Addressing the Risk of Anal Cancer in Baltimore City, By Dr. Leonard Sowah

On the first approach by our division chief to work on a project to develop an anal cancer screening program I must admit I was a skeptic. Like most physicians I believed high resolution anoscopies were not really supported by any good evidence and did not support the need for the procedure. Over the course of several months however a close evaluation of the medical literature left me with more questions than answers.

In 2014 as it is now there was no clear evidence supporting the benefit of anal pap smears as a mode of screening to reduce the risk of anal cancer. Our initial look at the literature however suggested that HIV patients who were gay were close to 80 times more likely to be diagnosed with anal cancer. Review of the medical literature did suggest that anal cancer followed a clinical course similar to that of cervical cancer before cervical pap smears became widely available.

The next question we had to consider was this; “In the absence any good evidence on the benefits of screening; what was our best course of action?” After much discussion my colleague Dr. Riki Buchwald and I decided to take on this task with the option of including an evaluation mechanism within the project.

An initial survey of our colleagues revealed that the concept of an anal cancer screening clinic in the setting of a HIV clinic had a lot of support. Riki and myself were fortunate in being able to secure support from our department and the Ryan White Program office with the equipment and the training required.

The wonderful nursing staff in our clinic humored us and spent a few mornings with a local surgeon in private practice to familiarize ourselves with the clinic workflow. The local colorectal surgeon is highly experienced in this procedure and had been a good practice to refer our patients. The clinic was located in Towson and was not ideal for our low-income Baltimore patients with significant transportation challenges though.

Whilst getting the money for the equipment as well as the location in the clinic for setting up our equipment had to go through multiple hospital committees we got everything lined up.

By January 2015 we were up and running and in March 2015 we got IRB approval to survey our participants as well as potentially follow then up to determine the impact of screening.

This clinic which we started continued after my tenure of employment with our parent health system and provided care for our gay HIV positive patients for several years. Though it was well received by the patients that we saw our referral volumes fell far short of our expectations.

Prior to starting the project our survey suggested that our clinical colleagues considered the lack of a screening program and trained physicians in high resolution anoscopy a barriers to screening. Our experience after developing the clinic suggested that there may be barriers intrinsic to our providers.

One provider that I discussed this with suggested that there was just too much to do and adding anal pap to the long list was an additional burden. We had anticipated this will be a problem in our initial discussions and had offered to do anal paps as well as the high resolution anoscopies if required. 

Another provider said there was no good data suggesting that screening had any benefit.   This was an argument which we both shared and was the reason we had insisted on running this as a program with an evaluation component. 

Another mentioned that we were doing this because we were only interested in the data for publication. This I would say was false, but anyways as academic physicians I am surprised that colleague expected a different course of action. 

I no longer work in that clinic and my colleague Dr. Buchwald has moved to another site in Baltimore city to help increase provider capacity. The question that I am asking myself is what would become of this project?  I do not really know what lies in the future.

I am however glad that Riki would continue to provide high resolution anoscopies in Baltimore City albeit in a different clinic. In this challenging regulatory environment with difficulties with third payer reimbursement rates; projects like this that target clinical quality would require more institutional support to survive. A recent study suggests continual increase in anal cancer rates among in both men and women. It is estimated that crude rates of anal cancers will soon exceed cervical cancer in US women. Unfortunately, in the absence of screening most individuals are diagnosed late. Most providers in the field were not even performing digital ano-rectal exams (DARE) on their patients.

Early last month our clinical practice article describing our experience developing this project was published in the Journal of the International Association of Providers in AIDS Care.  What I learned from this project was that as physicians we do not always realize why we make certain decisions and are more often than not unaware of how our beliefs and biases shape our clinical choices.

I would suggest that both physicians and patients be aware that our decisions are not always as rational and well thought out as we believe. We must be more proactive at questioning our own decisions and be more receptive to external feedback.

Anal Cancer Screening: Provider Survey article 

Anal Cancer Screening: Program Development & Patient Survey

Leonard Sowah is a physician in Baltimore Maryland