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Addressing disparities in cancer prevention and treatment among sexual and gender minorities (SGM) is a national health priority given that they experience higher rates of cancer and worse physical and mental health outcomes compared to the general population.1Jackson S.S. Han X. Mao Z. et al.Cancer stage, treatment, and survival among transgender patients in the United States.J Natl Cancer Inst. 2021; 113: 1221-1227Crossref PubMed Scopus (57) Google Scholar,2Cancer disparities Report.org. American Association for Cancer Research, Philadelphia2022www.cancerdisparitiesprogressreport.orgGoogle Scholar The study by Dr. Nyitray and colleagues3Nyitray A.G. McAuliffe T.L. Liebert C. et al.The accuracy of anal self- and companion exams among sexual minority men and transgender women: a prospective analysis.Lancet Reg Health Am. 2024; 31100704https://doi.org/10.1016/j.lana.2024.100704Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar touches upon this significant, yet under-addressed, healthcare burden among men who have sex with men (MSM) and transgender women (TW). Anal cancer, most commonly squamous cell carcinoma caused by the Human Papillomavirus (HPV), has been on the rise in the United States.4Deshmukh A.A. Suk R. Shiels M.S. et al.Recent trends in squamous cell carcinoma of the anus incidence and mortality in the United States, 2001–2015.J Natl Cancer Inst. 2020; 112: 829-838Crossref PubMed Scopus (170) Google Scholar A coalescence of unique risk factors, barriers to health care access, and limitations of screening guidelines and healthcare infrastructure underscores the importance of addressing the anal cancer burden among MSM and TW, groups who disproportionately impacted.5Fein L.A. Cunha I.R. Wong A. Schlumbrecht M.P. Duthely L.M. Potter J.E. Low perceived anal cancer risk and screening utilization among high-risk transgender men and women living in an HIV/STI epicenter.AIDS Behav. 2021; 25: 2210-2218Crossref PubMed Scopus (5) Google Scholar, 6Stier E.A. Clarke M.A. Deshmukh A.A. et al.International Anal Neoplasia Society's consensus guidelines for anal cancer screening.Int J Cancer. 2024; 154: 1694-1702Crossref PubMed Scopus (3) Google Scholar, 7LGBT populations' barriers to cancer care.Semin Oncol Nurs. 2018; 34: 21-29Crossref PubMed Scopus (37) Google Scholar Nitray et al. have done an excellent job of highlighting all of these challenges and providing meaningful results that provide confidence in self-screening as a tool for anal cancer early detection. Among MSM and TW, there is often a hesitance to accessing routine health care screenings due to longstanding stigmatization and mistreatment imposed upon these populations by the healthcare system.8Ayhan C.H.B. Bilgin H. Uluman O.T. Sukut O. Yilmaz S. Buzlu S. A systematic review of the discrimination against sexual and gender minority in health care settings.Int J Health Serv. 2020; 50: 44-61Crossref PubMed Scopus (190) Google Scholar Among gender expansive persons, such as TW, encounters with healthcare professionals can often result in uncomfortable and unnecessary exams and questioning, which can exacerbate gender dysphoria. Therefore, self-conducted testing and screening, when medically appropriate, is a strategy that can mitigate the distress of some healthcare encounters. It has been shown to be both feasible and acceptable, even preferred, among sexual and gender minority (SGM) persons.9Prétet J.L. Baraquin A. Barret A.S. et al.Anal and oropharyngeal HPV distribution in HIV-negative multipartner MSM using self-sampling kits for HIV and sexually transmitted infection screening.J Med Virol. 2023; 95e29068Crossref PubMed Scopus (0) Google Scholar,10McCartney D.J. Pinheiro T.F. Gomez J.L. Carvalho PGCd Veras M.A. Mayaud P. Acceptability of self-sampling for etiological diagnosis of mucosal sexually transmitted infections (STIs) among transgender women in a longitudinal cohort study in São Paulo, Brazil.Braz J Infect Dis. 2022; 26102356Crossref PubMed Scopus (3) Google Scholar MSM and TW are also more likely to be uninsured and face more socioeconomic barriers to accessing healthcare,11Bosworth A. Turrini G. Pyda S. et al.Health insurance coverage and access to care for LGBTQ+ individuals: current trends and key challenges.Office Health Policy. 2021; (2021-07. Issue Brief No. HP-2021-14)Google Scholar further underscoring the importance of developing and evaluating mechanisms for self-testing. The International Anal Neoplasia Society (IANS) has recently released consensus guidelines for anal cancer screening among high-risk groups, in particular MSM and TW.6Stier E.A. Clarke M.A. Deshmukh A.A. et al.International Anal Neoplasia Society's consensus guidelines for anal cancer screening.Int J Cancer. 2024; 154: 1694-1702Crossref PubMed Scopus (3) Google Scholar These guidelines were founded upon a landmark national, multi-site study (ANCHOR) that demonstrated treatment of anal high-grade squamous intraepithelial lesions (HSIL) could reduce anal cancer risk.12Palefsky J.M. Lee J.Y. Jay N. et al.Treatment of anal high-grade squamous intraepithelial lesions to prevent anal cancer.N Engl J Med. 2022; 386: 2273-2282Crossref PubMed Scopus (147) Google Scholar In the IANS guidelines, digital anal rectal examinations (DARE) are recommended at all screening visits in combination with anal swab collection for cytology and/or high-risk HPV testing. Abnormal results should prompt referral for high resolution anoscopy (HRA). IANS acknowledges the inherent limitations of HRA infrastructure, which requires costly equipment and training and is currently only accessible in large cities in the United States, Western Europe, and Australia. The IANS guidelines, and those of other medical societies, underscore the importance of the DARE for anal cancer screening, particularly when referral to HRA services is not available. Given the limitations of HRA, DARE truly is the cornerstone of anal cancer screening and remains an important tool in the arsenal of anal cancer treatment and prevention. For SGM persons, Nitray et al. have demonstrated that self or partner anal exams, while not a substitute for DARE, are a promising tool for detection of early-stage anal lesions when treatment is more likely to be successful. Self-exams and screenings are an invaluable tool among SGM populations who face unique challenges to accessing healthcare, and Nitray et al. present a new application of this concept that could meaningfully impact early anal cancer detection. Development and implementation of educational tools and awareness strategies, in concert with SGM community engagement and support, will be crucial to widespread adoption of this method. Future study of self-exams, their application, and acceptability for other SGM persons, including transmasculine and non-binary individuals assigned female at birth, would provide necessary insight into anal cancer screening for vulnerable groups. I applaud Dr. Nitray et al. for their study that presents a sensitive approach to an important, yet often neglected, aspect of SGM health care that acknowledges and seeks to overcome known barriers to healthcare often faced in this population. Lydia A. Fein MD MPH: literature search, writing. Rebecca L. Barnett: writing, review, editing. No conflicts of interest. Funding: None. The accuracy of anal self- and companion exams among sexual minority men and transgender women: a prospective analysisSexual minority men/transgender women may self-detect SCCA when malignant lesions are much smaller than the current mean dimension at presentation of ≥30 mm. Full-Text PDF Open Access
Fein et al. (Tue,) studied this question.