Doctors Want Pap Test For Gay Men

SAN FRANSISCO - Bay Area doctors are leading a campaign to bring gay men into their offices for a basic exam that women have been enduring for decades -- the Pap test.
The goal is to push back rising rates of anal cancer, a preventable disease that has increased 37 percent in the United States since a decade ago, when the total number of cancer cases increased only 1 percent.
Anal Pap smears would help doctors spot precancerous lesions and wipe them out before they have a chance to turn malignant, say supporters of widespread use of the exam among gay men. But nationwide, doctors have been reluctant to embrace the screening test, partly because there is disagreement over whether it's effective or even necessary.
Dr. Joel Palefsky, director of the Anal Neoplasia Clinic at UCSF, encourages anal Pap tests for gay men and other groups at high risk of developing anal cancer.
"We haven't proven it yet, but we believe that we are likely to be preventing anal cancer," said Palefsky, who hopes this summer to publish results from a study on anal cancer prevention. "Our approach is to move forward on the assumption that we are preventing cancer and working in parallel to the kind of research studies that will convince everyone else."
Anal cancer is one of the rarer and less deadly forms of cancer in the United States. In 2006, there were about 4,660 cases, and 660 deaths, accounting for less than 1 percent of all cancer cases, according to the American Cancer Society.
While rates of anal cancer are low in the general population -- and more women than men get anal cancer every year -- they're disproportionately high among gay men and people who are HIV-positive or have other immune-suppressive conditions. Part of the explanation for increased cases of anal cancer is better reporting of the disease, but Bay Area doctors say it also could be tied to HIV rates.
Studies have shown rates of anal cancer as high as 35 cases for every 100,000 people among gay men -- a figure comparable to rates of cervical cancer in women before Pap tests were introduced as a screening tool 60 years ago. Since then, rates of cervical cancer have fallen 70 percent.
"Anal cancer is a silent issue that's been building for at least 10 years," said Jason Riggs, a spokesman for the Stop AIDS Project. "You've got consumers who are for the most part completely unaware that there's a health issue going on until it hits the cancer stage. And it's sad because it's incredibly preventable."
Like cervical cancer, anal cancer is caused by the human papilloma virus, or HPV, a sexually transmitted disease that will infect the vast majority of adults in their lifetime. Most people are able to shake off HPV without ever knowing they have it. But a small group of men and women will get lesions that could turn into cancer in the cervix, vulva, anus or penis.
Last year, the Food and Drug Administration approved the first vaccine for certain strains of HPV that are most likely to cause cancer. But it was approved for use in women and girls only, with the most likely candidates for the vaccine being preteen girls who have not yet had sex. The vaccine is considered most effective when used before someone has become infected with
HPV.
Clinical studies are under way to determine whether the vaccine, called Gardisal, should be used by men and boys, too. In the meantime, gay men have started asking for the vaccine even without FDA approval.
Bay Area doctors who work with patients at risk for anal cancer say the Pap test appears to be an effective preventive tool. Pap tests, which use swabs to get samples of cells in the cervix or the anus, can show whether abnormal lesions have developed, a condition known as dysplasia.
Not all anal lesions will turn into cancer, but the same is true for dysplasia in the cervix and breast, and generally those lesions are removed without question, say doctors who support widespread anal Pap tests.
But some doctors say they can't support a standard policy on Pap testing until they see studies proving that screening really prevents cancer.
"Pending really definitive clinical trials, at this point we advocate for a physician's best judgment," said Dr. Michael Horberg, director of HIV-AIDS for Kaiser Permanente and an HIV specialist at Kaiser Santa Clara Medical Center. "It's up to the discretion of the clinician as to whether they'd want to do a formal Pap test or a visual inspection."
That said, if a patient requested an anal Pap test, "I'm sure it would be an honored request," he added. And Horberg said doctors and nurses who work with gay men are vigilant about checking for HPV and signs of anal dysplasia.
Technology for removing anal lesions has improved significantly in the past decade, so that a procedure that in the past was very painful and took months to recover from often is now an outpatient procedure with a week or two of recovery.
The UCSF clinic that specializes in removing anal lesions has a four-month waiting list, in part because of the increase in cases, and in part because patients and doctors are more comfortable with the new technology.
But outside the Bay Area, not many communities have the infrastructure to remove anal lesions, or even the expertise to read the results of an anal Pap test. And because anal cancer itself is very treatable with chemotherapy and radiation, doctors nationwide haven't seen much point in performing a Pap test when there's not much they can do about an abnormal result. Instead, they wait for the cancer to develop.
"Anal cancer does very well with chemotherapy and radiation. It's very effective treatment," said Dr. Mark Welton, a colorectal surgeon with the Stanford Comprehensive Cancer Center who treats patients with anal dysplasia. "But if you're given a choice between treating it and preventing it, I'd certainly choose the latter."
from The San Francisco Chronicle