International Journal of Colorectal Disease

https://doi.org/10.1007/s00384-020-03640-9

ORIGINAL ARTICLE

Management of anal intraepithelial neoplasia and anal squamous

cell carcinoma at a tertiary referral centre with a dedicated infectious
diseases unit: an 18-year review
M. Power Foley 1,2 & M. E. Kelly 1,2 & C Kerr 2,3 & C. Kennedy 1,2 & D. Gallagher 2,4 & C. Gillham 2,5 & B. J. Mehigan 1,2 &
P. H. McCormick 1,2 & C. Bergin 2,3 & J. O. Larkin 1,2

Accepted: 14 May 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Introduction Anal squamous cell carcinoma (ASCC) is a rare malignancy with rising incidence rates. Risk factors include human
immunodeficiency virus (HIV) infection, high-risk sexual activity and HPV-related genitourinary dysplasia/neoplasia. There is
an overlap between high-risk patients and those attending HIV Medicine/Sexual Health (HMSH) services. We hypothesised that
HMSH involvement may facilitate earlier referral to colorectal surgeons, with better outcomes.
Methods Retrospective review of all ASCC and anal intraepithelial neoplasia (AIN) treated at a tertiary-referral hospital with a
dedicated HMSH clinic between 2000 and 2018. Comparative analysis was performed of demographics, management and
outcomes between HMSH and non-HMSH patients.
Results One hundred and nine patients had anal pathology, eighty-five with ASCC (78%) and twenty-four with AIN (22%).
Seventy (64%) were male. Median (range) age at ASCC diagnosis was 51 years (26–88). Thirty-six percent of all patients
attended HMSH services, 28% were HIV positive, and 41% of males were men-who-have-sex-with-men (MSM).
Eighty-one ASCC patients (97.5%) were treated with curative intent. Sixty-seven (80%) had primary chemoradiation therapy.
Fifteen (17.5%) had primary surgical excision. Twelve (14%) developed recurrent disease. Ultimately, seven required salvage
APR. Overall 3-year survival (3YS) was 76%.
HMSH patients were significantly younger at ASCC diagnosis (p < 0.001), with a higher prevalence of HIV, HPV and MSM.
HMSH attenders also tended to be diagnosed at earlier stages, were less likely to develop recurrence and achieved better overall
outcomes, with a superior overall 3YS than non-HMSH patients (92% vs 72%, p = 0.037).
Conclusion ASCC incidence is increasing worldwide. The HMSH cohort has emerged as a distinct subpopulation of younger,
high-risk, male patients. Collaboration between HMSH and colorectal surgeons offers an opportunity for risk reduction strategies
and earlier intervention.

Keywords Anal Pathology Squamous Cell Carcinoma . Anal Intraepithelial Neoplasia . HIV Medicine/Sexual Health

What does this paper add to the literature?

The high incidence of premalignant and malignant anal pathology among
HIV-Medicine/Sexual Health service users is well documented in the
literature; however, to date, there are no studies looking at oncological
outcomes in this unique cohort from a colorectal surgery perspective.

* M. Power Foley 3
Department of Genitourinary Medicine and Infectious Disease, St
foleymp@tcd.ie James’ Hospital, Dublin 8, Ireland
4
Department of Medical Oncology, St James’ Hospital, Dublin 8,
1
Department of Colorectal & General Surgery, St James’ Hospital, Ireland
Dublin 8, Ireland 5
Department of Radiation Oncology, St James’ Hospital, Dublin 8,
2
School of Medicine, Trinity College Dublin, Dublin 2, Ireland Ireland

Introduction
Anal squamous cell carcinoma (ASCC) accounts for 4%
of all lower gastrointestinal tract cancers [1]. The combi-
nation of increasing incidence rates and an observed epi-
demiological shift from older, female patients to younger,
male patients engaging in high-risk sexual activity has
renewed interest in this rare malignancy [2, 3]. In the
USA, a threefold increase in incidence in men (from 1
to 3 per 100,000) and a 1.7-fold increase in women (from
1.4. to 2.4 per 100,000) have been observed between
1973 and 2009. The most recent Surveillance
Epidemiology and End Results (SEER) statistics report
the median age of diagnosis is 62 years, and that the
overall incidence remains slightly higher in women. The
5-year survival rate is reported to be 63.8% for all disease
stages [4]. The National Cancer Registry of Ireland
(NCRI) review of HPV-related cancers reports a signifi-
cant annual increase (3–4%) in ASCC over the last decade
[5]. Cigarette smoking, chronic immunosuppression (hu-
man immunodeficiency virus (HIV) infections, solid-
organ transplant recipients on anti-rejection regimens or
patients on long-term corticosteroids) and high-risk sexual
activity (defined by the World Health Organisation as
engaging in unprotected sexual intercourse, penetrative
anal intercourse, and sexual intercourse with multiple
partners, intravenous drug users, sex workers or partners
with prior sexually transmitted infections) are all
established risk factors for ASCC [6–9]. However, chron-
ic infection with the oncogenic human papillomavirus
(HPV) is the dominant driver of carcinogenesis in
ASCC and its precursor lesion, anal intraepithelial neopla-
sia [10, 11]. It has been determined that 88–94% of ASCC
can be attributed to HPV, particularly high-risk genotypes
like HPV-16 and HPV-18 [12–15].
Multiple international studies have reported significantly
higher rates of ASCC in HIV-positive patients, compared with
the general public [16–19]. Recently, the synergistic effect of
immunosuppressive HIV infection with oncogenic HPV in-
fection has been identified as a strong risk factor for the de-
velopment of high-grade AIN and ASCC. Men-who-have-
sex-with-men (MSM) are deemed to be a high-risk population
[20, 21].
There is a significant overlap between the patients at
highest risk for AIN and ASCC and those attending HIV
Medicine/Sexual Health (HMSH) services. The catchment ar-
ea of our institution has the highest prevalence of HIV in
Ireland (2.25/1000) [22, 23]. As of 2018, 2532 HIV patients
attended the HMSH clinic at our institution, of whom 48% (n
= 1217) were MSM [24]. We sought to investigate whether
patients attending the HIV medicine/sexual health services
who developed AIN or ASCC presented to colorectal sur-
geons at earlier stages and had better outcomes.
Int J Colorectal Dis
Methods
Study design and participants
This single-centre series, examining the period from 2000
to 2020, was conducted in accordance with the
“Strengthening the reporting of observational studies in
epidemiology (STROBE) statement” [1]. Prior to com-
mencement, ethical approval for a retrospective review
was granted by the local institutional committee. All pa-
tients treated for biopsy-proven anal intraepithelial neo-
plasia and anal squamous cell carcinoma between 2000
and 2019 at our institution were included in the analysis.
Patients were identified from a prospectively maintained
local cancer database (ASCC) and an electronic histopa-
thology database (AIN). Further demographic, clinical,
histopathological and outcome data were extracted from
electronic patient records. Demographic data included
age, comorbidities, risk factors and attendance at our in-
stitution’s HIV Medicine/Sexual Health clinic.
Aims
Primary aims were identifying the prevalence of known risk
factors for anal pathology among the total cohort and the HIV
Medicine/Sexual Health subcohort, and investigating the im-
pact of HIV Medicine/Sexual Health involvement on the age
of ASCC diagnosis, stage at diagnosis and objective survival
outcomes. Secondary aims were reviewing overall manage-
ment of ASCC at our institution.
Analysis
All data were tabulated using Microsoft Excel 2020
(Microsoft Corporation, Redmond, WA, USA) and
Statistical Package for the Social Sciences (SPSS) soft-
ware Version 24.0 (IBM SPSS Inc., Armonk, NY, USA.
IBM Corp) was used for data analysis. Normally distrib-
uted continuous data were expressed as mean ± standard
deviation (SD), while median (range) was used to de-
scribe the non-normally distributed continuous data.
Categorical variables were presented as count and percent.
Chi-square and one-way ANOVA tests were used to as-
sess significance between categorical variables. Non-
parametric data was assessed using a Mann-Whitney U
test or a Kruskall-Wallis test, depending on the number
of variables involved in the analysis. Kaplan Meier
Survival curves and life table analysis were used to assess
differences in overall and disease-specific survival be-
tween the two subcohorts at 3 and 5 years. A p value of
< 0.05 was considered statistically significant.
Int J Colorectal Dis
Fig. 1 Graphical representation
of two yearly incidence of all anal
pathology, AIN, ASCC at our
institution between 2000 and
2018, demonstrating increasing
incidence trends in ASCC and
overall
Results
Incidence, demographics and prevalence of risk
factors
Over an 18-year period, 109 patients were treated for AIN or
ASCC. Eighty-five patients (78%) had invasive squamous cell
carcinoma of the anus (ASCC). Of these 85, twenty patients
(18.3% of total cohort, 23% of ASCC cohort) had newly di-
agnosed concurrent AIN at the time of ASCC diagnosis. A
further 24 patients (22%) had AIN only, with no malignant
anal histology.
The annual incidence of ASCC at our institution increased
during the study period [Fig. 1].
Seventy patients (64.2%) of the total cohort were male,
accounting for 59% of the ASCC cohort and 83.3% of the
AIN cohort [Table 1]. Nine male patients (18%) and twelve
female patients (34.28%) had both AIN and SCC at initial
diagnosis. Seventy-one percent of the total male cohort had
invasive histology, compared with 89.7% of the total female
cohort.
The median age at diagnosis in the total cohort was 51
years (range 25–88). We looked at the impact of various fac-
tors on the age of diagnosis using one-way ANOVA non-
parametrical tests, tabulated in Table 2. Patients with ASCC
were diagnosed at an older age, compared to patients with
premalignant pathology (p = 0.004). It was consistently ob-
served that high-risk patients were diagnosed with anal
Table 1 Breakdown of gender in the total cohort, ASCC subcohort and
AIN subcohort
Gender Male
Total cohort 64.2%
n = 70
ASCC 59%
n = 50
AIN 83.3% n = 20
pathology at a younger age, notably HIV-positive patients (p
< 0.001), HPV-positive patients (p = 0.030), HMSH service
users (p < 0.001) and MSM (p < 0.001).
Tables 3, 4, and 5 outlines the prevalence of various
established risk factors for anal pathology, including smoking
(69% of total cohort), HPV-positive status (45%) and HIV-
positive status (28.4%).
Forty-four (40.4%) of the total cohort had been treated for a
prior sexually transmitted infection (STI), including twelve
cases of syphilis and fourteen cases of genital herpes simplex
virus (HSV). Seventeen out of thirty-nine women (43.5%) had
prior gynaecological neoplasia. Three patients had a prior sol-
id organ transplant and were on lifelong immunosuppression.
Progression from AIN to ASCC
Six patients (7%) progressed from AIN to ASCC during the
study period. The median interval between the diagnosis of
AIN and ASCC in these six patients was 25.0 months (range
1–108). No risk factors demonstrated significance in our co-
hort (Fig. 2).
.
Management of anal squamous cell carcinoma
Of note, specific treatment details were unavailable for two
patients. Of those with complete data available, eighty-one
(97.5%) were managed with curative intent, while two
proceeded directly to palliation. Table 6 outlines the manage-
ment strategies. Fifteen patients had a primary surgical resec-
Female tion, with fourteen excision biopsies of locally resectable dis-
ease (not involving the sphincters). One patient had an exten-
35.8% sive perineal resection of perianal necrotising fasciitis caused
n = 39
by an undiagnosed ASCC. Sixty-seven patients (80.7%) had
41%
n = 35
primary chemoradiation therapy, while a single patient had
16.7%
radiation monotherapy. Of this cohort, seven patients did not
n=4 respond to medical therapy, of whom four ultimately required
a salvage APR, while the remaining three were palliated due
Table 2 Median age at diagnosis in the total cohort, ASCC subcohort and AIN subcohort. Breakdown of median age at diagnosis in each group in the presence/absence of various risk factors for anal
pathology, with statistical significant noted

Age [years (range)]

Total Gender HIV MSM (males) HMSH

Male Female HIV + ve HIV – ve Yes No Yes No

Total cohort 51 years 50.5 years 54.0 years 41.0 years 55.5 years 41.0 years 56.0 years 41.0 years 58.0 years
(25–88) (26–82) (25–88) (26–75) (25–88) (26–75) (32–82) (26–75) (25–88)
p = 0.112 *p < 0.001 *p < 0.001 *p < 0.001
ASCC 53.0 years 52.0 years (31–82) 54.0 years (25–88) 43.0 years 57.0 years 46.00 years 58.00 years 41 years 58 years
(25–88) (26–75) (25–88) (31–75) (32–82) (26–75) (25–88)
p = 0.701 *p < 0.001 *p = 0.009 *p < 0.001
AIN 42.0 years 41.0 years 61.0 years 36.0 years 49.0 years 33.50 years 50.0 years 38.50 years 56.50 years
(26–67) (26–67) (38–76) (26–58) (30–76) (26–67) (36–76) (26–67) (38–76)
p = 0.081 p = 0.055 *p = 0.025 *p = 0.009

Table 3 Breakdown of the presence/absence of well-established risk factors for anal pathology among the total cohort, ASCC subcohort and AIN subcohort

Risk factors

Smokers HIV HMSH MSM (males) HPV

Yes No Yes No Yes No Yes No Yes No

Total cohort 68.8% (n = 75) 31.2% 28.4% (n = 31) 71.6% 35.8% 64.2% 41.4% (n = 29) 58.6% 45% (n = 49) 55%
(n = 109) (n = 34) (n = 78) (n = 39) (n = 70) (n = 41) (n = 60)
ASCC 71.8% (n = 61) 28.2% 21% (n = 18) 79% 25% (n = 21) 75% 34% (n = 17) 66% 35% (n = 30) 65%
(n = 85) (n = 24) (n = 67) (n = 64) (n = 33) (n = 55)
AIN 58.3% (n = 14) 41.7% 54.2% 45.8% 75% (n = 18) 25% 60% (n = 12) 40% 79.2% (n = 19) 20.8%
(n = 24) (n = 10) (n = 13) (n = 21) (n = 6) (n = 8) (n = 5)
Int J Colorectal Dis
Int J Colorectal Dis

Table 4 Breakdown of the presence/absence of well-established risk factors among the total cohort, ASCC subcohort and AIN subcohort, with
demonstration of statistically significant higher prevalence in patients attending GUIDE services compared with those not known to GUIDE

HIV medicine/sexual health cohort Community referrals p

Total ASCC AIN Total ASCC AIN

n (%) 39 (36%) 21 (24%) 18 (75%) 70 (64%) 64 (76%) 6 (25%)

Male gender n = 36, 92% n = 18, 86% n = 18, 100% n = 34, 48.5% n = 32, 50% n = 2, 33% * < 0.001
Age 41.0 years 41.0 years 38.5 years 57.5 years 57.5 years 56.5 years * < 0.001
HIV + ve n = 30, 77% n = 17, 81% n = 13, 72% n = 1, 1.5% n = 1, 2% 0 * < 0.001
HPV + ve n = 31, 82% n = 15, 75% n = 16, 89% n = 18, 27% n = 15, 25% n = 3, 50% * < 0.001
MSM n = 26, 72% n = 14, 78% n = 12, 66% n = 3, 9% n = 3, 9% 0 * < 0.001
STI n = 35, 92% n = 18, 86% n = 17, 94% n = 9, 14% n = 7, 12% n = 2, 33% * < 0.001
Smoker n = 25, 66% n = 16, 80% n = 9, 50% n = 50, 76% n = 45, 75% n = 5, 83% 0.275

to the extent of disease and/or severe co-morbidities. Twelve [26–28]. However, there remains a paucity of literature
patients (14%) had biopsy-proven recurrence after primary looking specifically at the impact of early involvement on
treatment, ten after chemoradiation and two after primary sur- ASCC outcomes. It would seem reasonable that patients
gical resection. Two-thirds recurred locally (n = 8), while four who are compliant with attendance at regular HMSH appoint-
had distant metastases. Three patients were palliated at time of ments would be more vigilant about anorectal pathology and
recurrence. Overall, seven patients required a salvage APR, might therefore be referred at earlier stages to colorectal ser-
71% (n = 5) of whom had negative (R0) resection margins. vices. Our results observed that a 3-year overall survival was
The two patients with incomplete resections went on to devel- significantly higher in HMSH patients than non-HMSH at-
op further local recurrence within 8 and 9 months, respective- tendees (93% vs. to 72%, p = 0.037) and support the recom-
ly, at which stage they were palliated and later died due to mendation of a formalised surveillance pathway incorporating
complications of recurrent ASCC. both HMSH and colorectal clinical inputs. Although beyond
the scope of this review, the association between HPV infec-
Treatment and outcomes in cohort versus cohort tion and other genitourinary tract squamous cell carcinomas
highlights the importance of collaboration not only between
Table 6 describes the breakdown of disease characteristics, HMSH and colorectal surgeons, but also with gynaecologists.
management strategies and outcomes in total cohort, and il- Our institution has fostered a strong link between medical and
lustration of any significance differences between HMSH and surgical oncology, and gynaecology. All female patients with
non-HMSH cohorts a new diagnosis of AIN or ASCC are referred for full
HMSH patients had lower rates of recurrence, better sensi-
tivity to chemoradiation and less need for salvage APRs.
Table 7 illustrates the mortality and survival outcomes in Table 5 Breakdown of risk factors for progression from AIN to ASCC,
both cohorts. The overall mortality rate in the ASCC cohort with odds ratio (95% confidence intervals) and statistical significance of
was 30% (n = 25), with a cancer-specific mortality rate of 17% each
(n = 14). At 3 years, the HMSH cohort demonstrated a signif- Risk factors for progression AIN to ASCC
icantly better overall survival rate than non-HMSH patients (p
= 0.037). In addition, a 3-year overall survival for ASCC was Factor n (%) Odds ratio p value
also higher in HMSH cohort, as shown in Fig. 3.
Male gender 3 (50%) OR 1.469 p = 0.455
(95% CI 0.279–7.741)
Smoker 3 (50%) OR 3.625 p = 0.213
Discussion (95% CI 0.667–19.71)
HPV 4 (66.6%) OR 0.277 p = 0.335
(95% CI 0.047–1.614)
The incidence of anal pathology (AIN and ASCC) is increas- HIV 2 (33.3%) OR 0.542 p = 0.833
ing internationally. Our results are consistent with internation- (95% CI 0.091–3.232)
al reports, with an overall 5-year survival of 65% [25]. Over MSM 2 (66.6%) OR 0.268 p = 0.417
(95% CI 0.022–3.202)
one-third of our patients (36%) came from HIV Medicine/
HMSH 2 (33.3%) OR 0.679 p = 0.898
Sexual Health clinics, reaffirming studies which advocate (95% CI 0.115–4.005)
the development of dedicated screening and management
 Int J Colorectal Dis

Fig. 2 Graphical representation Biennial incidence of Anal Pathology in HMSH and Total Cohorts
of two yearly incidence of all anal 25
pathology and anal pathology in
HMSH and non-HMSH cohorts
at our institution between 2000 20

Number of New Cases

and 2018, demonstrating increas-
ing incidence trends in ASCC and All Pathology
15
overall
HMSH
10
Non-HMSH

0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018
Year

gynaecological assessment prior to commencing treatment to
screen for concurrent HPV-related genital tract lesions.
Conversely, 15% of our female cohort (n = 6) were referred
by gynaecologists who had identified suspicious anal lesions
[29].
The treatment of anal cancer has changed significantly since
1974, when the introduction of the Nigro chemotherapy regimen,
using 5-FU and mitomycin C (MF), marked a paradigm shift in
management, from surgical to medical therapies [30]. In 1996,
the seminal ACT1 randomised controlled trial (RCT) reported
this chemotherapy regimen combined with radiation therapy
(MF-CRT) significantly reduced locoregional failure [31].
Since ACT1, successive RTCs have created a strong evidence
base supporting concurrent chemoradiation (MR-CRT) as the
gold standard primary treatment for ASCC [32–40]. The concept
of organ preservation, while retaining APR as an option for
salvage of recurrence or persistent disease, is now well
established. In our cohort, 63 patients (76%) underwent primary
chemoradiation therapy. The only patients for whom primary
surgical intervention is recommended are T1N0M0 patients with
small, well-differentiated lesions not involving the sphincter
muscles [41]. Seventeen (22%) of our ASCC cohort had T1
lesions, of whom ten underwent primary surgical resection while
the remaining seven patients had chemoradiation.
Osborne et al. observed that upwards of 30% of patients
have persistent or recurrent disease after chemoradiotherapy
[42]. The main risk factors for this included the following:
HIV infection, high T and/or N stage at diagnosis and/or in-
ability to complete chemoradiotherapy. In our cohort, fifteen
patients (17.6%) had a recurrence and three patients (3.5%)
had persistent disease. Interestingly, in our series, neither HIV
status (p = 0.615) nor lymph node status (p = 0.615) influ-
enced recurrence. However, 66% (n = 10) of those with recur-
rent disease had a T stage of at least T3 at initial presentation.

Table 6 illustrates the

comparison of management Total HMSH Non-HMSH p value
strategies and outcomes in vs
patients. Patients tended to be n (%) 85 21 (25%) 64 (75%)
diagnosed at earlier stages with
smaller lesions more amenable to Age 53.0 years 41 years 57.5 years *p < 0.001
initial surgical management with T stage T1 17 (22%) 7 (35%) 10 (17%) p = 0.097
sphincter-sparing local resection
T2 23 (29%) 5 (25%) 18 (31%) p = 0.610
than did patients.
T3 24 (31%) 6 (30%) 18 (31%) p = 0.931
T4 14 (18%) 2 (10%) 12 (21%) p = 0.283
Nodal disease 22 (26%) 6 (28.5%) 16 (25.8%) p = 0.804
Distant metastasis 5 (6%) 1 (5%) 4 (6.5%) p = 0.767
Curative intent 80 (97%) 21 (100%) 59 (97%) p = 0.401
Primary surgical 15 (17.5%) 5 (24%) 10 (16%) p = 0.296
Primary chemo/RT 63 (76%) 16 (76%) 53 (84%) p = 0.411
Stoma 24 (28%) 5 (23%) 19 (33%) p = 0.641
No response to chemo/RT 9 (14%) 1 (6.25%) 8 (15%) p = 0.403
Recurrence 15 (17.6%) 3 (14%) 12 (31%) p = 0.380
APR 8 (9.5%) 2 6 p = 0.537
Negative margins 71.5% 100% 75% p = 0.180
Int J Colorectal Dis

0.676

0.533
Anal intraepithelial neoplasia (AIN) is a recognised precur-

–
sor to anal cancer, with HPV infection implicated in potenti-
Breakdown of disease characteristics, management strategies and outcomes in total cohort, and illustration of any significance differences between HMSH and non-HMSH cohorts
ating the neoplastic process. The natural history of the disease

(n = 3)

93.3%
parallels that of cervical intraepithelial neoplasia (CIN) and

Total

14%
24
cervical cancer [14, 15]. Low-grade lesions can be managed

–
with surveillance only, whereas options for high-grade lesions
include topical treatments (imiquimod, 5-fluoro uracil acid (5-
FU) or trichloroacetic acid), ablation (electrocautery (ECA),
HMSH

(n = 1)

100%
infrared coagulation (IRC) or laser) or traditional surgical ex-
Non-

20%
6 cision [43]. Lesions persisting despite topical treatment should

–
be excised and patients entered into a structured surveillance
programme [44]. However, the risk and natural progression
HMSH

(n = 2)
12.5%

90.9%
from premalignant AIN to invasive cancer remains unclear.
18

–
High-risk HPV strains, MSM, HIV, solid-organ transplant
recipients and previous HPV-related dysplasia and/or neopla-
0.466

0.715

0.050
AIN

sia at other sites have all previously been shown to be risk

p

factors for progression [45, 46]. In our cohort, the overall

progression rate from AIN to ASCC was 7% (n = 6 of 85),
(n = 25)

(n = 14)

all of whom had high-grade AIN III.

76.2%
Total

30%

17%

To date, there has been no clear international consensus

85

regarding the optimal frequency of screening high-risk

groups. The majority of calls for focused screening programs
come from HMSH services. Some have advocated screening
(n = 20)

(n = 11)
32.35%
HMSH

for MSM and/or HIV patients, based on the rates of anal

17.7%

69.7%
Non-

pathology observed in their attendance cohort. Goldie et al.

64
ASCC cohort

reported that screening for AIN in HIV-positive MSM patients

is cost effective [47]. However, routine screening programs
93.75%
HMSH

(n = 5)

(n = 3)
23.8%

14.2%

remain contentious. Despite this, there is robust support for

21

prophylactic vaccination against HPV in high-risk patients

[48, 49]. In addition, many advocates for joint HMSH and
colorectal out-patient clinics to expedite prompt investigation
*0.037
0.171

0.274

and management of suspicious lesions. It is evident from this

p

study that patients made up a significant portion of our total

(n = 28)

(n = 14)
26.9%

13.7%

79.7%
Total

109

(n = 21)

(n = 11)
HMSH

31.3%

72.3%
Non-

16%
70
Total cohort

HMSH

(n = 7)

(n = 3)
20.5%

92.6%
8.5%
39

Disease-specific mortality
Overall mortality
Mortality

Fig. 3 Kaplan-Meyer Curve illustrating 3-year survival in the ASCC

Table 7

cohort in HMSH and non-HMSH cohorts. The difference was not signif-
3YS

icant (p = 0.0504)
n

anal pathology cohort (36%, n = 39), and one-quarter of the
ASCC cohort (25%, n = 21). Our results support the imple-
mentation of formal screening partnership between HMSH
and coloproctology services. This is supported by the fact that
the HMSH patients are being diagnosed with ASCC signifi-
cantly younger than among their counterparts, with a median
of 41 years compared with 58 years (< p = 0.001). This high-
lights the opportunity for early intervention and therefore may
be a surrogate for better outcomes. In this study, HMSH pa-
tients with ASCC tended to present with less advanced lesions
than patients, had lower recurrence rates and enjoyed better
overall survival. We do acknowledge however the size of our
study is small, but not unexpected given the pathology.
However, this limits our ability to perform subgroup analysis
of other factors that may influence outcomes or for examina-
tion of functional difference between the two groups. A large
multicentre study would be necessary to accrue a large sample
size to ascertain other factors that are associated with earlier
intervention and/or survival. Despite this, rates of anal cancer
are increasing worldwide and we suggest better collaboration
between HMSH and colorectal surgeons offers an opportunity
for earlier intervention in high-risk patients and the chance to
risk reduce via several medical and surgical interventions.
Acknowledgements We would like to acknowledge Ms Chris Gleeson,
the data manager of the colorectal oncology service at our institution. We
also acknowledge the work done by Ms Lara Gander and Ms Caoimhe
Ryan, two medical students from Trinity College Dublin.
Availability of data and material Not applicable.
Code availability SPSS version 24.0 was used for statistical analysis, no
customised codes were generated.
Compliance with ethical standards
Ethical approval Approval was granted by the institution’s ethics com-
mittee prior to receiving access to the local cancer database.
Conflict of interest The authors declare that they have no conflict of
interest.
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