Do we really need guidelines for HRA during the COVID-19 pandemic?

Dear Editor,

We have read with great interest the recent guidelines of the International Anal Neoplasia Society (IANS) for the practice of high‐resolution anoscopy (HRA) in the era of coronavirus (SARS‐CoV‐2) disease (COVID‐19) [1].

COVID‐19 was first identified in Wuhan, China, in December 2019, and recognized as a global pandemic on 11 March 2020. Consequent to the COVID‐19 pandemic, scientific societies have published countless guidelines. These are not unequivocal and are not evidence based. In spite of this, IANS has proposed some guidelines on the use of HRA in anal cancer and its precursors.

Even if high‐grade anal intraepithelial neoplasia (AIN) is the direct precursor to anal cancer, the rate of progression to invasive carcinoma is between 1.3% and 3.2% at 5 years [2, 3]. The meta‐analysis performed by Machalek reported that rates of progression from AIN III to anal cancer are approximately 1 in 600 per year in HIV‐positive men who have sex with men (MSM) and one in 4000 per year in HIV‐negative MSM patients [2]. Moreover, the benefits of screening programmes targeting high‐risk populations are still controversial, and due to the low rate of progression screening is unlikely to be cost‐effective. Furthermore, anal screening tests are not designed to detect anal cancer.

Nyitray and Coll [4] have shown that digital ano‐rectal examination (DARE) has a high sensitivity for detection of anal neoplasms, as does self‐anal examination for singles or partner anal examination for couples. Concordance between clinicians’ result and participants was 91.2%. Neoplasms of ≥ 3 mm may be detectable by the clinician or self‐ or partner palpation.

Guidelines from the Italian Society of Colo‐Rectal Surgery (SICCR) suggest that the grade of recommendation for the use of HRA in screening for AIN is weak based on moderate‐quality evidence (2B) [5].

An additional factor is that SARS‐CoV‐2 viral RNA has been isolated from stools [1]. Whilst oro‐faecal spread is not thought to be a major factor in the epidemic, HRA practitioners need to be aware of it as a potential source of infection.

Considering all these aspects it is our opinion that HRA should be avoided during the COVID‐19 pandemic. HRA is a time‐consuming examination when adequately performed; it is very expensive, especially if performed with personal protective equipment; and it includes the potential risk of infection for personnel involved in the procedure.

Considering the costs of dealing with the problems posed by COVID‐19, the shortage of healthcare professionals and the lack of worldwide consensus evidence for HRA, this examination cannot be considered mandatory during the COVID‐19 pandemic.

The low risk of progression of AIN to invasive carcinoma, even in high‐risk patients, and the long time from diagnosis of AIN and progression do not justify the use of HRA and a screening programme during the COVID‐19 pandemic.

DARE with biopsy of suspicious palpable lesions of symptomatic patients could be considered sufficient during this period. A latency of 6–12 months is probably reasonable for these patients without affecting the natural history of AIN.

Conflicts of interest

None of the authors have any conflicts of interest to declare.