What everyone should know about Human Papilloma Virus (HPV) and anal cancer

Human Papilloma Virus (HPV) and anal cancer

HPV is a common sexually transmitted infection (STI). As John Aravosis has noted previously, HPV has been closely associated with a variety of cancers:

According to the National Cancer Institute, various strains of the sexually-transmitted HPV virus (there are many) cause `virtually all` cervical cancers, `most` (85% of) anal cancers, more than half of all oropharyngeal (mouth and throat) cancers, and half of vaginal, penile and cancers.

(There`s also been a particularly large increase in HPV-caused oropharyngeal cancers in men over the past few decade: `The incidence of HPV-associated oropharyngeal cancer has increased during the past 20 years, especially among men. It has been estimated that, by 2020, HPV will cause more oropharyngeal cancers than cervical cancers in the United States`.)

Not every infection of even the `right` strain will lead to cancer, but `infections that last for many years increase a person’s risk of developing cancer,` according to the National Cancer Institute.

While HPV is associated with a variety of cancers — most famously cervical cancer in women — I’d like to focus primarily in this article on anal cancer.

Gay Men: Anal cancer rates have been increasing in both HIV positive and HIV negative men who have sex with men (MSM). In MSM, anal carcinoma occurs in about 1: 100,000 men, with African-American men having a slightly higher incidence.

Women: Anal cancer can also be found in women who have had anal sex. Possibly the most famous woman to die from anal cancer was 70s icon Farrah Fawcett, who passed away in 2009.

Farrah Fawcett via Featureflash / Shutterstock.com">Shutterstock

Farrah Fawcett. Featureflash / Shutterstock.com

Both men and women can develop genital warts from some types of HPV. And HPV causes cervical cancers in women. There are about 3,000 new cases of anal cancer in women each year, with white women having more anal cancers than other races. And about 2,000 men will be newly diagnosed with anal cancer yearly.

What are the risk factors for developing anal cancer?

Here are some of the risk factors for developing anal cancer:

  • Having HPV: When tested, most anal carcinomas have been shown to be related to HPV. That does not mean that everyone who tests positive for HPV will end up getting cancer.
  • Anal sex: being receptive to anal intercourse (bottoming).
  • Older age: Most anal cancers occur in people over 50 years old.
  • Smoking: Smoking cigarettes has been found to be a risk factor for developing anal cancer.
  • Multiple sexual partners: Men and women who have had multiple sexual partners have a higher risk of developing carcinoma.
  • Drugs and other illnesses: Immunosuppressive drugs and diseases, or conditions that lead to immunosuppression (HIV, post-organ transplant, etc).

The most common symptoms of anal carcinoma are:

  • Bleeding from the anus or rectum
  • Rectal itching
  • Rectal pain
  • A growth (lump or mass) in the anal canal

Unfortunately, these symptoms are virtually identical with the symptoms of a hemorrhoid. Many people assume that the problem is a benign hemorrhoid, that it will will go away in time, and thus don’t seek treatment. This assumption allows the anal cancer to continue to grow and possibly spread.

Prevention of anal cancer

Ways of helping to decrease your chances of contracting anal cancer:

1. The HPV vaccine has been shown to decrease the risk of developing anal cancer. So vaccination is recommended for the prevention of infection.

Recommendations are that girls receive HPV vaccine early, before they become sexually active (around age 12). There is also good information that boys should probably get vaccinated with HPV vaccine at around this age, too.

Some men beyond their teens are getting the vaccinations (there are three shots over a six-month period) as well. John Aravosis recently wrote about getting vaccinated himself.  Keep in mind that if insurance, or some public health agency, isn’t paying for the vaccine, it’s not cheap — all three shots can cost around $500 or more.

2. Practice sater sex

3. Stop smoking

Men (and women) who have been receptive to anal intercourse should be aware of these symptoms of anal carcinoma and get checked for it if they occur. They may also have their physicians check them for signs of anal carcinoma on a regular basis. Examination for anal carcinoma may include: digital rectal exam, anuscopy, ultrasound exam, biopsy or Pap smear. Your primary care physician may do some of these tests on you, or he may refer you to someone who has more expertise and additional equipment available, like a gastroenterologist.

Let your doctor know if you’re at risk of having HPV/anal cancer

Please, make sure to let your doctor know that you may be at higher risk for anal carcinoma. Tell her if you know that you have HPV, if you’ve had receptive anal sex, multiple sex partners, if you’re gay, have symptoms that might be from rectal carcinoma, etc. Your doctor may not think to check for rectal cancer otherwise.

Anal cancer can spread, but slowly, When it does spread, it can be very difficult to treat, and may be fatal.

Which methods are used for treatment will depend on the size of the cancer, whether it’s spread, the patient’s general health, what the patient wants to do, and other factors. Treatment for anal cancer can include any or all of the following: surgery, radiation and chemotherapy.

So, if you meet any of the above criteria putting you at risk of anal cancer, have one or more of the symptoms described above, or just want to have a periodic screening, see your doctor and tell them the reason for your visit.  It could just save your life.

Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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19 Responses to “What everyone should know about Human Papilloma Virus (HPV) and anal cancer”

  1. Hue-Man says:

    I would add the most obvious: Watching TV causes promiscuity. Our culture is based on “sex sells”, especially straight sex involving beautiful women and men.

    The HPV vaccine debate, like condom-based sex education in schools, reminds me of the early response to the AIDS massacre – treating the disease might be seen as an endorsement of the “homosexual lifestyle”.

  2. Indigo says:

    Thank you.

  3. docsterx says:

    Sorry to hear about this. But thank you for helping him and getting active to help raise awareness of HPV.

  4. docsterx says:

    One of the arguments that some religious groups have against vaccination is that it “promotes promiscuity.” But that’s like saying that condoms and antibiotics should be banned because they promote promiscuity, too. If you let people with STIs suffer, they won’t be promiscuous. Of course they may become sterile or have other complications, as well.

    Using their logic: Having coed schools probably promotes promiscuity. Having female teachers for boys and male teachers for girls could promote promiscuity. School dances promote promiscuity. Female cheerleaders in tight uniforms promote promiscuity. Swimming competitions promote promiscuity. To them, it’s all about the possibility of sinful sex, not health.

    They’re ignoring the fact that the vaccine could literally be lifesaving in some cases. Not to mention, it could decrease others’ risk of getting HPV. If smallpox were listed as being sexually transmitted, would they lobby against the smallpox vaccine, even though that disease has killed millions?

  5. docsterx says:

    Dentists should do it because it’s hard to get such good exposure of the for a good exam of the mouth and throat in a doctor’s office. The dentist has the light source and instruments to really get a good look at the tongue, gums, cheeks behind the teeth, underside of the tongue, etc. that you just can’t get in a doctor’s exam room. But some don’t seem to do it. One of my former dentists never did an oral exam.

  6. Mike_in_the_Tundra says:

    That explains a lot about my dentist. I would guess that about 75% of her patients are gay men, so it’s a good thing she is doing.

  7. docsterx says:

    To give it a little better perspective, the number of anal cancers in men has increased three fold since the late 1970s.
    Just being exposed to the specific strains that cause anal cancers doesn’t mean that an anal cancer will occur. There are other factors that are involved. For example, men with HIV are at higher risk of getting an anal cancer than gay men who are HIV negative and are receptive to anal sex. Also, in general, HPV takes a while to cause any apparent disease. For example, if someone develops genital warts, the infection might have occurred months previous to their appearance.
    As to your previous doctor’s thoughts, true there weren’t protocols, but that doesn’t mean that getting an anal Pap is valueless. Having said that, it does take some expertise in reading anal Pap smears that not everyone has. However, he can do an anal swab to test for the presence of the carcinogenic strains of HPV to see if someone is in a high risk stratum.

  8. docsterx says:

    Yes, see above. He’ll look for lesions that might be caused by HPV. The dentist could also do the exam.
    Note that smoking nad drinking (especially heavy smoking and/or drinking alcohol) are also linked to oropharyngeal cancers like certain strains of HPV are. The risk is higher the more the patient smokes and/or drinks and the longer he has been doing those things. Adding a strain of HPV that is a cause of throat cancer, just increases the risk even more. So, to help decrease risk, stop smoking and alcohol only in moderation, if at all. And keep an eye out for the symptoms I mentioned above. And, when you examine your mouth, also look at the tongue and UNDER the tongue for abnormalities.

  9. docsterx says:

    All good questions.

    A plantar wart is caused by HPV. But it’s a strain that doesn’t cause cancer, it just causes warts on the skin. Often plantar warts form after exposure to HPV from a surface where the HPV has been deposited by someone else with a plantar wart: gym locker rooms, pool side areas, etc. where people walk barefoot.

    No, you won’t have the herpes that caused the plantar wart in your bloodstream. This virus stays in the skin where it causes the wart to form. They will normally subside even without treatment.

    Point of contact often means skin-to-skin contact from a person who has genital herpes to an uninfected partner. In your case, point of contact may have been the floor of the yoga studio and your bare foot. Or a gym locker room or gym shower or an other area where people were walking barefoot and shedding virus.
    Yes, the doctor can take a saliva sample and have it tested for the presence of HPV. But just having the type of HPV in the saliva that is associated with throat cancer doesn’t mean that there IS cancer of the throat. Your dentist and doctor can examine your mouth and the tonsils/upper part of the throat. But some ares are very difficult to visualize. If you notice any bleeding, bruising, ulcers that are slow to heal, hoarseness, discolorations (red, white and red and white mixed) or other abnormalities of yout mouth, tongue, tonsils, etc. let your doctor know.

  10. docsterx says:

    I there are a LOT of HPV strains. Only a few have been linked to cancers: cervical, throat, anal, etc. Most are fairly innocuous. Often, when people get these, they have no symptoms at all and their immune systems clean them up over time.

    And, right, exposure alone doesn’t mean that someone will get cancer.

    They can test to see exactly what strain(s) of HPV are present. They need to identify the virus’ DNA to type it. To see what type of HPV is present, the doctor will either take a swab of the area or use a small special brush. Then that goes to the lab for testing. Cost? No idea.

  11. GarySFBCN says:

    I’ve seen the stories. What I’m getting at is that, given the high numbers of STDs reported, by now we should have seen a greater uptick in these cancers, unless there is a newer, recent variant of the virus that causes cancer or a new genetic/environmental factor making us more susceptible to progressing from viral infection to cancer. Maybe we are getting better at diagnosing these cancers. But something is not right.

    Also FYI, my previous MD in San Francisco, who has a mostly gay male patient load, didn’t think getting pap smears were a good diagnostic tool, as there were not consistent protocols, nor did he ever find any cancers in the men he did test.

  12. Mark will weigh in in a bit, but I wanted to add something that he can expand on: There are MANY (several dozen) different strains of HPV, and I believe only 4 are associated with various cancers. And even if you’ve been exposed to one or more of those 4, it does not mean that you will get cancer.

    Also, I’d be curious for Mark to weigh in on how one tests for these various strains and whether you’ve been exposed – do they do a blood test? And is it expensive.

    One more point, I was told a few years back, by someone in the know, that even a gay man in his 40s should get the shot as while you’ve likely exposed to 1 of the cancer-associated strains by then (if you’ve been sexually active with more than one partner), you may not have been exposed to all 4 strains. Thus, this person in the know suggested that I get vaccinated, and I did.

  13. Mark will weigh in when he gets a chance, but I’ve been seeing a lot of reports about oral cancer rates growing sharply related to HPV.


    The “epidemic” Satterwhite speaks of, he said, is driven almost entirely by two bugs: HPV, and chlamydia. Chlamydia, a bacterial infection, is easily curable if it’s diagnosed. And there’s a very effective vaccine for the most dangerous forms of HPV that can trigger cervical, oral, anal, and penile cancers, and cause genital warts.

    But, Golden argued, “we have snatched defeat from the jaws of victory” by not pursuing effective strategies, such as school-based universal access to the HPV vaccine.


  14. dcBiGuy says:

    Thanks, Mark for the good information. I have more questions about the virus and how it is transmitted. A few years ago, I suddenly had a painful spot on the sole of my foot. My yoga teacher noticed it and told me that I had a plantar’s wart. She told me to keep it covered for yoga class and don’t walk on other peoples’ mats, and to disinfect my mat after class. She said to treat it by using a non-prescription wart remover. I did what she suggested and it went away quickly

    A few weeks later, I had a very thorough physical from my new gay doctor. He saw the remains of the healing and asked about it. I told him about the yoga teacher diagnosis and my treatment. He told me that he would have given me the same advice. Then he told me that the warts are HPV, which means I’ve been exposed to HPV. This was news to me. He asked me a lot of questions about my sexual history, and even though he thinks I’m low risk, he took an anal pap smear, which he has done each year since, and it always comes up negative. So what does it mean that I have been exposed to HPV? Is it latent in the blood stream? I also don’t understand the point of contact transmission. Is there a test for the throat similar to the anal pap smear?

  15. Mike_in_the_Tundra says:

    Let’s say one is a top, can a doctor examine their throat to check for HPV?

  16. California says:

    It may not be as rare as you think. My friends only know that I had pre-cancerous spots in my anal canal cut out – not that it was HPV. It’s kind of embarrassing talking about that kind of stuff.

  17. Hue-Man says:

    Announced last Thursday: “Alberta will start including boys in free school vaccinations that already protect girls from a virus that causes cervical and other types of deadly cancers.

    Health Minister Fred Horne says about 47,500 boys in Grades 5 and 9 are to receive the HPV vaccine next fall.” http://www.ctvnews.ca/health/health-headlines/alberta-expands-hpv-vaccines-to-boys-2nd-province-to-do-so-after-pei-1.1267927

    This surprised me: “Last November, the Calgary Catholic School Board reconsidered its opposition and voted to allow school-based HPV vaccinations for girls.”

  18. GarySFBCN says:

    The rate may be increasing, but it still seems somewhat rare. Shouldn’t we have seen ‘epidemic’ levels of oral/anal cancer by now?

  19. Indigo says:

    A close friend passed away a little more than a decade ago from throat cancer that was HPV-related. He was socially actively, almost certainly infected by casual gay sex partners in his younger years, and a delight to know. The ailment lingered for a good long time, transporting him to treatment centers got complicated at times and then resulting in hospitalization and his death, a very deep loss to our local community. Back then, the HPV-connection was not well understood and it fell to me to point out the connection and to lobby, if that’s the word, for better awareness of the danger of indiscriminate oral sex. Thanks, Dr. Mark, for the timely update and reminder.

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