Colon to Rectum

N Engl J Med. 2022;386(24):2273–82

Palefsky JM, Lee JY, Jay N, Goldstone SE, Darragh TM, Dunlevy HA, Rosa-Cunha I, Arons A, Pugliese JC, Vena D, Sparano JA, Wilkin TJ, Bucher G, Stier EA, Tirado Gomez M, Flowers L, Barroso LF, Mitsuyasu RT, Lensing SY, Logan J, Aboulafia DM, Schouten JT, de la Ossa J, Levine R, Korman JD, Hagensee M, Atkinson TM, Einstein MH, Cracchiolo BM, Wiley D, Ellsworth GB, Brickman C, Berry-Lawhorn JM; ANCHOR Investigators Group

Treatment of anal high-grade squamous intraepithelial lesions to prevent anal cancer

Background: The incidence of anal cancer is substantially higher among persons living with the human immunodeficiency virus (HIV) than in the general population. Similar to cervical cancer, anal cancer is preceded by high-grade squamous intraepithelial lesions (HSILs). Treatment for cervical HSIL reduces progression to cervical cancer; however, data from prospective studies of treatment for anal HSIL to prevent anal cancer are lacking.
Methods: The authors conducted a phase 3 trial at 25 US sites. Persons living with HIV who were ≥ 35 years old and who had biopsy-proven anal HSIL were randomly assigned, in a 1:1 ratio, to receive either HSIL treatment or active monitoring without treatment. Treatment included office-based ablative procedures, ablation or excision under anesthesia, or the administration of topical fluorouracil or imiquimod. The primary outcome was progression to anal cancer in a time-to-event analysis. Participants in the treatment group were treated until HSIL was completely resolved. All the participants underwent high-resolution anoscopy at least every 6 months; biopsy was also performed for suspected ongoing HSIL in the treatment group, annually in the active-monitoring group, or any time there was concern for cancer.
Results: Of 4459 participants who underwent randomization, 4446 (99.7%) were included in the analysis of the time to progression to cancer. With a median follow-up of 25.8 months, 9 cases were diagnosed in the treatment group (173 per 100,000 person-years; 95% confidence interval [CI]: 90–332) and 21 cases in the active-monitoring group (402 per 100,000 person-years; 95% CI: 262–616). The rate of progression to anal cancer was lower in the treatment group than in the active-monitoring group by 57% (95% CI: 6–80; p = 0.03 by log-rank test).

Conclusions: Among participants with biopsy-proven anal high-grade squamous intraepithelial lesion (HSIL), the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring

J.M. Palefsky, M.D., Professor of Medicine and Infectious Diseases, University of California San Francisco School of Medicine, San Francisco, CA, USA,

DOI: 10.1056/nejmoa2201048

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