Anal cancer is predominantly caused by human papillomavirus (HPV). In fact, it is estimated that over 93% of anal cancer cases are caused by HPV. HPV is the most common sexually transmitted infection. Nearly all adults will have HPV at some point in their lifetime. In the US, 79 million people, or 1 in 4 Americans, are currently living with HPV. In the UK, HPV is present in 1 in 3 people and 90% of individuals will come into contact with some form of the virus in their lifetimes.

There are over 100 strains of the HPV virus. For the majority of the population, the immune system will rid the body of the virus and HPV will not progress to cancer. For other individuals, HPV can lie dormant in their bodies and resurface as an HPV-related cancer decades later. HPV strains, and the infections they cause, can be classified as either low risk or high risk. Low-risk strains of HPV may manifest as genital warts. High-risk strains may turn into cancer.

There are steps you can take to decrease your chances of getting anal cancer. The only way to truly prevent HPV is to avoid all types of sexual contact, including manual intimacy (hand-to-genital contact). However, there are additional steps that can be taken to decrease your chances of getting HPV, which we discuss here. These steps involve preventative measures such as vaccination, smoking cessation, practising safer sex, maintaining HIV treatment, improving your immune system, as well as getting screened for anal cancer and precancer. Read on for more information.

HPV VACCINATION

Vaccines exist to protect individuals from the most cancer-causing strains of the virus. HPV is the cause of anal cancer 93% of the time. It also causes at least five other cancers, including cervical cancer. Since it is likely most people will have at least one intimate partner during their lifetime, HPV vaccination, screening and practising safe sex are important steps that will help reduce the chance of getting HPV and anal cancer.

The HPV vaccine is available in both the US and the UK. The HPV vaccines are recommended at an early age to protect against human papillomavirus because:

  • Early vaccination offers the fullest protection before children are exposed to the virus. HPV is transmitted through intimate skin-to-skin contact. Data suggest that there is minimal exposure to HPV at 11 and 12 years old as few are sexually active. 
  • Younger people have a better immune response to the vaccine.

 HPV Vaccine Recommendations in the United States

The Centers for Disease Control and Prevention (CDC) recommends routine vaccination for all male and female children at 11-12 years old. There are three vaccines licensed in the US to prevent HPV and certain HPV-related cancers: Gardasil 9, Gardasil and Cervarix. Gardasil 9 and Gardasil are indicated for both boys and girls. Cervarix is indicated for girls only. A catch-up vaccination is offered up to 26 years old for Gardasil and 25 years old for Cervarix.

Please see our section on Vaccination and Understanding the HPV Vaccine for more information.

Where can I get vaccinated in the US?

Speak to your healthcare provider about being vaccinated. Children in the recommended age range are covered by insurance or other programs. Providers who offer the vaccine include pediatricians, adolescent health providers, gynecologists, internal medicine and general practitioners.

The HPV vaccines are included in the federal Vaccines for Children (VFC) program, which offers free vaccines to children under the age of 19 who are uninsured or underinsured and have difficulty paying for vaccination. Many healthcare providers participate in this program. If children have insurance, the HPV vaccine is covered for the recommended age groups for males and females.

HPV Vaccine Recommendations in the United Kingdom

The HPV vaccine is offered to all female children aged 12-13 in the United Kingdom through school-based vaccination programs. The vaccine is offered in year 8 in England & Wales, S1/S2 in Scotland, and year 9 in Northern Ireland. Catch up is available for girls aged 14-18 in Scotland, England and Wales. The catch-up program in Northern Ireland ended for girls in 2014 and girls who did not obtained the vaccine in their year 9 now need to obtain it privately. Males are not currently covered in the vaccination program, although it is now offered in some private clinics out-of-pocket.

Please see our section on Vaccination and Understanding the HPV Vaccine for more information.

Where can I get vaccinated in the UK?

Females can be vaccinated at school for free if they are in the recommended age group 11-18. Males are currently not included in the vaccination program. Males interested in vaccination should speak to their healthcare provider, as some private clinics offer the vaccine to males but it may not necessarily be free.

In the UK we, along with many public health, sexual health, cancer and men’s health organizations, believe that boys as well as girls should have equal access to the HPV vaccine at the age of 12/13. 36 organisations have come together as a coalition called HPVAction to make the case for vaccinating boys.

The JCVI, which advises the government, is examining whether it is cost effective to vaccinate boys and is expected to report on their findings in 2017. Recently the JCVI recommended that the HPV vaccine also be offered to men who have sex with men (MSM) aged 14-60 who identify themselves at sexual health clinics. The HPV and Anal Cancer Foundation submitted testimony in response to this recommendation commending the JCVI in their efforts but explaining that it does not go far enough in protecting men against infection with deadly HPV.

PRACTIsING SAFE SEX

To decrease the risk of transmitting HPV it is important to practise safe sex and use a condom. To be most effective, condoms should be used properly during every sex act, every time. However, because HPV is transmitted through skin-to-skin contact, areas left exposed while wearing a condom during sexual activity are still vulnerable to HPV transmission.

MAINTAIN HIV TREATMENT

It is more likely that a person with an immunocompromised system will develop anal cancer. A strong immune system is important to fight off opportunistic infections such as HPV.

For individuals with HIV, maintaining antiretroviral therapy will help keep the immune system strong.

US – For more information on HIV treatment options, speak to your medical provider or visit AIDS.gov.

UK – For more information on HIV treatment options, speak to your medical provider or visit the NHS.

SMOKING CESSATION

Smoking increases your chances of developing anal cancer, as carcinogens (cancer-causing chemicals) in tobacco can affect the entire body. There is evidence that smoking may decrease the immune system’s ability to fight HPV infection. Studies have also shown that current smokers are at higher risk of developing anal cancer than former smokers and those who have never smoked at all.

US – For help quitting visit the CDC website on smoking cessation.

UK – For help quitting visit the NHS website on smoking cessation.

SCREENING FOR ANAL CANCER AND PRECANCER

Screening is important for people who are past the recommended age range for the vaccine. Even with vaccination, it is important to continue regular screening. This is because you may have been exposed to a strain of the virus not covered by the vaccine, or you may have been exposed before being vaccinated.

Anal cancer can be detected and monitored in its precancerous stages. Anal precancer is called AIN or Anal Intraepithelial Neoplasia. Please see our section on Anal Precancer for more information.

Scientists are still studying which populations to screen on a routine basis, how often to screen and what types of treatment are most effective. However, if you notice bleeding or discharge from the anus, anal itching, abnormal bowel habits including constipation, a lump near your anus, or anal pressure or pain, or any other sensation that has you concerned, see your doctor immediately and ask to be examined.

How do I get screened?

If you think you may have AIN or are at risk, it is suggested that you have a clinician screen you.

Screening may involve:

  • Visual inspection. However, appropriate and accurate screening may also include additional methods, as a visual check alone can fail to diagnose AIN inside the anal canal and changes that are subtle.
  • Digital ano-rectal exams or ‘DARE’: a doctor places his or her fingers inside the anal canal to feel for abnormalities. The purpose of this test is to look for abnormal masses or growths. This exam will only find tissue that is already cancerous.
  • An anal pap test: similar to a routine cervical pap test and involves sampling cells inside the anus to detect changes and abnormalities.
  • Anoscopy: a tube called an anoscope is placed inside the anus and a strong light illuminates the tissue.
  • High-resolution anoscopy or HRA: a more advanced anoscope with a high-resolution magnifying glass is used to examine and evaluate the tissue in the anus. This is the most precise examination for anal cancer and precancer.

Screening Guidelines

Routine screening guidelines for anal cancer or precancer have yet to be universally adopted because there have not yet been enough studies for the government and medical communities to recommend routine screening. The predominant guidelines tend to focus only on HIV-positive individuals. New York State, for example, recommends annual anal pap smears for HIV-positive men and women.

There is increasing evidence to support screening for precancers. The US National Institutes of Health (NIH) is currently funding what is known as the ANCHOR study, which will be the first randomized control trial for anal precancer screening efficacy and treatment. This is the first study that the NIH has ever supported on anal precancer screening. It is hoped that standards of care will be developed from this study and embraced by the government and medical community. You can read more about this study here. Read our letters to the National Cancer Institute in support of this study here and here.

Where Can I Get Screened?

Please see our Medical Resources page to find a clinician providing screening services in your area.