Joey Wahler (Host): They can be awkward to discuss, but crucial to undergo. So, we're discussing anal pap smears. Our guest is Dr. Ketan Thanki. He's a colorectal surgeon. This is weekly Dose of Wellness from Memorial Care Long Beach Medical Center. Thanks so much for joining us. I am Joey Wahler. Hi, Dr. Thanki. Welcome.

Ketan Thanki, MD: Hi Joey. Thanks so much for having me on today.

Host: Absolutely. We appreciate the time. And so as we alluded to, many people are uncomfortable talking about a subject like anal cancer, as you well know. But why is this conversation so important? And what does the data show about the impact of this particular cancer?

Ketan Thanki, MD: That's a great question. So while it can be a little bit embarrassing to talk about that part of our body, specifically the anus, anal cancer is one of the few cancers that is actually going up in incidence. In fact, over the past two decades, it's gone up about 3% every year. So while it is a rare cancer, it is becoming more and more common. But despite this rise, it is also largely preventable and very curable if it's caught early. And so, this conversation is genuinely urgent given these rising rates, but preventable..

Host: So, those are some pretty significant numbers in terms of the rise. Do you and yours have any idea of why that increase is occurring?

Ketan Thanki, MD: So, we don't know for sure. There are some theories that it could be in part due to rising rates of HPV. Sort of colonization on people. We know that about 70% of sexually active adults in America have HPV of some sort. It could also be due to people with immunocompromised states who are more susceptible to cancer-causing strains of HPV; living longer with those immunocompromised states, whether HIV, whether transplants for organs, we don't really know for sure. Could it also be due to more varied sexual practices becoming more mainstream? That's also a possibility. It's still a little bit too early for us to tell, though.

Host: And you mentioned HPV. Remind us, please, in a nutshell what that is.

Ketan Thanki, MD: So, HPV stands for human papilloma virus. Most commonly, this is the virus that causes warts. There are many strains. There are some strains that cause warts on your hands and feet. There are strains that cause genital and anal warts. And then, there are some strains that cause anal cancers and other cancers like cervical, penile, even oral, and pharyngeal cancer.

Host: Gotcha. So since we're talking about the importance of screening, who should consider anal cancer screening and are there certain risk factors that make it especially important for some?

Ketan Thanki, MD: Yes. So, there are several groups, who are considered high-risk. The first is going to be people living with HIV, especially men who have sex with men or those who have multiple sexual partners, or engage in frequent anal intercourse.

The next group would be men who have sex with men regardless of their HIV status. Then, women with a history of cervical or vulvar dysplasia because HPV can spread from one area to an adjacent area. Patients with solid organ transplants such as liver transplants, kidney transplants, who are on immunosuppression. And then, anyone who has a history of anal condyloma should also probably be screened.

Host: And simply put, what's the connection exactly between HPV and anal cancer? And is it all HPV that's related or just a certain type of it?

Ketan Thanki, MD: Great question. So, the vast majority of anal cancers are due to HPV, probably 90% or more. However, there are only some strains of HPV that cause anal cancer. And so, when you go to get tested for HPV, they can actually tell you which strains you have and whether those strains put you at-risk for developing anal cancer.

Host: Okay. So, what exactly are, Doctor, the screening tests for people who may be at-risk for anal cancer? What's done?

Ketan Thanki, MD: So, the most common and most widely accepted test is going to be the anal Pap smear. This is something that for women probably brings to mind on visits to their gynecologist and undergoing a cervical Pap smear. And it's very similar in terms of procedure. Just like with a cervical Pap smear, it involves using a swab to sort of swipe the inside of the anal canal and collect cells. And then, those cells are sent to a lab where they test them to see whether they're abnormal and whether there's HPV sort of colonizing them.

Host: And so, it sounds like This is really relatively simple and doesn't take very long, right?

Ketan Thanki, MD: You're correct. It's very quick. The actual procedure is done in a matter of seconds, probably about 10 seconds or so of discomfort that you even experience. And the visit is usually a very brief visit to the office.

Host: Now, as you well know, doctor, many feel nervous or uncomfortable when they hear the words anal pap smear. So, what do you do in your experience to kind of ease that and make people feel comfortable and positive about the experience, especially going in?

Ketan Thanki, MD: So, what we like to do is generally explain to patients exactly what it is that we're going to be doing. We try not to make them feel like they are in an extremely clinical or exposed environment. So generally, I don't have them completely disrobe or put on a gown. Usually, it involves lying on the exam table on their side in a comfortable position, explaining to them as we go through all of the steps, then what's going to be happening next. So, they're never caught by surprise. And generally, just exposing their buttocks and not their entire lower body or midsection. So while it would still be uncomfortable, it's not as intimidating And also, there are no surprises that might make them anxious.

Host: All right. Many adults don't realize the HPV vaccine is now recommended for people up to age 45. We only know about the prepubescent shot that's offered when people are kids. So, who should consider that vaccination and how can it still help to lower the cancer risk later in life?

Ketan Thanki, MD: So, the Gardasil vaccine, when it came out, only covered against four strains of HPV and has now been expanded to cover nine different strains, including the original four. Even if someone has been exposed to HPV, they're unlikely to have been exposed to all the strains. So, no matter what age you are up to the age of 45, there is still going to be protective benefit.

Generally, it's recommended that anybody between the ages of 27 and 45 have a discussion with their primary care doctor or provider, and talk about whether they are at elevated risk. Anyone who falls into the categories we talked about before, having HIV being a male who has sex with men, prior cervical or other HPV-related dysplasia or immunocompromised should definitely consider it. Because even though the earlier, the better, it is almost never too late to experience a benefit from getting the Gardasil vaccine.

Host: Absolutely. Couple of other things for you. First, can you go into a little bit more detail, please, about just how much of a difference, an early diagnosis as opposed to a later one can make when it comes to anal cancer, to really punctuate how crucial getting screened on a regular basis is, especially for certain people that are at-risk, as we've discussed.

Ketan Thanki, MD: Yes. So, very early cancers, that are not within the anal canal or that are completely removable through a small local surgery are treated once and done. Cancers that are still fairly early in their development, but have not spread outside of the anus are very responsive to chemotherapy and radiation and do not require surgery it's only after they have spread outside of the anal canal that they usually require prolonged chemotherapy or major surgery that could result in a colostomy bag. However, if it is, again, localized and not very advanced, it almost never requires surgery and almost never requires a colostomy bag.

Host: And so, to be clear for those joining us, wondering, "Well, if I'm just the average person and I don't know myself to be at risk," when should I start to get checked?

Ketan Thanki, MD: The age at which to start getting checked is very nuanced, depending on what risk factors you have. But that's why I think anybody who's listening to this should talk to their doctor and say, "I've heard that HPV can cause anal cancer. Should I be screened?" Just ask them. And then, they'll be able to explain in more depth than we can here on this podcast today what the details would be and whether they need to start getting screened.

Host: And so, in summary here, finally, it seems like your main message is if someone joining us is unsure about whether they should be screened or vaccinated, the best move is to go. And better safe than sorry. Speak to your physician and find out one way or the other, yes?

Ketan Thanki, MD: Yes, absolutely.

Host: Well folks, we trust you are now more familiar with anal Pap smears. Doctor, thanks so much again. We appreciate the time and the advice.

Ketan Thanki, MD: Thank you, Joey.

Host: Absolutely. And for more information, please visit memorialcare.org/cancer. And to schedule an appointment, please call 562-933-1877. And if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. And thanks so much again for being part of Weekly Dose of Wellness from Memorial Care Long Beach Medical Center.