April 8, 2020
Key Points
The situation is rapidly evolving and these guidelines represent our current understanding, which may change in the light of new research. Suggested policy is based on the following:
2. HRA Risk Assessment
Table 1 may help prioritise patients:
Table 1: HRA risk prioritisation
It is recognized that some centers will have discontinued all HRA and related procedures, due to local conditions. These recommendations are not intended to circumvent local Infectious Control measures.
Risk assessment |
Category 1 High |
Category 2 Intermediate |
Category 3 Low |
Priority |
Urgent |
As soon as possible |
May be deferred |
Definition |
HRA should occur within one month, unless epidemic situation is extreme - in which case, prioritise biopsy of clinically invasive lesions. Prioritized as first to be scheduled. |
HRA performed within 6 months, if possible. Symptom check-in by phone or telemedicine, repeat at 3 months. |
Defer HRA until resumption of normal clinic scheduling. Symptom check-in by phone or telemedicine, repeat at 3-6 months. |
Principal objective |
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Clinical cancer assessment |
Clinically highly suspicious of cancer. Digital Anal Rectal Examinations are an integral part of such an assessment. |
Within 6 months of first cancer treatment and those treated within 2 years ago. |
Low risk of cancer (unlikely within one year). |
HSIL surveillance |
HSIL clinically suspicious for cancer. Cytology or histology suspicious, but not diagnostic of cancer. |
Features concerning for progressive disease in previous exam (e.g. lesion characteristics that are very prominent). Cytology HSIL, not yet assessed with HRA. |
No current evidence of HSIL. No concerning features in previous exam. Cytology <HSIL or ASC-H (PHSIL). |
Investigation of symptoms/signs (lump, bleeding, pain, tenesmus) |
Symptoms or signs that have worsened or recurred |
Symptoms present but unchanged in 6 months > 1 year since last exam. |
No symptoms/signs. |
Specific considerations for the conduct of therapeutic HRA
Only cases with histologic confirmation of HSIL should be considered for treatment at this time.
Topical Therapies
Ablative Therapies
The risk of COVID-19 infection in the last 14 days should be assessed, using the factors in Table 2, both at the time of booking an appointment, and also prior to performing any procedure.
Table 2: Classification of potential SARS-CoV-2 infection risk in patients undergoing High Resolution Anoscopy
*Symptoms |
‡Contact |
Vulnerable Group |
|
Low risk |
No |
No |
<60 |
Intermediate risk - either |
Yes |
No |
60-70 years |
- or |
No |
Yes |
HIV with CD4: 200-500/mm3 |
High risk |
≥1 symptom* and |
Yes |
>70 years |
HIV with CD4≤200/mm3 |
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Innate/pharmacological immunosuppression |
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Transplant recipient |
*Symptoms include cough, fever, dyspnea and diarrhea
‡contact with known SARS-CoV-2–positive person
Based on: https://www.sciencedirect.com/science/article/pii/S0016510720302455?via%3Dihub
It is recommended that only those at low risk of having COVID-19 be seen for HRA. This may require waiting until the COVID-19 situation is clarified or resolved. Consider stopping all HRA services, in view of possible fecal-oral transmission from asymptomatic cases.
There is evidence of spread of coronavirus within the air of a room following a procedure. The risk from fecal transmission of the virus is not known. In addition to usual infection control measures, consider allowing 30 minutes between cases, in order to ventilate the room and reduce the risk of airborne viral transmission between cases.
Medical staff to wear surgical face masks (ideally n95, if available), avoid shaking hands, gowns and gloves upon entering the room, and until the patient leaves.
Clean door handles, chairs, desks, any surfaces touched, as well as clinical areas after each patient.
Use strategies to avoid patients sitting in the waiting room. These may include having patients wait outside and be called in when the room is ready and accessing them by mobile/cell phone. Ensure all seats are at least 1.5 meters apart.
5. Summary Recommendations
These guidelines are subject to changes as the COVID-19 pandemic evolves.
These recommendations are not to be considered definitive management guidelines and recognize that some individuals with abnormal anal cancer tests and histologic findings will require case-by-case review. These guidelines are subject to change, due to the fluidity of the healthcare environment. Providers should continue use of tracking protocols, to ensure that patients with abnormal results may be recalled when concerns for COVID-19 have diminished to the point HRA services may be reinstated, with priority given to those at highest risk of invasive disease. Once the COVID-19 outbreak is contained, patients should again be managed as per local guidelines.
Disclaimer:
These recommendations should never be a substitute for clinical judgment. Clinical judgment should always be used when applying a recommendation to an individual patient since they may not apply to all patient-related situations.
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