Of the over 80 types of human papilloma virus (HPV) that have been identified, only certain strains are oncogenic (cancer-causing). At the Community Forum on May 12, Dr. Lester Gottesman and Mary Jo Hoyt stressed that anal and cervical cancer are totally preventable in HIV-negative and HIV-positive people, and that in a developed country where screening tests are available, there should be no reported cases of either condition. Both speakers discussed the cancer screening and prevention strategies that should be used by people living with HIV. When followed diligently, these strategies are extremely effective.

The HPV-Cancer Connection

Certain strains of human papilloma virus can infect the cells that line both the anus and the vagina, and the virus is transmitted by direct contact (sexual or other contact). After infection, the virus lies dormant (inactive) underneath the surface of the skin in a layer of the skin called the papilla. An outbreak of genital warts caused by HPV occurs when stress rises, leading to increased propagation of the virus. Wart particles are then assembled in the top layer of the skin. If an individual is infected with a cancer-causing strain of HPV, and the HPV infection is not treated, the condition can progress to cancer. There are currently approximately 1.4 million clinical cases of HPV warts in the United States, with an estimated 5 million subclinical cases (people who have not been diagnosed).

The Basics of HPV

• HPV stands for Human Papilloma Virus
• Over 80 types of HPV have been identified.
• An individual can be infected with many different strains of HPV at the same time.
• HPV can cause warts (also known as papillomas) in the genital areas or the anus.
• Some strains of HPV lead to cancer (both anal and cervical); others do not.
• HPV warts are highly contagious; the virus is spread through sexual intercourse or any direct contact with a wart.
• The strains of HPV that most frequently cause cancer are strains 16 and 18.

Preventing Anal Cancer

Dr. Gottesman made suggestions for the prevention of anal cancer:

• Have an anal exam every two months in order to detect warts.
• Destroy warts as necessary.
• Have anal pap smears regularly - The doctor removes cells from the lining of the anus to check for abnormal (cancerous or pre-cancerous) cells.

Dr. Gottesman explained that there are two approaches to remaining cancer-free after the discovery of abnormal cells in an anal pap smear. One approach is to remove all abnormal cells, essentially stripping the lining of the anus. This surgical procedure is painful, and in Dr. Gottesman's estimation, unnecessary if the cells are not cancerous. In the 10 years that he has been following HIV-positive patients, no patients with abnormal cells found in an anal pap smear have progressed to anal cancer. Dr. Gottesman follows his patients carefully, removing warts and pre-cancerous lesions as they occur, but he never removes all abnormal cells.

If a patient presents with anal cancer, the standard treatment is a combination of chemotherapy (drug treatment) and radiation therapy (either internal or external). A patient is more likely to recover if his or her immune function is still relatively intact (more than 200 T-cells are present).

Questions and Answers for Dr. Gottesman

Q: You suggest an anal exam every 2 months. Who should perform this exam? A primary care provider or a colon/rectal surgeon?

A: Many well-meaning dermatologists and primary care providers are not able to provide comprehensive screening, either because they lack the proper tools for detecting warts or because they are not able to treat warts if any are found. It is best to have a colon/rectal surgeon perform these screening visits.

Q: Are warts in the vagina and the anus the same? Is cancer necessarily present?

A: Yes, HPV infects both areas, but does not necessarily lead to cancer. Cancer of the vagina/cervix and anus is totally preventable.

Q: Can we use the HPV vaccine in people who are already infected with the virus?

A: The newest treatments being developed for HPV are the antisense compounds, which prohibit the assembly of warts in the upper layer of the skin. These compounds are currently in clinical trials.

Q: Have you seen a decrease in pre-cancerous lesions in people who have done well on HAART?

A: Yes, the increased immune function is beneficial.

Cervical Cancer: Preventable with Pap Smears

In her presentation, Mary Jo Hoyt emphasized that HPV infection and the warts that can result are not as easy to detect on the cervix as they are in the anus. For this reason, regular pap smears are essential for detecting abnormal cells and preventing cervical cancer. A pap smear is a simple procedure in which a physician obtains cells from the surface of the cervix, using a special brush to collect a sample of cells from the area where most cancers begin to develop. The cells are placed on a slide and are examined with a microscope to check for abnormalities. The cervical pap smear is the only cancer screening test in the world that has decreased both the number of cases of a cancer and the number of deaths related to a cancer.

HIV-positive women should have two pap smears in the year of their diagnosis. If both smears are normal, pap smears can be performed annually.

Interpreting Pap Smear Results

If a pap smear detects the presence of abnormal cells, there are several different classifications for the abnormal cells. These classifications are:

• ASCUS - ASCUS stands for atypical squamous cells of undetermined significance. Persistent ASCUS results are often further evaluated by a physician through a process called colposcopy. A colposcopy is a magnification of the cells of the cervix in order to pick out cells to biopsy to determine if any cancerous cells are present.
• Dysplasia - In dysplasia, cervical cells undergo a series of changes in their appearance. The cells look abnormal under the microscope, but they do not invade nearby healthy tissue. There are three degrees of dysplasia, classified as mild, moderate, or severe.
• HSIL/LSIL - SIL stands for squamous intraepithelial lesion (SIL). HSIL describes high-grade SIL, while LSIL describes low-grade SIL. A squamous intraepithelial lesion is another term that is used to describe abnormal changes in the cells on the surface of the cervix. HSIL indicates a large number of precancerous cells, while LSIL describes early changes in the size, shape, and number of cells.
• CIN - CIN is another term that is sometimes used to describe abnormal cells. The term CIN, along with a number (1 to 3), describes how much of the cervix contains abnormal cells.
• Carcinoma in situ - Carcinoma in situ describes a pre-invasive cancer that involves only the surface cells and has not spread into deeper tissues.
• Cervical cancer, or invasive cervical cancer, occurs when abnormal cells spread deeper into the cervix or to other tissues or organs.

Therapeutic Options for LSIL and HSIL

Ms. Hoyt described several therapeutic options for both LSIL and HSIL. For LSIL, commonly used options are:

1. Local excision (cell removal).
2. No treatment/careful observation.
3. Cryosurgery - The use of liquid nitrogen to freeze tissue to extremely low temperatures, thereby killing the tissue.
4. Laser therapy - The destruction of abnormal cells with a light beam.
5. LEEP - The removal of the top layer of cells on the cervix. The cells are then examined to determine if cancerous cells are present.
6. Electrocautery - Removal of lesions using electric current to generate heat.

For HSIL, commonly used options are:

1. Cryosurgery.
2. LEEP.
3. Laser therapy.
4. Conization - The removal of a cone-shaped piece of the cervix.
5. Electrocautery.
6. Hysterectomy - The removal of the uterus (used after HSIL has recurred several times).

What are some of the High Risk Factors for Cervical Cancer?

• Early age of first intercourse (cells of the cervix might not be fully developed)
• Multiple sexual partners (increases chance of exposure to HPV strains 16 and 18 and other STDs).
• artner who has had multiple sex partners.
• Other STDs.
• Smoking.
• Infection with HPV strains 16 and 18.
• Immune Deficiency.

Questions & Answers for Mary Jo Hoyt

Q: If you have had a hysterectomy, should you still have pap smears?

A: Yes, because cell abnormalities can develop in the vagina.

Q: Can taking Vitamin A prevent the development of cervical cancer?

A: Although Vitamin A deficiency is often observed in women with cervical cancer, it is not known if Vitamin A supplements are effective for cancer prevention.

Q: Should HIV-positive women with normal pap smears have colposcopy performed?

A: Since a pap smear is only a screening test, it is possible that there will be "false normal" results. However, if pap smears are performed frequently, and are consistently normal, colposcopy is not necessary.

Q: Are there any symptoms of dysplasia or cervical cancer?

A: There are no symptoms of dysplasia. One symptom of early cervical cancer is abnormal bleeding, but other conditions (such as fibroids) can cause abnormal bleeding as well.

Forum summary writer - Anne Monroe.