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The incidence of anal cancer is higher in women than men in the general population and has been increasing for several decades. Similar to cervical cancer, most anal cancers are associated with human papillomavirus HPV and it is believed that anal cancers are preceded by anal high-grade squamous intraepithelial lesions HSIL. Our goal was to summarize the literature on anal cancer, HSIL and HPV infection in women, and provide screening recommendations in women.

Anal HPV infection is common in women but is relatively transient in most. The risk of anal HSIL and cancer varies considerably by risk group, with HIV-infected women and those with a history of lower genital tract neoplasia LGTN at highest risk compared with the general population.

While there are no data yet to demonstrate Did naomi do anal identification and treatment of anal HSIL leads to reduced risk of anal cancer, women in groups at the highest risk should be queried for anal cancer symptoms and have digital anorectal examinations to detect anal cancers. Healthy women with no known risk factors or anal cancer symptoms do not need to be routinely screened for anal cancer or anal HSIL.

The overall objective of this report is to summarize current knowledge of anal cancer, anal squamous intraepithelial lesions ASIL Did naomi do anal anal HPV infection in different risk groups of women, and provide recommendations for screening women for anal disease, based on expert opinion.

Introduction

The incidence of anal cancer has been increasing in the general population of women Did naomi do anal the last few decades, but the risk of anal cancer varies considerably by risk group. Although not yet proven in formal randomized controlled trials, like cervical cancer, anal cancer may be potentially preventable through screening to detect and treat anal precancerous lesions.

Given the variation in risk for anal cancer, ASIL and anal HPV infection, it is likely that an anal screening program would benefit some groups of women more than others. Three groups for investigation were created based on consensus discussions: Literature search were performed using key words ie. Each group also identified important articles that were missing from the searches.

Each group initially reviewed all the abstracts generated by the search and if any appeared Did naomi do anal, articles were then reviewed in detail.

More recent articles within 10 years were considered priority for review although it was recognized several articles were seminal and worthy reference. Reviews of the literature were summarized with relevant statistical comparisons. Recommendations from each group were based on the available evidence wherever possible, and on expert opinion. Health benefits, side effects, adverse effects, risks and available clinical expertise were all considered in formulating the recommendations to the degree that this information was available.

No literature was available on patient views or preferences. A formal cost-benefit analysis was not possible and was not done.

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Final recommendations were reviewed by all authors and agreed upon. The sponsoring organizations, the ASCCP and the International Anal Neoplasia Society did not influence the content of the review or the recommendations, nor did any commercial entity. Anal cancer is a rare disease comprising only 0. In there will bean estimated new anal cancer cases "Did naomi do anal" deaths.

Non-squamous anal cancers include adenocarcinomas some of which may be misclassified rectal adenocarcinomas extending into the anal canal and melanomas. In the US, the incidence of anal cancer has been increasing steadily over the last decade, rising approximately 2. Although HIV is known to contribute to the rising incidence in males, the reasons for these increases in the general population of women is less clear. Death rates have also been rising on average 1. Overall, anal cancer is diagnosed in slightly more women than men.

An estimated women in the US will be diagnosed with anal cancer in and will die of their disease.

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Anal cancer is also a cancer of older individuals with a peak in those aged years and a median age for diagnosis of 60 years. Persistent infection with the same HPV type is a necessary intermediate step between infection and cancer. However, several differences are worth noting.

Despite similar high HPV infection rates in the cervix and anal canal in young sexually active women see below for further discussioncervical cancer is 4 times more common than anal cancer with an incident rate of 7. Prior to cervical cancer screening, cervical cancer had an incidence of 35 perWithout prospective longitudinal data regarding the incidence and duration of anal HPV, including regression and transience of infection, establishing temporal causality has not been possible.

Establishing HPV as the causative agent for cancer using criteria proposed by Hill 9 is not as strong for anal cancer and other anogenital carcinomas as it is for cervical cancer. The Hill criteria include defining a temporal relationship between infection and disease, biologic gradient, plausibility, coherence and experimental evidence. Additionally, there are no large prospective pathologic repositories from which to define the natural history of progression of anal precancers to invasive anal cancers.

As rectal and anal cancers likely have different etiologies, these limitations result in inaccurate estimates of HPV-associated anal cancers. For purposes of this review, cytology results are reported as anal squamous intraepithelial lesions SIL and histopathologic diagnoses are reported as anal intraepithelial neoplasia AIN. Although anal cancer is rare in the general population, there is growing literature examining anal HPV infections in healthy women.

No large scale studies have been performed to date, so much of Did naomi do anal literature is based upon selected cohort studies. These provide useful information but may not be representative of or generalizable to the wider community. Several cross-sectional studies have reported high rates of anal HPV infection in young women. In one of the largest studies of healthy women, the Hawaiian cohort study, ethnically diverse healthy women over 18 years mean 38 years were recruited from clinics and provided cervical and anal specimens for HPV detection.

Women with a cervical infection had a greater than 3 fold increase risk of anal infection. Anal intercourse AI was associated with anal infections but only for those without a concomitant cervical infection. The distribution of HPV genotypes in the anus was more heterogeneous than in the cervix and there was a greater proportion of low risk HPV types. Detection of anal HPV was also associated with higher lifetime and recent numbers of anal and vaginal sex partners, younger age at first anal intercourse, and history of Chlamydia and anogenital warts.

Another cross-sectional study reported on the control arm of the Costa Rica HPV vaccine trial 12 in which women aged years provided a single anal swab sample at year 4 for HPV analysis. All had been sexually active. Overall anal and cervical HPV prevalence were high, Anal hrHPV prevalence was HPV 51 and 52 were the most common HR types.

Multiple infections were common. Concurrent cervical HPV infections were present in One of the first prospective studies of anal HPV infections published was by Goodman et al 13 These investigators followed women from the Hawaii cohort described above. The incidence of hrHPV infection was For HPV 16, enrolment prevalence was 4. Non-viral risk factors included younger age, white ethnicity, lower socio-economic status, greater number of lifetime Did naomi do anal partners, past use of noncontraceptive estrogens and condom use.

Actual risk varied whether acquisition was high risk, low risk or any HPV type. Further analysis 14 showed a relative risk of They also found an increased risk of 8.

In addition, risk of anal infection was enhanced by the presence of multiple HPV Did naomi do anal in the cervix. Few studies have examined clearance of HPV. Shvetsov et al 16 evaluated clearance patterns of anal HPV infection for of these same Hawaiian women.

Relative Hazards varied by HPV type. In contrast, Moscicki et al 17 found anal HPV 16 slower to clear than other hrHPV infections in their study of 75 young women mean age This slower clearance was likely due to the longer observation period mean follow up was 85 months and the stricter definition of clearance i. Relative hazard varied by HPV type. A change in sexual partner was associated with HPV 16 clearance, probably reflecting cessation of re-exposure and infection by the previous partner.

Compared with studies of anal HPV detection, data on the prevalence, incidence and risk factors for anal squamous intraepithelial Did naomi do anal SIL in healthy women are extremely limited. No studies have been performed in a truly population-based sample of U. As with anal HPV infection, most studies of anal SIL have been done in groups of women known to be at increased risk of anal cancer, including those with HIV infection, other forms of immunosuppression, and presence of cervical or vulvar HPV-associated lesions see Sections on Immunosuppresion and Lower Genital Lesions.

Most of the control groups were considered to be at high risk of HIV infection since they often had histories of drug abuse or numerous sexual partners. One such study of HIV-infected and uninfected adolescents and young women found a prevalence of abnormal anal cytology of 5.

Women who agreed to anal testing had annual anal cytology. Two studies that focused on women with lower genital tract neoplasia LGTN described below also included a control group of healthy women. Koppe et al 21 performed screening high resolution anoscopy HRA and HRA-guided biopsy, if applicable, on 74 healthy women with Did naomi do anal cervical cytology and no history of genital warts recruited from a gynecologic practice.

Healthy controls had at least 2 recent normal cervical cytology tests interval not described and normal genitoscopy. All women had colpscopy and HRA. Since neither of these studies performed anal cytology nor random biopsies, the prevalence of AIN may have been underestimated see below for discussion of HRA. In summary, although anal cancers Did naomi do anal rare in healthy women, the prevalence of anal HPV of one or more genotypes is common in healthy young sexually active women and is comparable to the prevalence of cervical HPV, if not greater.

Genotype concordance with the cervix is common; therefore, the cervix may act as a reservoir for anal infection or vice versa. Most anal HPV infections are transient, consistent with the low rate of Did naomi do anal cancers in healthy women. Persistence of anal HPV is influenced by co-existing cervical infections, alcohol use, and lack of condom use.

Investigation of the natural history of anal HPV infections in healthy women is hampered by patient selection biases, frequent incident infections, and multi-type infections. The rate of progression of untreated high-grade AIN in healthy women is not known. Since anal cancer rates are much lower than cervical cancer, it is not clear if the same rates can be applied to high-grade AIN. However, the increasing rates of anal cancer among women underscores the importance of identifying women with high-grade AIN and studying factors associated with progression.

Host immune response is critical in containing almost all viral infections and HPV is no exception. Although the immune response is complex, the predominant immune arm important in clearance of established HPV infections is thought to be the cell-mediated pathway primarily involving T-cells.

The association between HPV and immune dysfunction was first noted in immunosuppressed patients including transplant patients noted to have an increased risk of developing warts.

"Did naomi do anal" best studied of the immunosuppressed groups are persons with HIV infection. Numerous studies now demonstrate a strong association between HIV infection and anal cancer. Incident anal cancer was ascertained from medical records, patient interviews or linkage with cancer registries. They also compared time periods before Did naomi do anal after the availability of highly active anti-retroviral therapy HAART.

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