Anal Cancer Screening Practices in Liver Transplant Centers Across the United States: A Nationwide Practice Study

Introduction: Transplant recipients are at an increased risk of developing anogenital Human Papillomavirus (HPV)-related disease, including anal high-grade squamous intraepithelial lesions (HSIL) and cancer compared with the general population, largely due to impaired cell-mediated immunity. There are currently no well-established guidelines for anal cancer screening in this population, and timely primary and secondary prevention practices remain scarce. The aim of this study is to understand the knowledge, attitudes, and practices of anal cancer screening in adult liver transplant candidates and recipients at transplant centers across the United States (U.S.). Methods: An online questionnaire was created that consists of four sections, with questions on the transplant center’s practices regarding anal cancer screening, barriers, facilitators and needs with regard to anal cancer screening, and HPV vaccination. The survey was sent to medical directors with publicly available emails from liver transplant centers across the U.S (n=113). Results: We received a total of 20 responses (18% response rate), from liver transplant centers across the U.S. of which 2 were incomplete and were not included in the analysis (Figure). Half of the responses (n=9) were from large transplant centers performing more than 100 transplants per year. Out of all responses, only 2 centers have formal guidelines for anal cancer screening, 7 centers perform screening without formal guidelines, 6 centers do not screen and 3 centers responded “not sure” of the current practices. All respondents believe that data on the impact of screening on anal cancer incidence would support decisions on screening, and access to specialists for screening/high-resolution anoscopy (HRA) would be helpful or very helpful on a 5-point Likert Scale. Regarding screening practices, 3 centers perform anal cytology followed by HRA for abnormal results, and 3 centers perform HRA for all screened patients. Only 5 centers assess HPV vaccination history regularly. Conclusion: Results from a cohort of liver transplant centers from around the country reveal non-standardized anal cancer screening practices among transplant centers. These results underscore the urgent need for better data on anal cancer screening in transplant populations as well as for access to specialist care. The results may help catalyze a more standardized screening approach to anal cancer screening in transplant patients.Figure 1.: Map of the United States with number of centers participating in the survey by UNOS region Table 1. - Neighborhood Index Geographic granularity # of studies utilizing index Index domains Study Income Education Housing Employment Other Author/year Liver-related outcome Findings Area deprivation index Census block group 2 • Families below poverty level, %• Income disparity• Median family income, $• Population < 150% poverty threshold, % • Population aged ≥25y with at least a high school education, %• Population aged ≥25y with < 9y of education, % • Median home value, $• Median gross rent, $• Median monthly mortgage, $• Owner occupied housing units, %• Households with 1+ person per room, % • Civilian labor force unemployed (aged ≥16y), %• Employed persons aged ≥16y in white-collar occupations, % • Single parent households with dependents < 18y, %• Households without a motor vehicle, %• Households without a telephone, %• Occupied housing units without complete plumbing, % Nichols 2022 Liver transplant waitlist removal due to nonadherence No association Goldstein 2021 HCV prevlence High ADI associated with increased HCV prevalence Community health score County 1 • Median household income, $ — — — • Years of potential life lost• Children with low birth weight, %• Adults with poor or fair reported health, %• Adults’ poor reported physical health days• Adults' poor reported mental health days• Individuals reporting tobacco use, %• Adult obesity prevalence• Physical inactivity prevalence• Rate of preventable hospital stays Akateh 2020 Survival after liver transplant No association Custom index 1 • People below poverty level, % • Educational attainment in population ≥25y, %• High-school graduate or higher, % • Families that are married householders, %• Families with different residence 1y ago — • Civilian noninstitutionalized population with a disability, %• Single-female head of household, %• Single-male head of household, %• County-level Gini index of income inequality• Grandparents responsible for grandchildren, %• Married women, except separated, %• Married men, except separated, % DuPre 2020 Risk of Hepatitis A More disadvantaged profiles associated with increased risk of Hepatitis A Facility income quartiles Zip code 1 • Median income of each patient’s zip code area of residence, divided into quartiles — — — Uppal 2020 Rate of treatment for liver metastases from colon cancer High FIQ (ie high nSES) associated with higher rates of treatment Multiethnic Study of atherosclerosis (MESA index) Individuals 1 • Median household income, $• Households receiving interest, %• Dividend or net rental income, $ • Adults ≥25y who completed high school, %• Adults ≥25y who completed college, % • Median value of owner-occupied housing units, $ • Employed persons ≥16y in executive managerial or professional occupations, % — Ortiz 2020 Risk of liver cancer High MESA quartile (ie low nSES) associated with higher risk of liver cancer Neighborhood deprivation index Census tract 3 • Households below poverty status, %• Households with < $30,000 income per year, %• Households on public assistance income, % • Population aged ≥25y who did not graduate high school, % • Housing units with ≥1 occupant per room, % • Unemployment, %• Males in management positions, % • Female headed households with dependent children, % Ortiz 2020 Risk of liver cancer High NDI quartile (ie low nSES) associated with increased risk of liver cancer Major 2014 • Risk of HCC• Chronic liver disease (CLD) mortality • Low NDI not associated with increased risk of HCC• Low NDI associated with increased CLD mortality Marcus 2018 Likelihood of receiving treatment for Hepatitis C High NDI associated with decreased likelihood of receiving treatment for Hepatitis C Roux index Census block group 1 • Median household income, $• Households receiving interest, dividend, or net rental income, % • Adults aged ≥25 who had completed high school, %• Adults aged ≥25 who had completed college, % • Median home value, $ • Employed people ≥16 in management, business, science, or arts occupations, % — Akateh 2020 Survival after liver transplant No association Social deprivation index Variable 1 • Families living in poverty, % • Individuals with less than 12 years of education, % • Families living in rented housing, %,• Overcrowded housing, % • Unemployed adults ≤65y, % • Single-parent households, %• Households without a car, % Giammarino 2020 Risk of nonalcoholic steatohepatitis (NASH) High SDI associated with increased risk of NASH Socioeconomic position index Variable 1 • Median household income, $• Families below the US poverty line, % • Population aged ≥25y who did not graduate high school, % • Expensive homes, % • Working class, %• Unemployment, % — Ortiz 2020 Risk of liver cancer High SEP quartile (ie low SES) associated with increased risk of liver cancer Townsend index Variable 1 — — • Crowding, %• Renter, % • Unemployment amongst ≥16y, % • No car ownership, % Ortiz 2020 Risk of liver cancer High Townsend quartile (ie low SES) associated with increased risk of liver cancer Yost index Census block group 2 • Median household income, $• Families below 200% of the poverty line, % • Liu education index (% aged ≥25 years with college, high school and less than high school) • Median house value, $• Median rent, $ • Individuals with blue collar jobs, %• Unemployment amongst ≥16y, % Ortiz 2020 Risk of liver cancer High Yost quartile (ie low SES) associated with increased risk of liver cancer Sangaramoorthy 2022 Risk of HCC High Yost quartile (ie low SES) associated with increased incidence of HCC