Although it has not been documented rigorously, there is a reason to believe that anal cancer could develop very much the way cervical cancer does. The change in the cells begins with mild atypica, progresses to more serious abnormal change (mild, moderate and severe dysplasia), before developing into frank anal cancer. Doctors have known about the relationship of HPV and anal cancer from long experience with gay men, who have a high incidence of this cancer due to receptive anal sex practice. We need the expertise of these physicians, now that HPV has been recognized to be a growing concern for women and recognized as a cause of cervical, vaginal, and vulvar cancer and is now publicly discussed as a cause of anal and oral cancer.
It is important that colo-rectal surgeons develop expertise in high-resolution anoscopy and an interest in recognizing abnormal change at an early stage. Gynecologists are specially trained in colposcopy to view and recognized abnormal cellular patterns that can be biopsied, diagnosed, and treated. It takes time and training to become very good at these procedures.
At the moment, there is no consensus among our specialities about how to monitor for and evaluate the presence of anal HPV. An HPV swab test can be done in the anal area. Pap smears can be done in this area. But there are no national guidelines for primary care doctors about when to do these tests, and no guidelines about what to do with the results. We don’t have a treatment protocol for anal dysplasia that is universally used.
The result is that women with high-risk HPV of the genital area are almost never tested for anal HPV, even if the woman expresses concern about her risk. That means that cells that could be treated earlier, before there is frank malignancy, are not found.
We don’t want women to wait for a diagnosis until they have rectal bleeding or a feeling that there is a constant fullness in the anal area. These are symptoms of many benign diseases but also the symptoms of anal cancer. We have to have a plan based on what is known and what evaluations are available.