Anorectal Carcinoma Screening in Gay Men: Implications for ...



Anorectal Carcinoma Screening in Gay and Bisexual Men: Implications for Nurse Practitioners in University and College Health Practices

Christopher W. Blackwell, Ph.D., ARNP-C

Assistant Professor, School of Nursing

College of of NursingHealth & Public Affairs

University of Central Florida

PO Box 162210

Orlando, FL 32816-2210

Leslee A. D'Amato-Kubiet MSN, ARNP

Instructor

College of Nursing

University of Central Florida

(407) 823-2517 (voice)

(407) 823-5675 (Fax)

cwblackw@mail.ucf.edu

KEYWORDS: ANAL CANCER, ANORECTAL CARCINOMA, COLLEGE STUDENTS, GAY MEN, HEALTH DISPARITIES, PAPANICOLAOU SCREENING

ABSTRACT

Although the overall prevalence rate of anorectal carcinoma is relative low in the general population, among gay and bisexual men, the rates are much higher among gay and bisexual men. Nurse Practitioners (NPs), working in college- and university-based practices are in a unique position to help decrease the frequency of the disease among gay and bisexual men through the application of proper screening techniques, specifically, the anal Papanicolaou (Pap) cytology screening. This article examines the role of the NP in university practice settings in screening anorectal carcinoma among gay and bisexual men. Data regarding the prevalence of anorectal carcinoma among gay men is presented along with applicable techniques for completing a thorough health history, performing a physical examination, and obtaining an anal cytology Pap smear. Finally, implications are provided for future research and the education of future NPs working in this field.

Introduction

Gay and bisexual men present unique health concerns to the United States healthcare system23. Health disparities pertinent to this population include higher incidences of infection with HIV/AIDS; higher rates of substance abuse, including alcohol and tobacco; greater risk of depression, anxiety, and suicide; higher prevalence of hepatitis and other sexually transmitted diseases; and increased risk of developing prostate, testicular, and colon/anorectal cancers23.

While no critical inquiry has assessed the precise number of gay or bisexual men on university/college campuses, it is estimated that approximately ten percent of the American population identifies their sexual orientation as non-heterosexual13. The American College Health Association (ACHA) has identified gay, lesbian, bisexual, and transgender (GLBT) health issues as a top priority in their cultural competency statement regarding non-discrimination21. ACHA indicates that campus climates supportive of equality and tolerance promotes the overall health of the college21.

The mandate for the creation of inclusive environments reaches far beyond the health setting. It is the responsibility of American colleges and universities to create an environment of equal access for all students, regardless of cultural differences; their emphasis should go beyond tolerance and focus on valuing multiculturalism22. Yet research suggests the climate on university and college campuses for GLBT students is proliferated with discrimination and inequality. A comprehensive assessment of campus climate for GLBT students found more than one-third (36%) of all undergraduate students have experienced harassment within the past year; twenty percent feared physical violence directed toward them; and more than half (51%) conceal their sexual orientation or gender identity to avoid intimidation22. Perhaps of even greater significance, forty-one percent of study participants stated their college/university was not addressing issues related to sexual orientation and gender identity22.

These findings highlight the significant duty of university/college health nurse practitioners (NPs) in reducing health disparities in gay and bisexual men. NPs working in universty/college health should assess the sexual orientation of every client and identify certain health risks condign to that orientation. In addition, NPs need to apply appropriate health promotion and disease detection strategies aimed at reducing rates of anorectal cancers in gay men. To detect anorectal carcinoma, men who have sex with men (MSM) should be receivingOne of these is annual Papanicolaou (Pap) screenings of men who have sex with men (MSM) to detect anorectal carcinoma anuall.y24.

Prevalence of Anorectal Carcinoma among Gay Men

The prevalence rate of anal carcinoma is relatively low in the general population, with an estimated at 0.9 cases per 100,0001. However, the rate is estimated to be much higher among gay and bisexual men. Aamong men who have sex with men (MSM), the prevalence rate is estimated to be as high as 35 per 100,0002,3,4. This prevalence rate finding directly mirrors the rate of uterine cervix carcinoma prior to the widespread implementation of cervical Pap screening4.

While the precise etiologic mechanism for the increased development of anal carcinoma among gay men is unknown, current research supports a link between ongoing sexual exposure to the human papillomavirus (HPV) and the consequent development of anorectal cancer5. Data suggests that gay men have an increased number of lifetime sexual partners and receptive anal intercourse6. In addition, several reasons for sexual risk-taking behaviors have been identified among this population, including AIDS burnout, low self-esteem, lack of peer support, and lack of access to preventative services7. Sexual risk-taking behaviors can increase opportunities for sexually-transmitted infections including the human immunodeficiency virus (HIV) and HPV, both of which have higher prevalence in gay men compared to heterosexual men8,3. Current estimates indicate that between 60%-75% of men who have sex with men are infected with HPV8.

Receptive anal intercourse can also provides a mechanism for infection with HPV, including; subtypes 16, 18, 31, 33 and 35, which are associated with neoplasia9. Other anal-insertive sexual practices among gay men are also believed to be potential risk factors for anal carcinoma10. Infection with the Human Immunodeficiency Virus (HIV) is associated with greater risk or HPV exposure and infection5; 63%sixty-three percent of all new HIV and Acquired Immunodeficiency Syndrome (AIDS) diagnoses are among men who have sex with men11.

Analogous to the pathophysiology of exposure to HPV and subsequent clinical development of cervical and uterine cancers in females, malignant cellular changes associated with exposure to HPV have been shown to occur in the male rectum25, 26, 27. Because most infections with HPV are asymptomatic and no diagostic test exists which can detect the presence of HPV26, 27, cytology screening to detect occult presence of abnormal and potentially cancerous cells is of paramount importance. In addition, because clients often correlate HPV infection with genital warts and may do not want to discuss screening with their provider in the absence off they do not have genital lesions;, the this makes education of the client about the importance of an annual Pap screening necessary. NP must be educate the client about the necessity for an anal Pap test.

If administered to identified high-risk populations, annual anal cytology screenings have been predicted to be both cost effective and clinically effective9. Annual anal Papanicolaou (Pap) screenings in HIV-positive gay men would could result in incremental costs of $16,600 per adjusted life year saved, which is comparable to other preventative health screenings9. Nurse Practitoners (NPs) working in primary care or infectious disease are especially poised to reduce this health disparity among homosexual men. While it is often difficult to approach sensitive issues related to human sexuality, it is essential. for the NP to adequately assess a client’s sexual orientation to help prevent illnesses with higher prevalance rates among gay men, including anorectal carcinoma.

Because data suggest the majority of GLBT college and university students conceal their sexual oreintation identity to avoid mistreatment and harrasment, it becomes the responsibility of the NP to create an open and supportive environment which promotes the client’s ease in discussing issues pertinent to sexuality and disease associated with sexual contact and activity. Asking of health history questions related to sexuality is often challenging for practitioners. Perhaps of most importance is the approach that is non-judgmental and provides respect and empathy for the client28.

Approaching the Sensitive Topic of Sexual Orientation

Most researchers experts suggest that practtioners approach the questioning of a client’s sexual orientation in a direct manner, ascertaining if the client has sexual relationships with men, women, or both13,14. Using the term “sexual preference” is not recommended, as this implies the individual made a choice regarding his sexual orientation15. Statements which are leading or imply judgment or which are leading are inappropriate; for example, questions such as “You aren’t gay, are you?” or “Do you have a wife?” are to be avoided. Instead, non-biased questions such as, “Do you have sexual relationships with men, women, or both?” or “tell me about your sexual partners” are more effective13. Estimates indicate that up to 10% of the American population have a sexual orientation other than heterosexual13; the NP must not assume a client’s sexual orientation, either heterosexual, homosexual, or bisexualmake the assumption of a client’s sexual orientation as either heterosexual, homosexual, or bisexual13.

Screening Gay Men for Anorectal Carcinoma during the Comprehensive Health History

Along with identificiation of a client’s sexual orientation, it is imperative to also screen the client for high-risk sexual activities which may increase his risk of anorectal carcinoma. The NP needs to investigate and document the client’s safer sex practices, frequency of anal intercourse, number of sexual partners over the last 12 months, consistency of condom use of partners and self, history of sexually-transmitted infections (STIs), Human Immunodeficiency Virus (HIV) serum status, date of last HIV serum screening, frequency of HIV screening, prescription drug regimens, and ilicit drug use, and alcohol, and tobacco use.

In addition, the NP should establish a the client’s baseline knowledge level of the client regarding annual Pap cytology screening and identify psychosocial influences which may decrease the likelihood of the client obtaining an annual anal Pap. The health history must contain specific commentsshould also be specific toward changes in GI routines and habits; the NP should must inquire as to bowel habits, passage of mucus and blood, abdominal pain, weight loss, and family or personal history of gastrointestinal diseases16.

Research indicates that individuals infected with HIV are at much higher risk for anorectal cancers than HIV-negative men5. HIV+ men are more likely to have lower functioning immune systems, making immunosurveillance of HPV and neoplasms less effective. Thus, wWhile screening for anorectal carcinoma is paramount for all gay men, it is especially important for those infected with HIV. Data indicate that gay men have an increased number of lifetime sexual partners with receptive anal intercourse, thus heightening their opportuunity for exposure and risk for contracting HPV6.

By assessing the client’s number of sexual partners over the course of a 12-month period, Therefore, the NP can make a direct correlation between a client’s number of sexual partners over the course of a 12-month period withfor an increased risk of possibly contracting HPV, the precursor of anorectal carcinoma. Although condom use should be encouraged and reinforced by the NP, there is an overall lack of data supporting the efficacy of condoms at preventing HPV17; this negates the belief that individuals who consistently use condoms with their sexual partners are at lower risk of HPV.

Certain sexual practices, which may not be common amongspecific to gay men, also need to be addressed during the health history. For example, the insertion of methamphetamine (meth) into the rectum, a practice known as “booty bumping” is also believed to be a potential risk factor for anal carcinoma10. Meth use, in general, is more praevaelent in the gay community18; use of meth has been associated with suppression of highly active antiretroviral therapy (HAART) among HIV+ males, thus increasing the risk of infection with STIs, including HPV18. This highlights the importance of obtaining a thorough history of ilicit and prescription drug use by the client. While it is important to obtaindocument history related to a client’s intake of alcohol, inquires have failed to correlate alcohol use with unprotected anal intercourse19.

There is a significant lack of data assessing the impact of psychosocial influences on obtaining an annual anal Pap screening. However, the NP can assess knowledge deficits and misconceptions the client might have regarding the Pap screening and alsos well as educate the client regarding the purpose, frequency, and effectiveness of the test. Although researchers vary in their recommendation of frequency of Pap screenings among gay men, both annual and biannual screenings have been demonstrated as being cost-effective, particularly among HIV+ gay men12.

Physical Examination Findings of Anorectal Carcinoma

Physical assessment findings may include gross lesions visible on the exterior surface of the anus; however, visible findings are not always present9. Other pPhysical examination findings which may indicate possible malignancies includeincluse polypoid masses, or more commonly, which are possible malignancies; another common form ofthe presentation is of a firm, nodular, rolled edge of an ulcerated malignancy. Diffuse peritoneal metastases from any source may develop in the area of the peritoneal reflection, just anterior to the rectum. In some cases, Aa firm to hard nodular rectal shelf may be just palpable with the tip of the examining finger20.

The elusive nature of anal carcinoma to be detected via inspection and its often asymptomatic presentation causes most diagnoses to be missed, increasing the risk of preinvasive disease9. Because the cells which line the female cervix share similar physiologic characteristics to the cells which line the anus9, the Papanicolaou (Pap) screening test, typically used to detect the presence of cellular dysplasia among cervical tissue, is also employed to detect dysplasia in the cells which line the anus9,5.

Obtaining an Anal Pap Cytology Screening

The technical procedure for obtaining an anal Pap smear is fairly similar to that of obtaining a cervical smear. The NP should use a Dacron cotton swab; wooden sticks are to be avoided because of their increased tendency to splinter and break3. The male should be placed in the lateral recumbent position. Without direct visualization, the swab should be inserted approximately 5-6 cm. The NP should apply direct, firm, lateral pressure on the swab handle while rotating and slowly removing it from the anal canal. The NP should ensure that the transition zone, where columnar epithelial cells of the rectum separate from the keratinized cells of the anal mucosa, is sampled, as data suggest most anal intraepithelial neoplasms arise from this zone2.

The recommended preservation method is Liquid liquid cytology is the recommended preservation method; t. This eradicates the chance for artifact from drying and also decreases the amount of fecal matter and bacteria that can interfere with interpretation of the cytological sample3. Although not preferred, air-dyring and fixation can be applied if liquid cytology is impossible. Pathological screening for atypical squamos cells of undetermined significance (ASCUS) is essentially the same as that employed to interpret HPV-related lesions of the cervix3. If a client’s anorectal screening indicates ASCUS or higher, he needs to be referred to an anorectal specialist for an anal colposcopy using both anoscope and colposcope3.

Summary and Conclusion

Given the unique holistic relationships Nurse Practitioners have with their clients, they are posied to promote cancer screening techniques that reduce overall morbidity and mortality of high-risk populations, including the gay or bisexual male college/university student. This article has explored the higher prevalence rates of anorectal carcinoma among homosexual men compared to heterosexuals and has also discussed etiologic considerations and the importance of annual Pap screening among this group. Along with a comprehensive health history, considerations, limited physical examination findings were also provided. Directions on how to perform the tehcnical procedure for obtaining an anal cytology sample were specifically outlined.

While this inquiry has focused primarily on HPV and anorectal carcinoma screening, NPs in college and university based health practices have the opportunity to serve as client advocates and be leaders in decreasing the diaparity of diseases in GLBT clients. A top priority for the American College Health Association is reducing health disparities among minorities29. To help meet this objective, clinicians should apply evidence-based interventions which have the potential to reduce specific diseases among vulnerable populations. Data have supported anorectal screenings as both cost effective and clinically significant in detecting malignancies9. However, much more data is needed.

Consideration for Future future research studies should focus on current psychosocial barriers which may be preventing gay men from obtaining Pap screeings. In addition, there has been very little inquiry assessing NP attitudes toward or knowledge of the use of Pap screenings to detect anorectal carcinoma in gay men. Advanced practice curricula needs to emphasize the health disparities that exist among gay men, ;specifically higher rates of HPV infection and anorectal carcinoma. In addition, cultural competency topics taught in graduate education need to include applicable content areas condign to gay, lesbian, bisexual, and transgender (GLBT) individuals.

In conclusion, while data suggest that anorectal carcinoma rates are increasing among gay males, through dilligent health promotion, prevention, and screening strategies, NPs can help reverse this trend. Early detection of malignancies can yield better health outcomes by allowing interventions to begin sooner. By applying evidenced-based methods, NPs can effectively reduce the morbidity and mortality rates within this vulnerable population. College- and university-based practitioners have the unique position to serve as advocates and leaders in promoting anorectal Pap screenings as a standard of care for gay and bisexual male clients who utilize college/university-based health services. Closing paragraph needs to mention something about possibilities of treatment for early detection. It is mentioned earlier in the paper, but does not carry through. The whole idea is early detection, like for cervical pap’s.

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