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Home Other HPV Cancers Other HPV Cancers Interview with Stephen E. Goldstone, M.D.

Interview with Stephen E. Goldstone, M.D.

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The author of The Ins and Outs of Gay Sex--A Medical Handbook for Men discusses anal cancer screening and the barriers gay and lesbian patients face in obtaining quality health care.

While most discussions of HPV and cancer understandably focus on diseases of the cervix, “high risk” types of the virus, so named because of their association with malignancies, are also linked with a number of anogenital cancers and, increasingly, some head and neck diseases.

Spurred partly by the actor Farrah Fawcett’s well-documented battle and death from the disease in 2009, anal cancer is one HPV-related cancer receiving growing attention. While relatively uncommon (the American Cancer Society estimates about 5,200 cases and 700 deaths per year in the U.S.), anal cancer rates are much higher among men who have sex with men (MSM), especially those living with HIV (weakened immune systems have difficulty suppressing HPV) and men and women with HIV. Also, the economic costs of diagnosing and managing anal cancers are estimated to be $92 million annually, not an insignificant sum in an era when health care dollars are stretched thin. Interest in anal cancers has also been piqued by evidence that suggests HPV vaccines have promise in preventing the disease.

To learn more about anal cancer and the unique challenges gay and bisexual patients face in navigating the health care system, HPV News recently chatted with Stephen E. Goldstone, MD. Dr. Goldstone, a Fellow of the American College of Surgeons, is member of the American Society of Colon and Rectal Surgeons. He is also an Assistant Clinical Professor of Surgery at the Mount Sinai School of Medicine and has a surgical practice in New York City. Dr. Goldstone is an expert on gay men’s health and authored the best-selling book The Ins and Outs of Gay Sex -- A Medical Handbook for Men.

Who should be screened for anal cancer?
New York is the only state that has posted screening guidelines for anal cancer, and they refer strictly to HIV-positive patients: they say all HIV-positive men and women should be screened. There’s some disagreement beyond that as to who needs screening, but I believe both HIV-positive and -negative MSM, and women with vulvar and vaginal dysplasia, and maybe even women with high-grade cervical dysplasia should be screened.

Why do you recommend anal cancer screening for women with cervical disease?
HPV is often found in the anal canal in women, and in fact some studies show women have higher rates of anal HPV than cervical. The anus may actually be a reservoir, so if they’ve had high-grade cervical dysplasia, they may well have HPV present in the anal canal, too, meaning they may need treatment for possible high-grade anal dysplasia.

Are there means of contracting anal HPV apart from anal sex?
Absolutely; we see anal HPV in men and women who’ve never had anal sex. For example, there are heterosexual men who get anal HPV, and this probably involves anal touching, such as autoinoculation from one part of a person’s body to another part of his body, or even from a partner touching him there. HPV is an infection that virtually no one who is sexually active avoids, unless both partners met as virgins and have never had other partners.

How do anal and cervical Pap tests compare?
There are differences. A cervical Pap is done with a speculum insertion but an anal test is done blindly, so a big difference with the anal test is you don’t see the area you’re sampling. So, the anal Pap is probably less accurate than the cervical test when it comes to predicting disease. A patient with an abnormal anal Pap test needs to undergo a diagnostic procedure called high-resolution anoscopy [HRA], which essentially is like a colposcopy a woman gets to her cervix, but instead it’s done in the anal canal. HRA requires special training and unfortunately there aren’t a lot of doctors who do it.

How is anal cancer treated?
Small lesions caught early can be excised (cut away) with a margin of healthy tissue. If not caught early or if it’s deep in the anal canal, treatment is radiation or chemotherapy. It is a very curable cancer, but we’d like to catch these lesions like we do in the cervix, before they become cancer, when they’re even easier to treat.

How are anal precancers managed?
Targeted excision, or targeted destruction, where you can cut away or burn the lesion. Clinicians also have the option of doing laser or even applying chemicals to treat these lesions.

Would you ever take a “wait and watch” approach with anal precancers, such as is often done with cervical lesions?
Some people recommend that, but I’m not one of them! I think if you have a precancerous lesion, you treat it as long as the patient is healthy and has a good life expectancy. There’s plenty of research that shows people treated with watch and wait have much higher progression rates to anal cancer than those who have their lesions destroyed or ablated. For someone with a limited life expectancy, though, then clearly it’s fine to watch a precancerous lesion.

How much of an issue is it for gay and bisexual patients to talk openly with healthcare providers?
I think gay and lesbian patients need to find a provider with whom they can talk and feel comfortable in bringing up their issues. In most areas of the country, I think you can find somebody, but keep in mind there remain communities where it’s not acceptable - and maybe not even safe- for gays and lesbians to talk openly about their sexuality, even with a health care provider. Whether someone is gay or straight, getting good medical care means being able to talk with your provider about your sexual practices and sexual fears. You have to be completely honest, because your sexual life is important to your overall health and well-being. If you’re having sex with multiple partners, then you need to discuss what kind of sex you’re having so your risk of STD’s can be evaluated. There are many people who have same sex partners but who would never say to a clinician “I’m gay” because they don’t consider themselves that way. What’s important to discuss is what you actually do when you’re intimate, not how you view yourself.

What steps should gay and bisexual patients take to insure quality health care?
I think it’s important that we’re all provided health care from an understanding clinician who treats us with respect. If you are gay or bisexual, you need to find a provider who’s gay-friendly, and that doesn’t mean they have to be gay themselves. The Gay and Lesbian Medical Association keeps a list of clinicians who are gay-friendly, so that’s a good place to start. Also, if a patient ever finds they aren’t treated with respect, or that an encounter doesn’t go the way it should, many insurance companies allow you to lodge complaints against providers. We do have rights as patients to expect quality care, dignity, and attention to our needs from our clinicians. Please, demand nothing less from your health care providers. Also, it’s important that we as patients educate our providers. For example, the quadrivalent HPV vaccine is approved for males 9-26 years of age and if you want it, then go ahead and ask your provider. I think all males in that age range should have it, so don’t let anyone tell you it isn’t important for boys and young men to be vaccinated. HPV causes a lot of problems, warts and precancerous areas, and I think it’s important that patients are proactive and assertive, and not afraid to speak up. Just tell your provider what you expect, and what you need to know.

Hu, D and Goldie, S. The economic burden of noncervical human papillomavirus disease in the United States. American Journal of Obstetrics and Gynecology. 2008; 198:500.e1-500.e7.