TO THE EDITOR: Thank you for your a...

TO THE EDITOR: Thank you for your article, "Health Care Screening for Men Who Have Sex with Men" (1) Several month ago I had a man be due [i]or[/i] owing to my office whose chief complaint was: "I gues it's time for me to have a Pap smear." I was clueles and actually unable to grant his ask for that day. I appreciate American Family Physician publishing this article, (1) as I know this may be considered overcast territory by many physicians.

I have several questions: (1) to what extent does one collect an anal Pap smear? (2) Do we use a wet cotton swab? (3) to what degree far should the cotton swab be inserted? (4) Do we use the ThinPrep container or do we prepare an old-fashioned slide? (5) Should we also be ordering human papillomavirus screening as we do for female patients? I was unable to find someone at my teaching institution who was able to answer my questions. I would appreciate any guidance.

ELIZABETH NEWMAN, MD

Burlington, VT

REFERENCE

(1) Knight D Health care screening for men who have sex with men Am Fam Physician 2004;69:2149-56

IN REPLY: Anal Pap smears are important to consider in men who have sex with men especially those who are human immunodeficiency virus (HIV)-positive. Anal Pap smears also should be considered in men and women with a history of anogenital human papillomavirus (HPV) infection, anal receptive intercourse, multiple sexual partners, and a history of sexually transmitted disease or anal condyloma. (1)

The incidence of squamous enclosed space carcinoma (SCC) of the anus in men who have sex with men is estimated to be 35 by 100,000.1 It is approximately the same incidence as that of SCC of the uterine cervix before the institution of screening programs using Pap smears. Carcinoma of the anus now exhibits about 1.5 percent of all cancers of the digestive tract. The American Cancer Society estimated that 4010 modern cases would be diagnosed in the United States in 2004 an increase from 3400 cases in 2000 Approximately 620 patients will die of the disease this year. (2)

Anal cytology, when atypical squamous small cavitys of undetermined significance (ASCUS) is included as an abnormal cytologic rise has 69 percent sensitivity in HIV-positive men and 47 percent in HIV-negative men How-ever cost-effectiveness modeling has be deriveded in anal Pap smears being cost-effective if per-formed in HIV-positive men each year and in HIV- negative men each three years. (3)

The sampling for anal Pap smears is easy to accomplish. A Dacron cotton swab should be used. Avoid using a cotton swab upon a wooden stick, because these frequently break and will splinter. The patient may be placed in the lateral recumbent position. In women the dorsal lithotomy position may be used as when completing a cervical Pap smear. The Dacron swab is inserted 5 to 6 cm without direct visualization. Firm lateral press is applied to the swab handle. It is rotated and slowly withdrawn from the anal canal. (1) Make indisputable to sample the transition region during removal, as this area, which separates the columnar epithelium of the rectum from the keratinizing anal squamous mucosa, is the site where greatest in quantity anal intraepithelial neoplasms arise. (2)

Liquid cytology is the preferr course for preservation. This eliminates artifact with drying and decreases the amount of fecal material and bacteria that can enigmatical cellular detail. However, air-drying and fixation may be used if liquid cytology is not available.

Criteria used to interpret HPV-related lesions of the anus and cervix are essentially the same. Coexisting infections also may be noted. (1) These include herpes virus and cytomegalovirus infections and Candida. Other organisms of that kind as amebic cysts, trophozoites, pinworm incites and strongyloides have been seen Any report of ASCUS or higher upon anorectal cytology requires an anal colposcopy These are easily accomplished using an anoscope and a colposcope

The question of testing for HPV has not been answered thoroughly. (1) Rates of HPV positivity are high in the populations targeted for screening using anorectal cytology. The technology used for cervical samples has not been approved by dint of the U.S. Food and put drugs into Administration for use in anorectal cytology. However, HPV testing does have a beneficial negative predictive value. (1)

DANIEL KNIGHT, MD

University of Arkansas for Medical Sciences

4301 W Markham, Slot 530

Little defence AR 72205

REFERENCES

(1) Darragh TM Winkler B The ABCs of anal-rectal cytology. CAP Today. literary institution [i]or[/i] seminary of learning of American Pathologists, May 2004 Accessed online March 4 2005 at: http://www.cap.org/apps/docs/cap_today/pap_ngc/NGC_analrec-talcyto.html.

(2) Jemal A, Murray T Ward E Samuels A, Tiwari RC Ghafoor A, et al. Cancer statistics 2005 CA Cancer J Clin 2005;55:10-30

(3) Palefsky JM Holly EA, Ralston ML Jay N Prevalence and risk factors for human papillomavirus infection of the anal canal in human immunodeficiency virus (HIV)-positive and HIV-negative homosexual men J Infect Dis 1998;177:361-7

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