From the Guidelines
Patients with a history of high-grade anal dysplasia who have undergone condyloma excision should continue regular anal Pap smears for surveillance, with no clear evidence to support discontinuation after a certain number of consecutive normal results. When considering the management of patients with a history of high-grade anal dysplasia, it is crucial to prioritize their morbidity, mortality, and quality of life outcomes. The evidence from the NCCN clinical practice guidelines in oncology 1 emphasizes the importance of surveillance following treatment of anal cancer, including more frequent anoscopy for individuals with HIV. Although the provided study primarily focuses on surveillance and survivorship in people living with HIV treated for anal cancer, its recommendations on regular anal cytology for the detection of anal dysplasia can be applied to patients with a history of high-grade anal dysplasia. Key points to consider in the management of these patients include:
- Regular anal cytology for the detection of anal dysplasia, as recommended by the NCCN guidelines 1
- The importance of high-resolution anoscopy if high-grade AIN is identified
- Counseling on infertility risks and referral for fertility counseling as appropriate
- Discussion of posttreatment pelvic physical therapy and anal dilators with an appropriate healthcare provider for patients who engage in receptive anal intercourse Given the potential for significant recurrence rates (20-50% within 5 years) and the persistence of high-risk HPV types, ongoing surveillance with regular anal Pap smears is essential, even with normal results. Patients with additional risk factors, such as HIV infection, immunosuppression, or ongoing HPV exposure, should maintain lifelong surveillance with more frequent screening. Regular digital anorectal examinations should also be performed as part of the follow-up regimen, and any abnormal findings during surveillance would warrant referral for high-resolution anoscopy and possible biopsy to evaluate for recurrent disease.
From the Research
Anal Dysplasia Screening and Management
- Patients with a history of high-grade anal dysplasia are at increased risk of recurrence and should undergo regular screening 2, 3.
- Anal Pap smears are a useful screening tool for detecting anal dysplasia, but their sensitivity and specificity can be variable 4, 5.
- The presence of high-risk oncogenic HPV-types can increase the sensitivity of anal cytology in detecting high-grade dysplasia 5.
- Patients with a history of abnormal cervical Pap smear, cervical intraepithelial neoplasia, cervical cancer, and high-risk HPV are at increased risk of anogenital dysplasia and should be screened for anal dysplasia 6.
Discontinuation of Anal Pap Smears
- There is no clear evidence to support the discontinuation of anal Pap smears after a certain number of consecutive normal results 2, 4, 3.
- Patients with a history of high-grade anal dysplasia should continue to undergo regular screening due to the high risk of recurrence 3.
- The decision to discontinue anal Pap smears should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 4, 6.
Risk Factors for Anal Dysplasia
- HIV infection is a significant risk factor for anal dysplasia and cancer 2, 4, 3.
- High-risk oncogenic HPV-types, such as HPV 16 and 18, are associated with an increased risk of anal dysplasia and cancer 4, 5, 6.
- Other risk factors for anal dysplasia include a history of abnormal cervical Pap smear, cervical intraepithelial neoplasia, cervical cancer, and high-risk HPV 6.
- Behavioral risk factors, such as anal intercourse, smoking, and having multiple sexual partners, also increase the risk of anal dysplasia 6.