The Open AIDS Journal


ISSN: 1874-6136 ― Volume 9, 2015

Early Impact and Performance Characteristics of an Established Anal Dysplasia Screening Program: Program Evaluation Considerations



Christopher Mathews1, *, Joseph Caperna1, Edward R. Cachay1, Bard Cosman2
1 Department of Medicine , University of California, San Diego, CA, USA
2 Department of Surgery , University of California, San Diego, CA, USA

Abstract

Background:

Screening for invasive anal cancer and its precursors is being increasingly advocated as a response to increasing incidence among HIV-infected persons. We implemented a comprehensive screening program in 2001 and report our early experience to inform monitoring and evaluation of such programs. Our research aims were: (1) to estimate incidence of and mortality from invasive anal cancer (IAC) before (1995-2000) and after (2001-2005) screening program implementation and (2) to examine potential screening program quality indicators.

Methods:

The study cohort included all patients under care for HIV infection at UCSD Owen Clinic between 1995-2005. Person-time incidence rates (IR) and case survival of IAC were estimated for the pre-screening (1995-2000) and post-screening (2001-2005) periods. High resolution anoscopy (HRA) operator accuracy was estimated by kappa agreement between cyto-histologic comparisons. Program quality indicators included: (1) screening coverage; (2) percent technically unsatisfactory cytology smears; (3) time between 1st abnormal cytology and 1st HRA; and (4) time between last clinic visit and last cytology.

Results:

28 cases of IAC and 13,411 person-years were observed between 1995-2005. IRs (95% CI) pre-screening and post-screening were 199 and 216 per 100,000 person-years, respectively. There was no routine treatment of high grade squamous intraepithelial lesions (HSIL) during the study period. The percent of patients with IAC requiring chemoradiation decreased from 90.9% to 70.6% (p=0.36). There was a significant improvement in cyto-histologic agreement at HRA with increasing operator experience (r=0.92, p=0.025). Screening coverage was 73% of the target population. Among 14 providers, the percent unsatisfactory cytology smears averaged 27% but varied from 0 – 62%. The median time from 1st abnormal cytology to 1st HRA was 258 days. The median interval between the last cytology and the last clinic visit was 207 days.

Conclusion:

(1) The overall IR of IAC did not decline in the screening era and was higher than previous estimates for HIV cohorts; (2) stage shift to IAC of more favorable prognosis is a reasonable screening goal; (3) HRA accuracy varied by provider experience; (4) because of delay in access to HRA, digital rectal exam should be combined with cytology screening to detect palpable disease.

Keywords: Anal dysplasia, screening, HIV..


Identifiers and Pagination:

Year: 2007
Volume: 1
First Page: 11
Last Page: 20
Publisher Id: TOAIDJ-1-11
DOI: 10.2174/1874613600701010011

Article History:

Received Date: 17/10/2007
Revision Received Date: 31/10/2007
Acceptance Date: 5/11/2007
Electronic publication date: 29/11/2007
Collection year: 2007

Article Information:

2007 Bentham Science Publishers Ltd.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.5/), which permits unrestrictive use, distribution, and reproduction in any medium, provided the original work is properly cited.


* Address correspondence to this author at the University of California, San Diego, 200 West Arbor Drive. San Diego, CA 92103-8681, USA; Tel: (619) 543-3939; Fax: (619) 543-7841; E-mail: cmathews@ucsd.edu



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