulvar	4,340	940	50%
Penile	1,360	320	35%

It's important to talk to your doctor about your risk factors for HPV and ask about testing options. Anal cancer does not affect all groups equally. In general, more women than men are diagnosed with anal cancer.

HIV-negative MSM are seventeen times more likely to develop anal cancer than non-MSM, and HIV-positive MSM are twice as likely as HIV-negative MSM to develop it. Rates of anal cancer are especially on the rise in older MSM with HIV. While HIV treatment has been successful at prolonging the lives of people with HIV, a weakened immune system over a long period of time can allow for an infection like HPV to develop into cancer. Sexual experiences that occurred years or even decades earlier may have resulted in an HPV infection that can lead to a malignancy years later.

A woman who has persistently tested positive on a cervical HPV test may be at higher risk for having an HPV infection in the anus that can lead to anal cancer. Women with a history of cervical cancer or vulvar cancer may also be at higher risk. Anal sex is not a requirement for anal HPV infection or anal cancer in women (or men), as studies have shown HPV infection to be present in the anal canal of heterosexual men and women without a history of anal sex, including adolescent females. This is why women should request anorectal exams as part of a routine check-up, and women with persistent high-risk HPV cervical infection should speak with their doctor about annual anal Pap smears. Current New York State recommendations are that all men and women with HIV should get an annual anal Pap smear.

A study published in 2010 concluded that anal cancer rates are rising among people with HIV and that HIV treatment does not appear to reduce the risk of developing it. However, there has been speculation by scientists that since HIV treatment improves immune function, it may prevent the progression of HPV to anal cancer. Still, it is clear that people with HIV have a significantly higher risk for anal cancer than those who are HIV negative. On its HPV information website, the CDC states "some experts recommend yearly anal Pap tests to screen for anal cancer in gay and bisexual men and in HIV-positive persons. This is because anal cancer is more common in those populations."

Certain other factors such as smoking and a higher number of sexual partners may also be linked to an increased risk of anal cancer.

HPV and Anal Cancer Screening

In order to monitor potential HPV disease, everyone should have regular checkups after the onset of sexual activity. The cervical Pap smear and regular gynecological check ups have dramatically reduced the numbers of cases of cervical cancer in the U.S. in the last 40 years. But neither gender is regularly screened for HPV risk in other parts of the body, such as the anus or the mouth.

Women are routinely screened for cervical cancer when they receive their annual Pap smear at the gynecologist. But men often fall through the cracks when it comes to routine screening because anal HPV tests and anal Pap smears are not commonly offered to them by physicians. There are currently no routine anal cancer screening protocols. Certain anal specialists suggest the best way to check for anal cancer is through a digital anorectal exam. The name may be confusing, since there is no digital equipment used in the examination -- in this case the "digit" is simply a finger. In fact, it is a simple procedure in which the physician checks the anus for any abnormalities using a lubricated, gloved finger, much like a prostate exam.

Another simple test to check for abnormalities is an anal Pap smear, which is similar to a cervical Pap smear. An anal Pap smear merely involves placing a small swab in the anus and sending if off to the lab. But some general practitioners insist on referring patients to a specialist for this simple procedure, creating a barrier that often leads to it not being performed.

If precancerous anal lesions are found, a high-resolution anoscopy is recommended. This is often performed after an abnormal anal Pap smear and involves a magnification of the anal canal using a device called a colposcope. Vinegar is applied to the lining of the anus to show areas of abnormalities and identify dysplasia. If a problem area is spotted, a biopsy may be taken. Precancerous lesions can be treated with topical therapies, frozen with liquid nitrogen, or burned off with heat or laser therapy. Since the anus makes up only about the last inch of the anal canal, these precancerous lesions can often be dealt with in an outpatient procedure.

Anal Cancer Treatment

There is a common protocol for the treatment of early stage anal cancer. It usually involves 30 days of radiation therapy, along with two cycles of chemotherapy. If caught early, cure rates are high, although this regimen can come with significant side effects, some of which may be long lasting. Radiation can lead to long-term gastrointestinal and sexual health dysfunction, including narrowing of the anus or vagina due to scar tissue formation, often making sexual activity painful. For men, it could mean erectile dysfunction.

Unfortunately, anal cancer is often misdiagnosed and its treatment delayed, leading to metastasized cancer in other parts of the body. If you are diagnosed with what is believed to be a hemorrhoid and it has not resolved for several weeks, despite all recommended treatments, discuss it with your physician and have it formally re-evaluated. MSM in particular should be very aware of changes in the anus. Any abnormal bleeding or new bumps should lead to an immediate examination -- by a specialist, if needed.

Unfortunately, when diagnosed in late stage, anal cancer can have devastating effects. One of the authors of this article lost her mother to anal cancer in 2010. Farrah Fawcett, the actress and model, lost her life to it the year before.

Regular check ups and testing have been credited with reducing cervical cancer rates in the U.S. over the last half century. With increased awareness, vaccination programs, improved screening practices, and proactive questions from patients, the HPV cancer burden for anal cancer and other HPV-associated diseases can be reduced in the U.S. in the coming years.

Our Mission

The HPV and Anal Cancer Foundation is a 501(c)(3) not-for-profit organization established in 2010. The mission is to provide support for patients and families, improve preventive care measures and fund therapeutic research.

Justine, Tristan, and Camille Almada started the nonprofit after their mother died from anal cancer. The organization aims to spread awareness and knowledge about the disease, breaking the stigma of a cancer that is often misdiagnosed and misunderstood. The organization also seeks to empower people living with anal cancer to feel unashamed about having HPV or anal cancer.

We encourage you to reach out to us with any questions, concerns, or to share your story with us at www.analcancerfoundation.org.

Camille Almada and Nicoletta Bumbac are members of the Board of Directors of the HPV and Anal Cancer Foundation.