EP492 - AIN Surveillance and Treatment: Establishing HRA Pathway for TRICARE Beneficiaries

ePoster Presenter(s)

• KZ

  Kaitlin P. Zurbrugg, MD

  General Surgery Resident
  San Antonio Uniformed Services Health Education Consortium
  San Antonio, Texas, United States

  Disclosure information not submitted.

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Author(s)

• 

  Galen Gist, MD

  Resident Physician
  Brooke Army Medical Center
  Houston, Texas, United States

  Disclosure information not submitted.
• MN

  Maria Navarro, MD (she/her/hers)

  General Surgery Resident
  San Antonio Uniformed Services Health Education Consortium
  San Antonio Uniformed Services Health Education Consortium
  San Antonio, TX, United States

  Disclosure information not submitted.
• 

  Katryna K. Thomas, MD

  General Surgery Resident
  San Antonio Uniformed Services Health Education Consortium
  San Antonio, Texas, United States

  Disclosure information not submitted.
• MG

  Matthew Geringer, DO

  Infectious Disease Physician
  San Antonio Uniformed Services Health Education Consortium
  San Antonio, Texas, United States

  Disclosure information not submitted.
• SM

  Serena M. Murphy, MD

  Assistant Professor
  BAMC
  San Antonio, Texas, United States

  All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose
• 

  Stephen E. Ranney, MD

  Assistant Professor
  San Antonio Uniformed Services Health Education Consortium
  San Antonio, Texas, United States

  All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose

Senior Author(s)

• 

  Bryan Kline, MD

  Assistant Professor
  San Antonio Uniformed Services Health Education Consortium
  San Antonio, Texas, United States

  All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose

Purpose/Background: TRICARE beneficiaries represent a unique population with integrated access to subspecialty care and coordination between multidisciplinary teams within Department of War (DoW) medical treatment facilities. Following the "Plan-Do-Study-Act" method, the objectives of this project are to: (1) evaluate our institution's referral patterns, high-resolution anoscopy (HRA) compliance, clearance rates, and current surveillance patterns to develop a standardized surveillance pathway based on risk factors; (2) implement the standardized pathway, following patients every 3-6 months; (3) analyze the rates of clearance, compliance to the surveillance pathways, and barriers to care; and (4) implement adjustments to enhance preventative and curative outcomes.

Methods/Interventions: All patients who underwent HRA within the past two years were reviewed. Data collected included referral source and timing, race, sex, age, anal intraepithelial neoplasia (AIN) history, anal cytology results, human immunodeficiency virus (HIV) status with CD4 count and viral load, smoking history, prior vulvar/cervical/vaginal dysplasia, immunosuppressive status, operative findings, pathology results, and surveillance plans.

Patients underwent HRA with colorectal surgery based on anal Pap results (ASCUS with LSIL or HSIL), human papillomavirus (HPV) positivity, or incidental AIN diagnosis. Those without dysplasia on HRA continued annual cytology follow-up with colorectal surgery or infectious disease, depending on clinic affiliation. High-risk patients-including those with prior cervical or anal dysplasia or immunosuppression-underwent HRA every 6-12 months. Patients with HSIL (AIN II/III) were followed every 3-6 months until pathology downstaged or no dysplasia was identified on repeat HRA.

Results/Outcomes: In total, 40 HRAs were performed on 27 patients. Most referrals originated from infectious disease after positive anal cytology in high-risk or HIV-positive patients, followed by referrals from gastroenterology, surgery, gynecology, or primary care for incidental or suspicious findings. 52% of patients within the cohort were HIV-positive, 26% reported current or former nicotine use, and 37% had known HPV-positive status. Of all HRAs, 40% were negative for dysplasia, 15% showed AIN 1, 10% AIN II, and 32.5% AIN III. One patient was diagnosed with invasive anal adenocarcinoma.

Conclusion/Discussion: AIN is a precursor to anal squamous cell carcinoma, and early identification and treatment are critical to preventing malignant transformation. Known risk factors include HIV infection, HPV exposure, smoking, prior cervical/vulvar dysplasia, anoreceptive intercourse, and immunosuppression. Implementation of a standardized surveillance protocol within the military healthcare system promotes continuity of care despite frequent relocations of patients and providers. This initiative lays the groundwork for a unified DoW-wide screening and management algorithm aimed at reducing anal cancer incidence in high-risk populations.

Plan-Do-Study-Act Model for AIN Surveillance Pathway
The Plan-Do-Study-Act method provides a linear representation of action required to develop, adapt, and implement our AIN surveillance pathway for military beneficiaries, improving patient care and addressing follow up needs