To the Editor
Crawshaw, et al. report a 4.5 and 6% 5-year progression rate to anal cancer in patients in the HRA and “expectant management” arms, respectively, and conclude the method of following the patient is not important.1 We would argue that the reported incidence of cancer in both arms was too high and we question whether the methods used by the authors to follow and treat patients in either arm were optimal. Their rates are not much different from estimates of progression among patients undergoing no therapy at all.2 In contrast to the statement that “AIN rarely progresses to cancer”, extended over an average lifetime, these rates would lead to a high lifetime risk of anal cancer and should not be considered acceptable.
The data in this paper tell us little about how well a properly implemented prevention program might work. To achieve optimal results, HRA should be performed by well trained and experienced clinicians who have undergone rigorous evaluation and quality control, similar to that required for cervical colposcopy in cervical cancer prevention programs. Efforts must be to identify ALL HSIL-foci of HSIL that are not identified are also not targeted for ablation and can progress to cancer. The efficacy of HSIL treatment must be documented on posttreatment follow up since partially treated HSIL may progress to cancer. Patients must be followed regularly over a period of years because HSIL may require more than one treatment and there is a high incidence of metachronous disease. Data from a sufficient number of patients must be analyzed to permit scientifically meaningful conclusions. The paper by Crawshaw, et al. falls short on all of these counts. A large, randomized controlled trial called the ANCHOR (ANal Cancer/HSIL Outcomes Research) study has just begun and is designed to definitively address this question by randomizing more than 5,000 HIV-positive persons with HSIL to either treatment or close monitoring without treatment. Until the outcome of the ANCHOR study is known, we believe that it is a mistake to conclude that the methods used to diagnose and treat HSIL to prevent anal cancer do not matter.
Contributor Information
Joel Palefsky, Director, UCSF Anal Neoplasia Clinic, Research and Education Center, Professor of Medicine, University of California, San Francisco, joel.palefsky@ucsf.edu.
Michael Berry, Associate Director HPV-Related Clinic Studies, Professor of Medicine, University of California, San Francisco
References
- 1.Crawshaw BP, Russ AJ, Stein SL, et al. High-resolution anoscopy or expectant management of anal intraepithelial neoplasia for the prevention of anal cancer: is there really a difference? Dis Col Rectum. 2015;58:53–59. doi: 10.1097/DCR.0000000000000267. [DOI] [PubMed] [Google Scholar]
- 2.Machalek DA, Poyntn M, Fenyi J, et al. Anal human papillomavirus infection and associated neoplastic lesions in men who hav sex with men: a systematic review and meta-analysis. Lancet Oncol. 2012;13:487–500. doi: 10.1016/S1470-2045(12)70080-3. [DOI] [PubMed] [Google Scholar]