The THOMAS Study: A Pilot Study for Patient-Administered Anal Cancer Screening.

Offer anal cancer screening only where there is capacity to perform high-resolution anoscopy (HRA) and to treat what it finds. Screening is RECOMMENDED for: MSM and transgender women with HIV, beginning at age 35; all other people with HIV, and MSM and transgender women without HIV, beginning at age 45; solid organ transplant recipients, beginning 10 years post-transplant; and persons with a history of vulvar HSIL or vulvar cancer, beginning within 1 year of that diagnosis. Screening may be CONSIDERED via shared decision-making, and only where HRA capacity is adequate, for persons aged 45 or older with a history of cervical or vaginal HSIL/cancer, perianal warts, persistent (>1 year) cervical HPV16, or autoimmune conditions. Screen with anal cytology alone, high-risk HPV testing alone (with HPV16 genotyping), or hrHPV-cytology co-testing, all three perform acceptably; HRA is the DIAGNOSTIC procedure for an abnormal screen, not itself a screening test. Perform digital anal rectal examination as part of the physical exam at every screening visit. Refer immediately to HRA for any abnormal cytology, ASC-US or worse, when screening is by cytology alone, since there is no hrHPV result available to triage it; for ASC-US or worse cytology accompanied by a positive hrHPV result on co-testing; for ASC-H or HSIL cytology regardless of HPV result; and for any HPV16-positive result regardless of cytology. Repeat screening in 12 months after NILM cytology alone or a negative HPV test alone, or after ASC-US cytology with negative hrHPV; repeat in 12-24 months after co-testing that is both NILM and hrHPV-negative. Where HRA capacity is reduced, restrict immediate referral to ASC-H/HSIL cytology and to HPV16-positive results, and manage the remainder with repeat screening. Treat HSIL found at HRA-directed biopsy rather than observing it: in ANCHOR, treatment reduced progression to invasive cancer by approximately 57% in people with HIV aged 35 and older.