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A smear in the rear

Gay men at a greater risk for anal cancer, pap smears recommended for detection

By Anthony Martinez Beven

Originally printed 5/28/2009 (Issue 1722 - Between The Lines News)

Ask Dr. Paul Benson, a Berkley-based general practitioner, about anal cancer and you'll learn some things you didn't know - mainly that the incidence rate among gay men greatly exceeds that of heterosexual men, as well as the occurrence of cervical cancer in women.

Like cervical cancer, the Human Papillomavirus causes anal cancer. Benson said he diagnoses one to two anal cancer cases each year, "and that's a lot."

In general, gay men are at a 35 times higher risk for developing anal cancer when compared to the rest of the population, according a study published in The New England Journal of Medicine.

The risk for HIV-positive gay men is more than doubled.

"It's increasing year after year," Benson said of national anal cancer rates among gay men. Additionally, more are dying from it, because many don't know to ask about it, and most doctors don't know to check for it, he confirmed.

Statewide, there were 283 cases of anal cancer among men between 2000 and 2005, according to the most recent data collected by the Michigan Department of Community Health. The state health department does not separate cases by sexual orientation, said Georgia Spivak, a statistician specialist.

Anal cancer is localized to the first six inches of the large intestine, while colon cancer affects up to six feet of the large intestine, according to the Center for Colorectal and Pelvic Floor Disorders at the University of Southern California.

Benson works with non-profit organizations, such as the Midwest Aids Prevention Project, on anal cancer awareness and also gives informational presentations at local physician conferences about once a year, he said.

"A lot of doctors aren't educated to look for it but that's increasing," Benson said.

Origin and diagnosis

Dr. Jon Hain, a proctologist and colorectal surgeon with Colon/Rectal Specialists of Southeastern Michigan, said gay men who have contracted HIV through anal receptive intercourse are also likely to have other sexually transmitted diseases, such as HPV.

HPV affects approximately 65 percent of HIV-negative gay men, and nearly 95 percent of HIV-positive gay men, according to New England Journal study. Condoms only provide about a 50 percent protection rate against HPV, Benson said.

There are approximately 100 different strains of HPV, also called genital warts, but only nine strains are known to cause anal cancer, Benson said. Getting HPV depends on the health of someone's skin and immune system, as well as the extent of exposure, he added.

"The warts are painless and can often be confused for hemorrhoids," Benson said. Larger genital warts are less likely to become cancerous, while smaller warts are more likely to turn cancerous, he said.

The only detection method for anal cancer that currently exists is an anal pap smear, which is identical to the vaginal pap smear for women, Benson said. He performs between 100 and 150 anal pap smears a year.

"There is no standard protocol to check men for anal cancer. If we had an active screening program, we'd pick it up earlier before it turns into cancer," Benson said. "Doctors think about checking women for cervical cancer with annual pap smears, but not with men."

There are five stages of anal cancer, according to the American Cancer Society, and most gay men diagnosed in the later stages of this cancer type, Benson said.

Treating anal cancer

Treatment for anal cancer typically involves chemo and radiation therapy, according the Center for Colorectal and Pelvic Floor Disorders. Surgery is not usually required for anal cancer.

Hain said surviving anal cancer is depends on a variety of factors, one of which is, unfortunately, socioeconomic status.

"A lot of the men I treat have health insurance, so patients I see with this disease have pre-cancer conditions," he said, adding preventative health care isn't available to everyone, particularly those in urban areas.

"It's all about access to appropriate health care," Hain said.

The New England Journal study says that gay African-American men have experienced the sharpest increase in anal cancer cases and have the lowest survival rates. More African-American men get anal cancer than any other race, according to the Centers for Disease Control and Prevention.

Hain said that the HPV vaccine, primarily marketed for women, may also be applicable to gay men. Merck, the company that produces the only HPV vaccine, Gardasil, is seeking approval from the U.S. Food and Drug Administration for use among boys and young men, the Wall Street Journal reported.

"There is a big push to use it for men, especially men who engage in anal receptive intercourse, and recent studies are showing that it's starting to help," Hain said.

Benson said most insurance companies cover the costs associated with HPV vaccine, but only for women, the only FDA-approved vaccination group. The vaccine, which must be taken in a series of three doses, costs a total of $360, or $120 per dosage.