Introduction
Method
Search strategies and data sources
Inclusion criteria
Exclusion criteria
Levels of evidence
Results
Country of origin and clinical society | Guideline level of evidence/grading system | Screening | Treatment | Follow-up |
---|---|---|---|---|
United States of America | ||||
American Society of Colon and Rectal Surgeons (ASCRS) | Stewart et al. [7] GRADE Recommendation System | Anal Cytology can be used in high-risk populations as part of a directed screening programme but not recommended as a universal screening technique (2B) HPV genotyping can be used as an adjunct within the screening programme (2B) High resolution anoscopy can be used as a screening technique but only when used by experienced practitioners (2B) | Topical treatments such as Imiquimod, 5-Fluorouracil, Cidofovir and Trichloroacetic acid can be used to treat low-grade and high-grade AIN. (2B) Ablative treatments can be used for high-grade AIN (2B) HPV vaccination is not recommended as a form of secondary prevention of AIN (2A) | Patients treated for AIN may be observed without regular cytology, HPV testing or HRA but any visible or palpable disease should be treated (2C) |
National Comprehensive Cancer Network (NCCN): People Living with HIV | Reid et al. [25] GRADE Recommendation System | No recommendations for routine screening but accepts that HIV specialists do screen using varying methods and at different frequencies High resolution anoscopy should be performed if high-grade disease is identified (1C)a | Topical therapies, ablative therapies and surgical excision are safe and offer short term efficacy (1C)a Electrocautery better choice of therapy in men who have receptive anal intercourse (1B)a | No recommendations |
New York State Department of Health AIDS Institute (NYSDOH) | New York State Department Levels of Evidence and Recommendation System Medical Care Criteria Committee and Brown [26] | Annual history (2A), digital rectal examination and anal cytology (3A) in HIV positive patients ≥ 35 years Refer for high resolution anoscopy if anal cytology is abnormal (2A) Cervical cytology if abnormal anal cytology (3A) Annual high resolution anoscopy if high-risk HPV genotypes (GRADE 1C)a | AIN1—surveillance only (3A) AIN2/3—recommends treatment (no preference stated) (3A) | AIN1—high resolution anoscopy in 1 year (3A) AIN2/3—high resolution anoscopy 6 months after treatment (3A) |
United Kingdom | ||||
Association of Coloproctology of Great Britain and Ireland (ACPGBI) | Geh et al. [6] ASGBI Guidelines recommendation system | All suspicious lesions in high-risk groups should be biopsied and/or excised (D) Female patient with AIN should also be screened for gynaecological intraepithelial neoplasias (D) | AIN 2 and AIN 3 should be discussed and managed within a specialist anal cancer MDT (D) Consider HIV testing in persistent or multifocal anal dysplasia (C) For HIV positive homosexual men electrocautery may be better tolerated than topical treatments such as imiquimod and 5-Fluorouracil (B) | High-risk patients follow-up 6 monthly for 5 years (D) |
Europe | ||||
Italian Society of Colorectal Surgery (SICCR) | Binda et al. [27] Oxford Level of Evidence and US Preventive Series Task Force Grading Recommendations | High resolution and biopsy for histology a better test than anal cytology (2B) Digital rectal exam must be performed as well as anoscopy and anal cytology (1B) Genotyping HPV is not required if High resolution anoscopy and biopsies of concerning areas is undertaken (2B) | High-grade dysplasia should be treated either with topical treatment or ablative therapies (1B) Electrocautery recommended for anal canal lesions and Imiquimod for anal margin lesions (1B) Recommends the use of Imiquimod, 5-Fluorouracil, Cidofovir (2B), Photodynamic therapy and Trichloroacetic acid (2C), infrared coagulation, electrocautery, and carbon dioxide laser (2B) for the treatment of anal dysplasia Can also consider wide local excision of a lesion if less than 1/3 anal circumference (2B) Recommends vaccination for primary prevention of HPV elated dysplasias (1B) and HPV vaccination as secondary prevention for patients with previously treated anal dysplasia (3C) | Digital rectal examination, anal cytology, and high resolution anoscopy every 4 months for 3 years then annual follow – up for 2–3 years (2B) Follow-up at 6 and 12 months (2B) |
German Society of Dermatology (GSD) | Esser et al. [28] GRADE Recommendation System | Annual screening recommended for HIV positive patients (1C) a Screening should include history and examination and anal cytology. If abnormalities patients should be referred for high resolution anoscopy (1C) a Other high-risk patients are defined as patients with a history of a previous HPV related dysplasias or cancers (including oral, anal and genital) and patients with a persistent HPV infection lasting longer than 1 year or condylomata acuminata. They should receive high resolution anoscopy once every 3 years. (1C) a | Low- and high-grade dysplasia can be treated with topical treatments or surgical excision. (1C)a The authors prefer surgical excision and ablative therapies over topical and recommend topical treatments as an adjunct therapy. (opinion) AIN 1 can be observed rather than treated if appropriate. (opinion) | Low- and high- dysplasia to be followed up in 3 months with high resolution anoscopy, cytology and clinical assessment (opinion) Can return to normal surveillance programme if four negative results 3–6 months apart (opinion) |
European AIDS Clinical Society (EACS) | European AIDS Clinical Society Panel (2020) [29] GRADE Recommendation System | Screening recommended for HIV positive men who have receptive anal intercourse and HIV positive patients with a previous diagnosis of HPV dysplasia Digital rectal examination and anal cytology every 1–3 years in patients with HIV (1C)a Anoscopy if anal cytology is abnormal (1B)a Cervical screening in women who are HIV positive (1A)a | Efficacy of 9 valent HPV vaccine is questionable if HPV related dysplasias have already occurred (1A)a | No recommendations |
Hellenic Society of Medical Oncology (HESMO) | Gouvas et al. [30] Oxford Level of Evidence and US Preventive Series Task Force Grading Recommendations | Screening recommended in high-risk populations (defined as HIV positive patients, MSM, women with history of cervical cancer, perianal condylomata and solid organ transplant recipients) (4B) Recommends annual digital rectal examination and anal cytology or if available high resolution anoscopy (4B) | Topical and ablative therapies acceptable for treating high-grade disease (3B) | Regular follow-up of high-grade disease is mandatory (A) |