White Coat Underground

The news reports are cryptic. One news report about Farah Fawcett’s cancer went on for five paragraphs before they told us what type of cancer. Cancer is a tough enough diagnosis—there is still a fear and stigma associated with the “C” word which may lead to people putting off diagnosis and treatment. This effect may be magnified when the cancer occurs on the “naughty bits”, such as the breasts, vulva, penis, or in Farah Fawcett’s case, the anus (at least according to news reports). In general, the later a cancer is diagnosed, the worse the prognosis, so it’s important to reduce this stigma. With that in mind, let’s shed some light on anal cancer. (And yes, there are pictures of anuses below the fold—they won’t kill you.)

Anal cancer, like cervical cancer (and some penile and oral cancers) is in most cases caused by a virus. This virus is human papilloma virus (HPV). This virus commonly causes anogenital warts.

i-b24a8e5ddae5e979efc06f799220c6a4-SOA-Condylomata-acuminata-around-anus.jpg

A large number of patients with squamous cell carcinomas of the anus
have a history of this lesion

Anogenital warts are often asymptomatic, and HPV infection can lead to cancer even without causing warts. In looking at risk factors for anal cancer, in men anal-receptive intercourse is strongly associated with anal cancer. In women it is strongly associated with greater than ten sexual partners and with a history of other sexually transmitted diseases. In other words, like cervical cancer, many anal cancers (mostly the squamous cell type) are a sexually transmitted disease, and therefore preventable. (For a little detail on how this virus causes cancer, see this.)

Anal cancers used to be treated by big-ass surgeries (pun intended) which left patients with a colostomy, that is, a hole in their abdomen to which they hook up a bag to catch their poop. Now it is usually treated with a combination of chemotherapy and radiation.

Whenever I have a patient who complains of genital warts, I check them for anal warts (and often find them, in both men and women). There has been research into using anal Pap smears in high-risk individuals, just as we do cervical Pap smears for most women. There has also been promising work on DNA tests for HPV. But none of this will do us any good if we don’t focus on prevention and do our best to destigmatize discussions of “naughty bits”.

We must remember that the fact that a disease is preventable does not mean that culpability must be assigned. Once someone is sick, judging them based on their illness is a nasty, nasty thing to do. But we can make strides in prevention by encouraging condom use and looking more closely at HPV vaccination for boys and girls. It’s time to remind ourselves that avoiding talking about diseases of the penis, vulva, anus or any other part only leads to more disease.

Comments

#1 larkspur
April 6, 2009

Absolutely. Some years ago, an acquaintance of mine died of rectal cancer. I don’t believe shyness or shame caused any delay in his diagnosis (nor do I know if his or any other type of rectal cancer is often linked with HPV), but how he described the onset was kind of poignant.

He’d noticed rectal bleeding, and decided it warranted a visit to the doc, but he told his wife and two close friends that he was going to the chiropractor, because he was too embarrassed to tell them he had a problem with his butt.

He later said that he got over his shyness stat, because there was his rectum, front and center, so there’s no way you can’t talk about it, especially with everyone looking at it.

Unfortunately it had metastasized; there was just the smallest dot on his liver. He had some good time, then some hard and heroic time, and then we lost him.

I’m old, so I remember when breast cancer held a similar stigma. You just didn’t talk about it. Somehow, getting cancer in a woman-part was, like, Eve-related or something.
#2 Dianne
April 6, 2009

Larkspur: Rectal cancer is quite different from anal cancer (it forms in the intestinal mucosa rather than the squamous mucosa of the anus) and as far as I know has no correlation with HPV or any other virus.

I’m sorry about your friend.
#3 Donna B.
April 6, 2009

While having radiation treatment for a benign meningioma, I met a 90 year old woman who had cancer of the vulva (at least that’s the term I remember.) She absolutely was the most hilariously open person I’ve talked to in years. She would say things like “I knew that part of my body was going to cause me trouble from the time I was 14 years old.”

I really had no idea there was a stigma attached to breast cancer. That surprises me.
#4 NationalOstomySupport
April 7, 2009

Thanks for shedding light on this all-too-often hidden topic. And thanks for mentioning ostomy in a matter-of-fact way. More than half a million Americans live with an ostomy (due to severe inflammatory bowel disease, congenital problems, or cancer of the bowel or urinary tract that could not be otherwise treated). And I mean LIVE, not just exist. They take part in all usual aspects of life, with nobody the wiser to their altered plumbing. Our national support organization, United Ostomy Associations of America, and its 280 affiliates can claim some of the credit for helping people connect with each other and, with that support, “arise from the ashes of disease” like our symbol, the Phoenix. ~~ Ken Aukett, UOAA President
#5 Ray Ingles
April 7, 2009

What’s the status on approval of Gardasil for boys? We’ve no daughters, but boys can get HPV too, with negative consequences…
#6 Dianne
April 7, 2009

Looking at Orac’s post on the same issue, it seems that the disease has metastasized and that Ms. Fawcett may have suffered a delay in treatment through the use of CAM.
#7 Zetetic
April 7, 2009

So… The morning news today says Ms. Fawcett’s cancer has metastasized to the liver. I wasn’t aware that HPV induced lesions could go that crazy! But, of course, even basal cell carcinoma can do major damage.
#8 Art
April 7, 2009

Someone needs to send a copy of that photo to all the anti-HPV vaccination folks. Don’t want vaccination? How do you feel about you, or your kid (either sex) having some of this.
#9 larkspur
April 7, 2009

Dianne, thanks for the information about how rectal cancer differs.

If we are speaking plainly, then we have to enunciate what horrifies us, or what grosses us out. This post is about anal cancer, as well as other genital types of cancer, and since the HPV virus is involved, and sexual contact is a mode of transmission, that just opens a whole huge can of stigma. People are looking at pictures of Farrah Fawcett and imagining her being butt-fucked. I would loathe being a celebrity in such a situation. I would loathe being a celebrity at all, I suspect, since plenty of purely healthy sexual fantasy goes on about celebrities, and I am a reserved sort of person.

This is from Web MD:

…According to the American Cancer Society, 85% of anal cancers are associated with persistent infection with the sexually transmitted virus.

[snip]

According to both the American Cancer Society and National Cancer Institute, other risk factors for anal cancer include being over 50 years old, having many sexual partners, having receptive anal intercourse, having a weakened immune system, frequent anal redness and soreness, and being a smoker….

We can talk till we’re blue about how most human beings are actively sexual at some point in their lives, but malignant evidence of it is still going to be used or considered punitively. I don’t know if it’s worse than the drop-off of sympathy that can happen when a smoker gets lung cancer.

So: can a person get anal cancer absent HPV infection (i.e., is that 15% explicable)? Can a certain incidence of anal cancer occur with no other obvious risk factors than god-awful bad luck? Will we ever be able to talk about butt-stuff in the manner that creatures who all have butts should be able to talk about it? Damn. I mean, I have pretty stubborn IBS, and thus I’m nearly always exhibiting some kind of danger sign, so information is really important.
#10 catgirl
April 9, 2009

I agree that early diagnosis is important. I just found out that my friend’s my mom has cervical cancer. She’s an immigrant from a place where gynecological visits are not usually done on a regular basis. Fortunately, her prognosis is good, but I hope this convinces my friend to start getting pap smears regularly.
#11 sparky
April 10, 2009

5) Boys can get Gardasil as an off-label use. Just ask your primary care doctor.
#12 sadrice
November 14, 2009

11) Boys can get it, but insurance won’t pay and it’s quite pricey, though I hear it recently got approved for something or other for men, so that may change. I’d like it because even if it isn’t likely to hurt me, I’d feel like crap if I passed it on to someone. I really don’t understand why they don’t routinely give them to males. I mean, where do they think (most) of the women are getting HPV from?
#13 Catharine
January 20, 2010

Excellent post, Pal. In my opinion, not vaccinating boys kinda blames women for the STI, denies that any significant number of males engage in homosexual sex (either routinely or at any point in a man’s life) and is just plain irresponsible. Far as I know, HPV is not a huge problem in the lesbian community, so who, then, is spreading the virus? (answer=males) This is not to say that getting infected with the virus is only the ‘man’s fault’ but doesn’t it make it obvious that men, too, deserve to be protected by the vaccine? As you mentioned, we must all enter in to a sexual encounter with open eyes and more importantly, barrier protection (no glove, no love). As parents, we must openly discuss the real dangers of sex not from a place of judgment but out of concern for our children’s safety.
#14 Destiny Lewis
March 5, 2010

Yea man safe sex thats all.
#15 HPV sucks
March 12, 2010

FYI- hpv is spread by skin to skin contact (hands can transmit it too) so condoms do NOT protect you. Also you can get anal symptoms of hpv without ever having anal sex or any type of anal play, so don’t be so quick to assume that Farrah liked it up the butt. Luckily the FDA has now approved the vaccine for men too. However, the vaccine only vaccinates against 4 of the hundreds of strains, and although I was vaccinated, it got me nowhere.