Early Impact and Performance Characteristics of an Established Anal Dysplasia Screening Program: Program Evaluation Considerations

Abstract

Abstract:Background: Screening for invasive anal cancer and its precursors is being increasingly advocated as a response to increasing incidence among HIV-infected persons. We implemented a comprehensive screening program in 2001 and report our early experience to inform monitoring and evaluation of such programs. Our research aims were: (1) to estimate incidence of and mortality from invasive anal cancer (IAC) before (1995)(1996)(1997)(1998)(1999)(2000) and after (2001)(2002)(2003)(2004)(2005) screening program implementation and (2) to examine potential screening program quality indicators. Results: 28 cases of IAC and 13,411 person-years were observed between 1995-2005. IRs (95% CI) pre-screening and post-screening were 199 and 216 per 100,000 person-years, respectively. There was no routine treatment of high grade squamous intraepithelial lesions (HSIL) during the study period. The percent of patients with IAC requiring chemoradiation decreased from 90.9% to 70.6% (p=0.36). There was a significant improvement in cyto-histologic agreement at HRA with increasing operator experience (r=0.92, p=0.025). Screening coverage was 73% of the target population. Among 14 providers, the percent unsatisfactory cytology smears averaged 27% but varied from 0 -62%. The median time from 1 st abnormal cytology to 1 st HRA was 258 days. The median interval between the last cytology and the last clinic visit was 207 days. Conclusions:(1) The overall IR of IAC did not decline in the screening era and was higher than previous estimates for HIV cohorts; (2) stage shift to IAC of more favorable prognosis is a reasonable screening goal; (3) HRA accuracy varied by provider experience; (4) because of delay in access to HRA, digital rectal exam should be combined with cytology screening to detect palpable disease.

Improving Anal Cancer Screening in an Ambulatory HIV Clinic: Experience from a Quality Improvement Initiative

“…14 Matthews and colleagues 14 found that the percentage of patients receiving anal cancer screening via anal cytology was 73% by the end of the 5-year study period. As the University of Colorado's anal health program continues to expand, it is anticipated that the anal cancer screening rate will approach that in other HIV treatment centers with regular access to anal dysplasia specialists.…”

“…9,10 Therefore, some experts have advocated for early identification of anal cancer as a way of improving survival and outcomes for persons diagnosed with SCCA. 8,[11][12][13][14] The development of SCCA has been linked to the precursor lesion of anal intraepithelial neoplasia (AIN). 15 This is similar to cervical intraepithelial neoplasia (CIN), the precursor for cervical cancer.…”

Screening HIV-infected patients for non-AIDS-defining malignancies

“…Comparable analyses for other groups, including women, have not been performed. A single-center study of the early impact and performance of an established anal dysplasia screening program (including 8.4% women) over a follow-up period of 10 years revealed screening detected earlier disease (stage migration); however, the overall incidence rate of invasive anal cancer did not change [24].…”

The Need for Anal Dysplasia Screening and Treatment Programs for HIV-Infected Men Who Have Sex With Men

“…Screening for dysplasia and early anal cancer without treatment of dysplasia has not been shown to reduce anal cancer rates (Mathews, Caperna, Cachay, & Cosman, 2007). Two main issues arise regarding treatment of anal dysplasia when it is discovered in HIV-infected MSM:…”