EP487 - Race/ethnicity and HIV status are associated with increased total number of procedures necessary for treatment of anal dysplasia

Purpose/Background: Anal dysplasia, a precursor to anal cancer, is most often detected through anal Pap smear in high-risk groups such as men who have sex with men and people living with HIV. These patients often need to undergo repeated treatments once HPV-associated disease has been identified, due to the risk of disease progression posed by persistent dysplasia in immunocompromised patients. We aimed to describe the characteristics of patients with abnormal anal cytology and identify predictors of persistent dysplasia requiring treatment, to inform future surveillance strategies to improve equity.

Methods/Interventions: This is a retrospective review of 590 patients seen by 2 colorectal surgeons in consultation for abnormal anal cytology at the Icahn School of Medicine at Mount Sinai (2019-2024). Demographics (age, sex, race, HIV status, sexual orientation, and insurance), cytology results, HRA/biopsy findings, and total number of treatments (surgery or fulguration) were collected. The primary outcome was the number of treatments, used as a proxy for persistent dysplasia. Between group comparisons were made using chi-squared tests to identify factors associated with persistent dysplasia.

Results/Outcomes: Amongst 590 patients, patients with high-grade lesions (HSIL, SCC; N=63) required more treatments than those with low-grade lesions on initial Pap smear (ASCUS, LSIL; N=527) (p < 0.001). Across racial groups, 33-47% of patients had abnormal HRA results requiring treatment. A greater proportion of Black (31.7%) and Hispanic (37.5%) patients did not receive treatment after abnormal Pap and HRA results. Most white (61.7%) and Asian (76.9%) patients received one treatment, without need for follow up, suggesting effective disease resolution. In contrast, 33.3% of Hispanic patients needed >2 treatments, suggesting greater disease persistence. While the rates of abnormal HRA results were similar amongst HIV-positive and negative patients (38.1% and 39.7%), 20.6% of HIV-positive patients required >2 treatments compared to 8.5% of HIV-negative patients. Both race/ethnicity and HIV status were significantly associated with persistent dysplasia (p=0.040 and 0.004). Sexual orientation (straight vs gay/lesbian, bisexual or queer) and insurance type (commercial vs Medicaid or Medicare) were not significantly associated with persistent dysplasia (p=0.373 and 0.620).

Conclusion/Discussion: Persistence of anal dysplasia is influenced by systemic disparities in care. Black and Hispanic patients were less likely to receive treatment and they were more likely to require multiple interventions when treated, suggesting less effective management. HIV-positive patients also required a greater number of treatments, while sexual orientation and insurance type did not affect persistence of disease. These disparities likely reflect barriers to care such as language, access to specialty providers, and gaps in patient education, underscoring the need for targeted strategies to improve equity in anal cancer prevention especially amongst high-risk patients.

Figure 1
Persistence of anal dysplasia by race/ethnicity (A), HIV status (B), sexual orientation (C), and insurance (D).