title: High-resolution anoscopy or expectant management for anal intraepithelial neoplasia for the prevention of anal cancer: is there really a difference?
abstract: BACKGROUND
  High-resolution anoscopy has been shown to improve identification of anal intraepithelial neoplasia but a reduction in progression to anal squamous-cell cancer has not been substantiated when serial high-resolution anoscopy is compared with traditional expectant management.
  
  
  OBJECTIVE
  The aim of this study was to compare high-resolution anoscopy versus expectant management for the surveillance of anal intraepithelial neoplasia and the prevention of anal cancer.
  
  
  METHODS
  This is a retrospective review of all patients who presented with anal squamous dysplasia, positive anal Pap smears, or anal squamous-cell cancer from 2007 to 2013.
  
  
  METHODS
  This study was performed in the colorectal department of a university-affiliated, tertiary care hospital.
  
  
  METHODS
  Included patients had biopsy-proven anal intraepithelial neoplasia from 2007 to 2013.
  
  
  METHODS
  Patients were treated with high-resolution anoscopy with ablation or standard anoscopy with ablation. Both groups were treated with imiquimod and followed every 6 months indefinitely.
  
  
  METHODS
  The incidence of anal squamous-cell cancer in each group was the primary end point.
  
  
  RESULTS
  From 2007 to 2013, 424 patients with anal squamous dysplasia were seen in the clinic (high-resolution anoscopy, 220; expectant management, 204). Three patients (high-resolution anoscopy, 1; expectant management, 2) progressed to anal squamous-cell cancer; 2 were noncompliant with follow-up and with HIV treatment, and the third was allergic to imiquimod and refused to take topical 5-fluorouracil. The 5-year progression rate was 6.0% (95% CI, 1.5-24.6) for expectant management and 4.5% (95% CI, 0.7-30.8) for high-resolution anoscopy (p = 0.37).
  
  
  CONCLUSIONS
  This was a retrospective review. There is potential for selection and referral bias. Because of the rarity of the outcome, the study may be underpowered.
  
  
  CONCLUSIONS
  Patients with squamous-cell dysplasia followed with expectant management or high-resolution anoscopy rarely develop squamous-cell cancer if they are compliant with the protocol. The cost, morbidity, and value of high-resolution anoscopy should be further evaluated in lieu of these findings.
authors.affiliation: Department of Colorectal Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Benjamin P
authors.initials: BP
authors.lastname: Crawshaw
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Russ
authors.forename: Sharon L
authors.initials: SL
authors.lastname: Stein
authors.forename: Harry L
authors.initials: HL
authors.lastname: Reynolds
authors.forename: Eric L
authors.initials: EL
authors.lastname: Marderstein
authors.forename: Conor P
authors.initials: CP
authors.lastname: Delaney
authors.forename: Bradley J
authors.initials: BJ
authors.lastname: Champagne
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000634:Aminoquinolines / Q000627:therapeutic use; D000970:Antineoplastic Agents / Q000627:therapeutic use; D001004:Anus Diseases / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D001005:Anus Neoplasms / Q000188:drug therapy / Q000473:pathology / Q000517:prevention & control*; D001706:Biopsy; D003131:Combined Modality Therapy; D005260:Female; D006801:Humans; D000077271:Imiquimod; D008297:Male; D008875:Middle Aged; D011230:Precancerous Conditions / Q000188:drug therapy / Q000473:pathology / Q000601:surgery*; D011351:Proctoscopy / Q000379:methods*; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D000634:Aminoquinolines; D000970:Antineoplastic Agents; D000077271:Imiquimod