Management of screening test results
A. Where HRA services are available
Abnormal screening results require more detailed investigation, ideally with HRA and biopsy, given that pre-cancerous HSIL lesions are typically asymptomatic and impalpable on DARE. The IANS recommendations for the management of test results modified for “low HRA capacity”, defined as greater than 6 months waiting time for HRA following referral for an abnormal screening test result, are shown in Table 3.
B. Where HRA services are not available
ASHM recommends that HIV referral services treating PLHIV develop facilities for diagnostic HRA as a priority. For at-risk individuals who live in areas with no certified HRA providers and are unable to travel, ASCC screening – including management of abnormal test results – should consist of an annual symptom assessment and DARE, practice guidelines for which have been published by IANS39. A positive DARE result is defined as a visible or palpable lesion of the peri-anus or anal canal that would arouse suspicion of pre-cancer or invasive disease. Such cases should be urgently referred to a local General or Colorectal Surgeon, potentially for examination under anaesthesia (EUA) and biopsy. Individuals should also be advised to present for care if any unexpected anal symptoms (pain/bleeding/lump) develop between screening appointments.
Table 3: Frequency and management of HPV screening test results
| Population | Interval if previously HPV-negative | Triage test | HRA | HPV testing interval after negative HRA |
|---|---|---|---|---|
| 1. GBM and TW living with HIV a | 3 years | Cytology | Immediate HRA regardless of cytology result
| 1 year |
| 2. Women, trans men and MSW living with HIV b | 3 years | Immediate HRA dependent on cytology result
| ||
| 3. PLHIV after treatment for anal cancer c | 6 months | HRA after 12 months
| ||
| 4. PLHIV with incidental HSIL d | 3 years | No HRA
|
| Table: Australian Modified Bethesda System for reporting anal cytology 64 | |
|---|---|
| Negative | There is no evidence of a squamous intraepithelial lesion or malignancy |
| PLSIL | Possible low-grade squamous intraepithelial lesion |
| LSIL | Low-grade squamous intraepithelial lesion |
| PHSIL | Possible high-grade squamous intraepithelial lesion |
| HSIL | High-grade squamous intraepithelial lesion |
| SCC | Squamous cell carcinoma |
| Unsatisfactory | Insufficient cellular material |
Understanding ASCC incidence by age is essential to inform potential screening programs. A nationwide data linkage study to identify cancer diagnoses in PLHIV was conducted in Australia between 1982 and 2012, demonstrated that the incidence of anal cancer in PLHIV aged between 35 and 64 years has increased significantly over the past three decades5. The age-standardised incidence of anal cancer per 100,000 person-years in three age groups, and overall, is shown in Table 1.
Notes:
a Age ≥35 years
b Age ≥45 years
c Chemoradiotherapy and/or surgery etc
d Lesions found at haemorrhoidectomy, colonoscopy or during diagnosis of other anal conditions
Acknowledgement of Country