We spoke with Ashish Deshmukh, PhD, at the University of Texas about his latest research findings on the rising incidence of anal cancer, as well as the events that drove him toward a career researching anal cancer and its eradication. We at the Anal Cancer Foundation are proud to work with researchers such as him, bringing light to these statistics and helping to spread the word about what all of us can do to bring anal cancer to an end.
Why was it important for you to focus on anal cancer? How did you come to this field of study?
My interest in anal cancer research is driven by both luck and its impact on my family. I grew up in a small town (Nashik) in India in a conservative family. Cancers, particularly diagnoses of cancers of genital organs, are considered a stigma in India. In the early 2000s, my grandmother was diagnosed with cancer. We (kids in the family) were never told what the disease was, but we knew that my grandmother was getting treatment in Mumbai. Fortunately, she recovered as the symptomatic diagnosis was still early stage (and treatable); however, 3 years after her initial diagnosis, the disease came back. This time she had to undergo abdominoperineal resection, which prolonged her life by 2 years but added a lot of suffering before she passed away. During that time, I was studying pharmacy and came to know that the disease that took her away from us was anal cancer. Personally touched by anal cancer, I started my doctoral training at UTHealth and started working as a graduate research assistant at MD Anderson Cancer Center with Dr. Scott Cantor. When I began my training, I was looking for a project both for my doctoral dissertation and to initiate my career trajectory. Scott mentioned several projects that he had, and one of them was focused on anal cancer (in collaboration with Dr. Elizabeth Chiao, who is currently at MD Anderson). Without any doubt in my mind, I picked anal cancer. I have been working on studying different aspects (epidemiology, determination of optimal prevention through screening and treatment, and HPV vaccination) of anal cancer since then (for almost 10 years now).
What did your most recent study find?
In our two most recent publications that utilized national data (nearly all cancer diagnoses in the US) both focused on studying anal cancer trajectories, we found that anal cancer rates are rising rapidly (nearly 3%/year) among US men and women, with a marked increase (>5% year) in individuals 50 years and older. What is troubling about this increase is that the proportion of patients diagnosed with advanced-stage disease (when 5-year survival is less than 40%) is increasing most rapidly. Another troubling find that emerged from our work was that anal cancer mortality rate also increased at a similar pace (>3% year) among US men and women. The rise in incidence was particularly prominent in White women (aged 50-70 years) and Black young men.
Cervical cancer is the most well-known and common cancer caused by HPV among women. In our recent study, we reported that in 2017 among elderly White women (aged >65 years) anal cancer rate and burden (annual number of cases diagnoses) has surpassed cervical cancer incidence, while among women aged 50-65 years, the incidence rate has neared the cervical cancer incidence. This indicates reaching a tipping point, where there is a strong need to increases our emphasis on research and prevention to combat this disease.
How did you come to the conclusion that anal cancer is one of the fastest accelerating cancer in the US?
While anal cancer is still relatively rare with less than 10,000 cases diagnosed annually, the rise (per year increase) in the incidence rate of anal cancer is comparable to liver cancer which is the fastest accelerating cause of cancer incidence in the US [Liver cancer is currently rising at a pace of 3% per year].
What would it take to stop the acceleration in cancers?
The HPV vaccine is an important evidence-based measure that can prevent nearly all anal cancer cases and thus has the potential to reverse the rising anal cancer incidence rates. However, nearly 46% of all adolescents did not receive the recommended HPV vaccine doses in 2019. There are some reports that the vaccination coverage has further dropped (~50-70% decline) in 2020 due to the COVID-19 epidemic. Furthermore, as documented by our team in a study recently led by Dr. Kalyani Sonawane, there is substantial HPV vaccine hesitancy in the US, with over 50% of parents of unvaccinated adolescents lack intent to vaccinate their kids, largely driven by unsubstantiated safety scarce. This is troubling. The HPV vaccine is a safe and effective cancer prevention vaccine. It is important that clinicians convey the benefits of the HPV vaccine to parents.
It is also important that persons at high risk of developing anal cancer speak with their clinicians if they are eligible to undergo anal examination (either anal cytology or digital anorectal examination) as it is likely (although we still lack strong evidence-based data) that the disease may get diagnosed at an early stage when it is curable.
Why is it important that there is a greater research focus on anal cancer?
Anal cancer is preventable, and we now have a good understanding of underlying risk factors (e.g., HIV, male to male sexual contact, history of cervical precancer/cancer, smoking, and immunosuppression) that elevate anal cancer risk. However, we are yet to have national evidence-based screening recommendations for anal cancer (similar to those available for cervical cancer), and the other challenge that we are currently facing is scarce screening resources. Furthermore, given that anal cancer is still relatively rare at the population level with an incidence rate of less than 3 cases diagnosed per 100,000 persons, screening all US adults may lead to unnecessary diagnostic procedures and treatment, adding anxiety and causing more harm than benefits. Therefore, it is important to identify at what age we should start screening? How frequently? And who should be screened for this disease?
What would you like families facing anal cancer to know?
The stigma around anal cancer needs to go away. The disease and treatment could add a lot of distress and can have a substantial impact on the physical and psychological well-being of the patient. It is extremely important to provide emotional support and comfort to a patient diagnosed with anal cancer.
What are you hoping to research next for anal cancer?
Our team is currently studying optimal ways to prevent anal cancer, including optimal use of screening and treatment for anal cancer prevention (i.e., who should be screened and treated for and how frequently). We hope that our work will lead to evidence-based screening recommendations. Our ongoing and future work also focuses on studying questions such as How to improve the distribution of anal cancer screening resources to maximize anal cancer prevention efforts? What can be done to mobilize screening resources and improve screening infrastructure? My team at UTHealth is also quantifying barriers to HPV vaccination and its long term benefits. My goal is to continue to contribute to the national and global efforts to curb the rapidly rising occurrence of and mortality caused by this disease.