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
College of Nursing
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)
KEYWORDS: ANAL CANCER, ANORECTAL CARCINOMA, COLLEGE STUDENTS, GAY MEN, HEALTH DISPARITIES, PAPANICOLAOU SCREENING
ABSTRACT
Objective: This article examines the role of nurse practitioner’s in college- and university- practice settings in screening for anorectal carcinoma among gay and bisexual men.
Participants: College- and University men who have sex with men.
Method Summary: Data regarding the prevalence of anorectal carcinoma among gay men is presented along with applicable techniques for completing a health history, performing a physical examination, and obtaining an anal cytology Pap smear.
Results: Although the overall prevalence rate of anorectal carcinoma is relatively low in the general population, 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.
Conclusions: Implications are provided for continued research and education of NPs in this setting.
Introduction
Gay and bisexual men present unique health concerns to the United States healthcare system. 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 cancers.1
While no critical inquiry has assessed the precise number of gay or bisexual men on university/college campuses, it is estimated that ten percent of the American population identifies their sexual orientation as non-heterosexual.2 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-discrimination.3 ACHA indicates that campus climates supportive of equality and tolerance promotes the overall health of the college.3
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 multiculturalism.4 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 intimidation.4 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 identity.4
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 have an obligation to 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. One of these is annual Papanicolaou (Pap) screenings of men who have sex with men (MSM) to detect anorectal carcinoma.5
Prevalence of Anorectal Carcinoma among Gay Men
The prevalence rate of anal carcinoma is relatively low in the general population, with an estimated 0.9 cases per 100,000.6 However, among men who have sex with men (MSM), the prevalence rate is estimated to be as high as 35 per 100,000.7-9 This finding directly mirrors the rate of uterine cervix carcinoma prior to the widespread implementation of cervical Pap screening.9
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 cancer.10 Data suggest that gay men have an increased number of lifetime sexual partners and receptive anal intercourse.11 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 services.12 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 men.8, 13 Current estimates indicate that between 60%-75% of men who have sex with men are infected with HPV.13
Receptive anal intercourse also provides a mechanism for infection with HPV, including subtypes 16, 18, 31, 33 and 35, which are associated with neoplasia.14 Other anal-insertive sexual practices among gay men could have potential for increased risk factors leading to anal carcinoma.15 Infection with the Human Immunodeficiency Virus (HIV) is associated with greater risk or HPV exposure and infection;10 sixty-three percent of all new HIV and Acquired Immunodeficiency Syndrome (AIDS) diagnoses are among men who have sex with men.16
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 rectum.17-19 Because most infections with HPV are asymptomatic and no diagostic test exists which can detect the presence of HPV.17, 19 Cytology screening to detect occult presence of abnormal and potentially cancerous cells is of paramount importance. In addition clients often correlate HPV infection with genital warts and do not want to discuss screening with their provider if they do not have genital lesions; this makes education of the client about the importance of an annual Pap screening necessary.
If administered to identified high-risk populations, annual anal cytology screenings have been predicted to be both cost effective and clinically effective.14 Annual anal Papanicolaou (Pap) screenings in HIV-positive gay men could result in incremental costs of $16,600 per adjusted life year saved, which is comparable to other preventative health screenings.14 Nurse Practitoners (NPs) working in primary care or infectious disease are especially poised to reduce the health disparity among homosexual men. While it is often difficult to approach sensitive issues related to human sexuality, it is essential for the health of the client and to decrease the transmission of disease.
While data suggests 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 activities. Asking health history questions related to sexuality is often challenging for practitioners. Assuming an approach that is non-judgmental and provides respect and empathy for the client will capitulate a clear and accurate dialouge between the practitioner and the client.20
Approaching the Sensitive Topic of Sexual Orientation
Most experts suggest 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 both.2, 21 Using the term “sexual preference” is not recommended, as this implies the individual made a choice regarding his sexual orientation.22 Statements which are leading or imply judgment 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 effective.2 Estimates indicate that up to 10% of the American population have a sexual orientation other than heterosexual;2 the NP must not make the assumption of a client’s sexual orientation as either heterosexual, homosexual, or bisexual.2
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, ilicit drug use, and alcohol and tobacco use.
In addition, the NP should establish the client’s baseline knowledge level 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 comments toward changes in GI routines and habits; the NP must inquire as to bowel habits, passage of mucus and blood, abdominal pain, weight loss, and family or personal history of gastrointestinal diseases.23
Research indicates that individuals infected with HIV are at much higher risk for anorectal cancers than HIV negative men.10 HIV positive men are more likely to have lower functioning immune systems, making immunosurveillance of HPV and neoplasms less effective. Whilst 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 HPV.11
By assessing the client’s number of sexual partners over the course of a 12-month period, the NP can make a direct correlation for 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 HPV;24 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 specific to gay men, 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 carcinoma.15 Meth use, in general, is more prevalent in the gay community;25 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 HPV.25 This highlights the importance of obtaining a thorough history of ilicit and prescription drug use by the client. While it is important to document history related to a client’s intake of alcohol, inquires have failed to correlate alcohol use with unprotected anal intercourse.26
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 as 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 positive gay men.27
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 present.14 Physical examination findings which may indicate possible malignancies include polypoid masses, or more commonly, the presentation 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, a firm to hard nodular rectal shelf may be just palpable with the tip of the examining finger.28
Anal carcinoma has an elusive nature because of the difficulty of detection via inspection and a frequently asymptomatic presentation; thus, most evaluations in early cases are challenging to diagnose, increasing the risk of preinvasive disease.14 Because the cells which line the female cervix share similar physiologic characteristics to the cells which line the anus,14 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 anus.10, 14
Methods: 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 must use a Dacron cotton swab; wooden sticks are to be avoided because of their increased tendency to splinter and break.8 The male client is draped for privacy and placed in the lateral recumbent position. Without direct visualization, the swab is inserted approximately 5-6 cm. The NP promptly applies direct, firm, lateral pressure on the swab handle while rotating and slowly removing it from the anal canal. The NP must carefully 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 zone.7
The recommended preservation method is liquid cytology. 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 sample.8 Although not preferred, air-dyring and fixation can be applied if liquid cytology is impossible. Pathological screening for atypical squamous cells of undetermined significance (ASCUS) is essentially the same as that employed to interpret HPV-related lesions of the cervix.8 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 colposcope.8
Results/Summary
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 pertaining to physical examination findings were also provided. Directions on how to perform the tehcnical procedure for obtaining an anal cytology sample were specifically outlined.
Comments
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 minorities.29 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 malignancies.14 However, much more data is needed.
Consideration for future research studies should focus on current psychosocial barriers which may prevent 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.