HPV epidemic in western nations. Screening refused, even though it could save lives.
Soaring rates of sexually-transmitted HPV infection are occurring among gay and bisexual men. Despite evidence linking anal HPV infection with the later development of anal cancer, the Department of Health is failing to offer life-saving screening programmes to men and women who have contracted HPV via anal sex.
This failure is putting lives at risk.
Gay human rights campaigner, Peter Tatchell, has written to the Health Minister, John Reid MP, setting out the problem and proposing remedial action (a copy of his letter follows below):
Secretary of State for Health
Department of Health
London SW1A 2NS
21 June 2003
Dear John Reid,
ANAL CANCER SCREENING & HPV EDUCATION CAMPAIGN
Please accept my congratulations on your new appointment.
I originally wrote to your predecessor, Alan Milburn, on 8 February 2002. Over 16 months have since elapsed. Despite several further letters, the Department of Health has failed to give a substantive response to evidence of a link between anal infection with the Human Papilloma Virus (HPV) and the subsequent development of anal cancer.
To date, the replies I have received have come from lower level officials and have not adequately addressed the medical and scientific issues presented.
I would appreciate receiving a personal reply from you. This would signal to the gay community, and to affected heterosexual people, that the government takes this matter seriously.
To summarise my evidence and proposals:
Anal cancer can be caused by HPV, and can be fatal. It is, however, usually non-lethal with early detection and treatment.
HPV can be sexually-transmitted, including during anal sex. Most sexually active people are now infected with one or more strains of HPV, some of which may result in cancerous lesions.
Anal HPV infection can lead to the subsequent development of anal cancer.
There are, therefore, strong medical and ethical arguments in favour of offering regular anal pap smear tests to everyone who has receptive anal sex.
Note: I am not proposing the screening of the whole population; only people who have been receptive partners during anal sex.
US research suggests 23 per cent of HIV-negative gay and bisexual men are infected anally with one or more strains of HPV, with the anal infection figure rising to 93 per cent for HIV-positive gay and bisexual men (Martins, The Hopkins HIV Report, May 2001). It is likely that infection rates are broadly similar in the UK.
These very high rates of anal HPV infection, especially among gay and bisexual men who are HIV-positive, have huge implications. As anti-HIV drugs prolong the life-span of people with HIV, there is a strong possibility that anal cancer will become a major disease and cause of death among this patient group.
Anal sex is not, of course, confined to gay and bisexual men. It is also experienced by 13 per cent of heterosexual men and women, according to the National Survey of Sexual Attitudes and Lifestyles (published in 1994 under the title Sexual Behaviour in Britain).
Screening for the potentially cancerous consequences of HPV infection is therefore a public health issue for people of all sexualities – homosexual, bisexual and heterosexual.
HPV can cause both anal and cervical cancer. Why is there a national education, screening and treatment programme for cervical cancer but not for anal cancer?
There is a compelling medical case for regularly screening everyone who has had receptive anal sex (either homosexual or heterosexual), using anal pap smear tests, similar to the vaginal pap smear tests used successfully to detect cervical cancer. The aim of screening would be to identify the first signs of anal cancer and initiate early intervention treatment, along the lines of the therapies currently offered to women with cervical cancer.
By regular screening, I am suggesting about once every three years.
The potential value of anal cancer screening is confirmed in studies by Dr Sue Goldie of the Harvard School of Public Health and Dr Joel Palefsky of the University of California at San Francisco. Their research was published respectively in the American Journal of Medicine in 2000 (108:634-41) and in the scientific magazine AIDS in 1998 (12:495-503) – and reported on BBC Online News, 9 November 2000.
According to another study, authored by Daling, Weiss and Hislop et al in the New England Journal of Medicine in 1987 (317:973-7), 35 gay men per 100,000 develop anal cancer; which is comparable to the 40 women per 100,000 who developed cervical cancer before the introduction of pap smear tests.
It is reasonable to assume that comparable rates of anal cancer may occur among some of the 13 per cent of heterosexual men and women who have had anal sex.
Screening has massively reduced deaths from cervical cancer. A similar screening programme among men and women who have anal sex could also identify cancerous and pre-cancerous irregularities; ensuring earlier treatment and enhanced survival.
Dr Goldie predicts anal pap smear tests every two to three years would cost around $US16,000 per year of life gained. Annual breast cancer screening, in comparison, is estimated to cost $US120,000 per year of life gained.
These figures indicate that pap smear tests for anal cancer would be highly cost-effective, compared to already existing screening programmes for other forms of cancer.
The efficacy of cancer screening was reinforced by Swedish research published in The Lancet on 25 April 2003. The study reported that breast cancer screening of women aged 40 to 69 had resulted in a 44 per cent decrease in deaths.
As has been proven with the directly comparable screening to identify cervical cancer in women, swift detection and treatment has medical, financial and social advantages: it ensures more successful treatment, saves lives, minimises family dislocation, and reduces health service costs in the long term.
It cannot be medically justifiable to treat people at risk of anal cancer differently from those at risk of cervical cancer. Both deserve the best service possible from the NHS.
The Department of Health has appeared to dismiss my proposals on the grounds that the incidence of anal cancer is relatively low (635 new cases in England and Wales in 2000). But this figure may disguise a hidden, latent health problem.
It depends on how you define anal cancer. Anal HPV infection can lead to cancer in the anus, rectum and perhaps even the lower colon. Your department’s statistics appear to refer to cancer that is strictly localised in the anus only (as opposed to the rectum and lower colon). This means the figures do not record all cancers that arise from anal HPV infection.
It might be helpful if anal cancer was more broadly defined to include all cancers of the anus, rectum and lower colon, where there is simultaneous evidence of HPV infection.
Alternatively, it might be better still if we abandoned the term anal cancer altogether and referred instead to HPV cancer (which would cover all the body sites where HPV-related cancers can develop, including in the cervix).
While this change in terminology and definition would be helpful in the long-term, for the moment, for purposes of this correspondence, I will continue using the conventional term anal cancer.
There is an additional problem with your department’s anal cancer statistics. HPV is a little like HIV. It can take 20 or 30 years for HPV infection to develop into cancer. The huge increase in anal HPV infection over the last 10 years may not develop into cancerous lesions for another 10 or 20 years. There is, therefore, no justification for complacency with regard to the current fairly low-level incidence of anal cancer.
Clearly, we need further research, including pilot studies to ascertain accurately the prevalence of HPV infection and anal cancer, and the correlation between the two. In particular, research is needed to identify the strains of HPV that can lead to anal cancer, and the process by which malignant lesions develop. There is also a need for research into treatment regimes, both at the pre-cancerous stage and once cancerous lesions have developed.
This research needs to be coordinated and funded by the Department of Health, and cannot be left to local health authorities or private laboratories (they are, as far as I know, not doing research in this area).
In the immediate term (the next one to two years), the Department of Health should:
Set up and fund pilot studies at 10 hospital GUM clinics, to screen people who have had receptive anal sex for (a) HPV infection and for (b) anal cancer or pre-cancerous irregularities (using the pap smear methods employed to screen for cervical cancer). The aim of these pilot studies would be to determine the scale of HPV infection and anal cancer, and to identify the strains of HPV that can lead to anal cancer and the process by which such cancers develop.
Fund treatment research at these GUM clinics, which would apply the therapies used to treat cervical cancer to the treatment of anal cancer, and experiment with new dedicated therapies.
In the medium term (four to five years from now), the Department of Health should:
Establish a national HPV and anal cancer screening programme for people who have had receptive anal sex (modelled on the screening programme for cervical cancer), together with a national treatment regime based on the above research into the most efficacious therapies.
Initiate a public education campaign to promote awareness of HPV infection and anal cancer, in order to encourage regular testing and early treatment by those who have been exposed to the HPV strains that can result in anal cancer.
I hope you will feel able to give me a personal and positive reply regarding these proposals.
Yours sincerely,
Peter Tatchell