Digital ano-rectal exams (DARE) are standard of care for persons with HIV in the US given high anal cancer incidence; however, they are underutilized [1,2]. In order to increase utilization, we set out to determine if it is possible that men having sex with men (MSM) might be able to report accurate findings after performing a self- (or partner-assisted) anal exam (SAE). Earlier detection of tumors should reduce anal cancer morbidity and mortality.
We conducted a feasibility study among 155 MSM, aged 27-80 years. A clinician skilled in performing DARE used a pelvic model to train participants in anal anatomy, the detection of abnormalities (i.e., hemorrhoids, warts, fissures, and tumors), and performing an SAE. Then, the clinician performed a DARE (without immediately disclosing results), and the man (or couple) was left in private to perform a self-anal exam (or partner-assisted anal exam). Men recorded a normal or abnormal finding, and completed a questionnaire. Percent agreement and Cohen’s kappa assessed concordance between clinician’s DARE and lay person’s SAE results. A colorectal surgeon verified the clinician’s results in a subset of men.
Men had a median age of 52 years, 17% were Latino, 48% were African American, and 64% were HIV-positive. Only 21% reported a DARE in the prior year. Over 95% of men classified the health of their anal canal correctly. Couples had almost perfect concordance with the clinician (kappa=0.84) while singles had fair concordance (0.23). Both singles’ and couples’ kappa was statistically better than the null of “no agreement” between clinician and participant (p<0.001). Clinicians’ DARE observed 7 abnormalities while the men’s SAEs noted 5 of these (71%). The 2 men who missed the abnormality had 3mm nodules/masses. The 5 men who correctly reported the abnormality had masses 4 mm or larger or hardened scars. Of 10 men who claimed an abnormality when there was no palpable pathology, the clinician’s DARE determined that 5 likely palpated stool. More than half (63%) of men reported never checking their anus for an abnormality; however, after performing an SAE, 96% said they would do it regularly if it was recommended (most opting for every month or every few months). Over 90% of men reported the procedure was acceptable and reported confidence in their ability to detect an abnormality. A majority (60%) said they would prefer to do their own SAE rather than go to a doctor for a DARE.
These results suggest that tumors of ≥4mm may be detectable by self-palpation among MSM and are encouraging given literature suggesting a high cure rate for anal cancer tumors ≤10mm.[3]
[1] New York State Department of Health-AIDS Institute: HIVQUAL-US. (2013). HIVQual-US Annual Data Report.
[2] Ong, J., Chen, M., Temple-Smith, M., Walker, S., Hoy, J., Woolley, I., Grulich, A., & Fairley, C. (2013). The inside story. Physicians' views on digital ano-rectal examination for anal cancer screening of HIV positive men who have sex with men. J Med Screen, 20(4), 188-191. doi: 10.1177/0969141313515463
[3] Ortholan, C., Ramaioli, A., Peiffert, D., Lusinchi, A., Romestaing, P., Chauveinc, L., Touboul, E., Peignaux, K., Bruna, A., De La Roche, G., Lagrange, J.L., Alzieu, C., & Gerard, J.P. (2005). Anal canal carcinoma: Early-stage tumors ≤10 mm (T1 or Tis): Therapeutic options and original pattern of local failure after radiotherapy. Int J Radiat Oncol Biol Phys, 62(2), 479-485.