Data points to a virus’ role, importance of prevention, detection, treatment
By LAWRENCE D. MASS, M.D.
In February 2003, The New York Times published a story by David Tuller reporting on cases of anal cancer—an ailment that is rare—among gay men. Reports in the gay press followed, including one this reporter wrote for American Bear magazine. My early thinking about this phenomenon mirrored that of other gay men—I assumed it was yet another opportunistic disease, like Kaposi’s sarcoma, also a rare cancer, seen predominantly in people living with AIDS.
The initial reports noted, however, that some of the anal cancer cases were diagnosed in HIV-negative, otherwise healthy men who have had sex with other men.
About a year after the Times story, I was outside the Dugout, the West Village Sunday afternoon bear bar, where I ran into B.G., a friend I hadn’t seen in months. He looked his usual sexy self, but when I asked how he was doing, he took me aside.
“It’s been a tough time,” he confided. “I have rectal cancer. I have to have surgery and chemo and radiation therapy, but they’re optimistic about recovery.”
B.G. is in his mid-40’s, HIV-negative, and in good health. He explained that his doctors told him he suffered from an atypical presentation of cancer of the colon—which is frighteningly common especially among middle-aged and older men, though rare in men as young as B.G.
“If I had a dime for every case of cancer of the colon I’ve heard about lately…” I told B.G.
Separate from the colon cancer I’ve encountered in my medical practice, one of the other recent cases I’d heard about was in my friend N.R., who is 60, but also HIV-negative and otherwise healthy. N.R. admitted that he had neglected to have the periodic colonscopy screenings recommended for men his age. B.G., despite his relative youth, had insisted on the procedure when he started seeing blood in his stool. Like B.G., N.R. had to undergo major surgery followed by chemotherapy and radiation therapy.
Until this September, I never made any connection between my conversations with B.G. and N.R. and the anal cancer reports. However, at a monthly dinner meeting of Physicians Referral Network—an organization of physicians involved in AIDS research and care, funded by a pharmaceutical consortium and stewarded in canny fashion by Dr. James Braun—I listened to a presentation by Dr. Steven Goldstone, an assistant clinical professor of surgery at Mt. Sinai who specializes in colorectal surgery and has become a leading authority on anal cancer. His news was a matter for concern—anal cancer was no longer so rare, at least among men who have a history of unprotected receptive anal sex. Goldstone said the frequency of such diagnoses warrants a screening anal pap smear for any man (or woman) who has ever engaged in such sexual activity.
That’s when it hit. Was it possible that my two friends with “cancer of the rectum” actually had anal cancer? I called B.G. “You said you had rectal cancer, a form of cancer of the colon. But did you in fact have anal cancer? Did they use that term?”
“Only later,” he told me, explaining that his doctors had originally misdiagnosed his cancer.
N.R. had the same story. Post-operatively he was told that his cancer of the colon was actually anal cancer.
Anal cancer is being diagnosed among those who are not HIV-infected, and more commonly among those who are HIV-positive, with a frequency that deserves our community’s attention. In the general population, anal cancer is relatively rare, about one for every 100,000 people. But in gay and bisexual men, the incidence is 35 per 100,000 or higher, with men who are HIV-positive twice as likely to get anal cancer as those who are not, according to researchers from the University of California at San Francisco, Stanford University, and the Harvard School of Public Health.
The villain is the Human Papiloma Virus (HPV), the same family of viruses highly associated with cancer of the cervix in women and anal warts in men who have sex with men.
In response to my question, Goldstone stated that anal pap smears are advisable for anyone who has had unprotected receptive anal sex, in the same way that women are routinely tested for cancer of the cervix with a cervical pap smear. Having been burned in the past for suggesting that gay men be routinely screened for hepatitis C—with the cost effectiveness of such an approach hotly debated—I asked Goldstone whether anal pap smears can be justified on this basis.
“Yes,” he said. “This has already been studied.”
He also said that a screening colonoscopy would typically not detect anal cancer “unless it’s advanced.”
In addition to checking back in with B.G. and N.R., I also asked other friends whether they had ever had an anal pap smear. Only one had. None of the others had ever heard of it. All of them are at risk.
As am I. Though I have avoided the risk of unprotected anal sex since the first reports of the HIV epidemic a quarter century ago, during the 1970s I had high-risk sex. I chose to schedule a pap smear at the Callen-Lorde Community Health Center, rather than with my excellent GI physician at Beth Israel—I wanted, at least this first time, to have it done by a practitioner in a gay clinic setting.
But it is worth noting here that studies of gay health have consistently affirmed the value of gay men and lesbians being out and comfortable with their health care practitioner. Whatever choices an individual has in terms of access to specialists and makes regarding disclosure to any physician, it is vital that his or her medical concerns and needs be met. Any medical professional is responsible for their malpractice in the event that homophobic ignorance, indifference, or hostility gets in the way of providing the best care. But if you’ve chosen not to disclose your orientation, then it’s up to you to make sure your health care concerns are otherwise addressed.
The silver lining to this alarming new finding about anal cancer in gay men is that by 2006 a new, highly effective preventive vaccine for HPV will become widely available. The vaccine was developed to prevent those strains of HPV that cause cancer of the cervix in women but it is expected to be as effective against those that cause anal warts and anal cancer. As with many issues in gay health, the patient is advised to keep abreast of developments on their own and to seek care from the most knowledgeable practitioners, including clinics based in the LGBT community. The doctor who doesn’t know you are gay is unlikely to recommend the HPV vaccine, in which case you’re going to have to ask for it.
Goldstone emphasized that the vaccine is still under development and said he is involved in a clinical trial of its efficacy in preventing anal warts and cancer. He indicated that research to date has shown 100 percent efficacy in preventing the viruses that cause cancers for which testing has been done when the vaccine is administered prior to infection. In an interview, he described those results as “incredibly exciting.”
Goldstone recommends that gay men who have had receptive anal sex receive rectal examinations within a year of their first experience, and repeat it every two to three years if they are HIV-negative and every year if they are positive. The exam should include a pap smear, which costs between $50 and $60. Though some doctors may not know how to perform the test, it is relatively easy for them to learn, involving the rotating of a moistened cotton swab on the anus, which is then placed in preservative and sent to a lab.
Even precancerous lesions can take years to progress to cancer, according to Goldstone, and can often be treated successfully. He addressed the ongoing debate about the potential pain involved in even minor surgery in such a sensitive area by noting that procedures available today involve minimal or no invasiveness. Anal warts have been shown to be a marker for anal cancer, with 60 percent including some area that is either cancerous or precancerous in a study with which Goldstone was involved.
Though not all precancerous conditions advance to cancer, Goldstone noted that once invasive cancer is present, the treatment involves more surgery and chemotherapy and radiation as follow-up.
The clear message Goldstone has for sexually active gay men is that prevention, regular screening, early detection, and treatment at the first possible opportunity are the key steps in mitigating the newly understood risks posed by anal cancer.
Dr. Steven Goldstone can be reached at 212-242-6500. The Callen-Lorde Community Health Center can be reached at 212-271-7200. Lawrence D. Mass, M.D., is a unit director in the division of Addiction Treatment Services of Beth Israel Medical
Center in Manhattan.