Feasibility of screening for anal cancer in HIV-positive people older than 50 years in Canada
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* Edward S. Weiss

I applaud McMillan and colleagues for their thoughtful and timely article on the health implications of aging with HIV.1 With regard to screening for anal cancer, their recommendation regarding annual Papanicolaou (Pap) tests is well-intentioned but, in the Canadian context, may not be appropriate.

A successful screening program relies on the availability of downstream resources to validate initial findings. For anal cancer, the appropriate investigation for an abnormal result on anal Pap test is high-resolution anoscopy, which is the equivalent of colposcopy for the cervix. Access to high-resolution anoscopy in Canada is extremely limited, with only a few clinicians in major urban centres providing this service. In the absence of reliable access to this type of screening, clinicians performing anal Pap tests will be left with no way to follow up on abnormal results.

Although I encourage more Canadian clinicians to get involved in performing high-resolution anoscopy, it may be wise in the interim to focus on performing a regular and thorough digital anorectal examination to detect early signs of anal cancer (such as induration or focal tenderness). Patients who have suspicious palpable findings can be referred to a general surgeon for an examination under anesthesia and possible excisional biopsy.

## Footnotes

*   **Competing interests:** None declared.

## Reference

1.  McMillan JM, Krentz H, Gill MJ, et al. Managing HIV infection in patients older than 50 years. CMAJ 2018;190:E1253–8.
    
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