Screening Strategies Among High-risk Populations for Anal Cancer
August 24, 2026 updated by: Lisa Flowers
The goal of the proposed research is to 1) examine the performance of emerging screening methods for anal high-grade squamous intraepithelial lesion (aHSIL), a precancerous condition of anal cancer, among populations at high risk for anal cancer and 2) characterize DNA methylation, immunologic response, and environmental factors associated with aHSIL.
Study Overview
Status
Recruiting
Detailed Description
Anal cancer, caused by persistent infection with high-risk human papillomavirus (hrHPV), is typically preceded by anal high-grade squamous intraepithelial lesions (aHSIL). The incidence and mortality of advanced anal cancer has been increasing in the U.S., with the greatest burden of disease and mortality in individuals with chronic impairment of the immune system. The study is important because the incidence of anal cancer is particularly high among certain groups. Findings will provide much-needed evidence for anal cancer screening strategies to reduce incidence of anal cancer and improve health outcomes. The study population includes individuals with chronic impairment of the immune system and females with a known history of high-grade lower genital tract neoplasia.
The study procedures include filling out self-reported questionnaires and collecting biosamples for study-related assays. HRA is part of the standard clinic procedure for this group of participants. Collected biosamples will be banked for future research use. In-person or remote signed consent may occur for the study.
Study Type
Interventional
Enrollment (Estimated)
500
Phase
- Not Applicable
Contacts and Locations
This section provides the contact details for those conducting the study, and information on where this study is being conducted.
Study Contact
- Name: Lisa Flowers, MD, MPH
- Phone Number: 404-251-8931
- Email: lflowe2@emory.edu
Study Locations
-
-
Florida
-
Miami, Florida, United States, 33136
- Recruiting
- University of Miami Miller School of Medicine-Sylvester Cancer Center
-
Principal Investigator:
- Isabella Rosa-Cunah, MD
-
Miami, Florida, United States, 33136
- Recruiting
- University of Miami School of Medicine at Jackson Memorial Hospital (JMH)
-
Principal Investigator:
- Isabella Rosa-Cunha, MD
-
-
Georgia
-
Atlanta, Georgia, United States, 30303
- Recruiting
- Grady Memorial Hospital
-
Atlanta, Georgia, United States, 30308
- Recruiting
- The Ponce Center
-
Contact:
- Lisa Flowers, MD
- Phone Number: 404 778 1380
- Email: lflowe2@emory.edu
-
-
Participation Criteria
Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.
Eligibility Criteria
Ages Eligible for Study
- Adult
- Older Adult
Accepts Healthy Volunteers
Yes
Study Population
People from Emory University and the University of Miami, consisting of U.S.-born and Caribbean-born Black people, also, a large Latinx population from the Caribbean, South, and Central America.
Description
Inclusion Criteria:
- 30-80 years of age
- Individuals with chronic impaired immune status
- History of lower genital tract neoplasia (LGTN), Zubrod Performance Status of 0-2
Exclusion Criteria:
- Patients treated for aHSIL less than 6 months before screening
- History of anal cancer and pregnant women.
Study Plan
This section provides details of the study plan, including how the study is designed and what the study is measuring.
How is the study designed?
Design Details
- Primary Purpose: Screening
- Allocation: Non-Randomized
- Interventional Model: Single Group Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
|---|---|
|
Other: Men with impaired immune status
At each study visit, participants will receive a digital anorectal examination followed by HRA, with directed biopsies of suspicious lesions.
An HRA-certified physician will collect anal swabs and HRA-directed biopsies for histological confirmation of disease and biomarker assays.
|
High-Resolution Anoscopy, or HRA, is a standard of care procedure for screening and detection of premalignant lesions of the anus.
Using a small, thin round tube called an anoscope, the anal canal is examined with a high-resolution magnifying instrument called a colposcope.
The application of a mildly acidic liquid on the anal canal facilitates the evaluation of abnormal tissue such as anal dysplasia.
Biopsies for histological confirmation of disease will be taken.
Biopsies' reporting will follow the terminology, criteria, and recommendations of the Lower Anogenital Squamous Terminology (LAST) project.
Histology results will be reported as benign, condyloma acuminatum, AIN grades 1-3, or cancer.
For the proposed project, aHSIL+ will be defined as AIN2 (p16 block-positive), AIN3, and cancer at the HRA encounter.
All other cases will be classified as
Other Names:
Anal cytology collection (swab samples) will be performed as part of the standard of care during this study.
The collected cells, suspended in the SurePath liquid-based medium, will be placed on a slide and microscopically examined by a board-certified pathologist.
The sample will then be interpreted using the Bethesda System: negative for intraepithelial lesion or malignancy (NILM), ASCUS, LSIL, ASC-H, or HSIL.
Pathologists interpreting the anal cytology will be blinded from hrHPV testing and biopsy histology.
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
To identify the infecting HPV genotype, DNA will be extracted from swab samples collected with the MagNA Pure LC DNA Isolation Kit III and an LC MagNA Pure system (Roche Diagnostics GmbH, Mannheim, Germany), followed by HPV typing using the TypeSeq assay, a laboratory prepared high-throughput next-generation sequencing assay developed by NCI will be performed as described.
The assay uses three sequential PCR steps resulting in barcoded L1 amplicons sequenced and submitted to a bioinformatics pipeline for typing.
This TypeSeq assay qualitatively detects and identifies 51 HPV genotypes (HPV types 3, 6, 11, 13, 16, 18, 26, 28, 30, 31, 32, 33, 34, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 61, 62, 66, 67, 68, 69, 70, 71, 72, 73, 74, 76, 81, 82, 83, 84, 85, 86, 87, 89, 90, 91, 97, and 114), including 14 high-risk (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68)
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
Dual immunostaining with p16/Ki-67 will be performed on the residual cytologic specimen by Roche MTM Laboratories (Heidelberg, Germany), using the CINtec®PLUS Kit according to the manufacturer's instructions.
The anal cytology material will be stained with a mouse monoclonal antibody directed against human p16INKa (p16) protein (clone E6H4) and recombinant rabbit monoclonal antibody directed against human Ki-67 protein (clone 274-11AC3V1), using the BenchMark ULTRA instrument (Ventana Roche).
Samples with insufficient cellularity will be excluded from the evaluation.
A trained cytotechnologist will review all cases for cells staining positively with both markers.
A slide will be considered positive if 1 or more squamous epithelial cell(s) stained positive for both p16 and Ki-67 and dual stain-positive cells will be semi-quantitatively assessed (0, 1, 2-5, 6-50, >50).
Other Names:
|
|
Other: Men without impaired immune status
At each study visit, participants will receive a digital anorectal examination followed by HRA, with directed biopsies of suspicious lesions.
An HRA-certified physician will collect anal swabs and HRA-directed biopsies for histological confirmation of disease and biomarker assays.
|
High-Resolution Anoscopy, or HRA, is a standard of care procedure for screening and detection of premalignant lesions of the anus.
Using a small, thin round tube called an anoscope, the anal canal is examined with a high-resolution magnifying instrument called a colposcope.
The application of a mildly acidic liquid on the anal canal facilitates the evaluation of abnormal tissue such as anal dysplasia.
Biopsies for histological confirmation of disease will be taken.
Biopsies' reporting will follow the terminology, criteria, and recommendations of the Lower Anogenital Squamous Terminology (LAST) project.
Histology results will be reported as benign, condyloma acuminatum, AIN grades 1-3, or cancer.
For the proposed project, aHSIL+ will be defined as AIN2 (p16 block-positive), AIN3, and cancer at the HRA encounter.
All other cases will be classified as
Other Names:
Anal cytology collection (swab samples) will be performed as part of the standard of care during this study.
The collected cells, suspended in the SurePath liquid-based medium, will be placed on a slide and microscopically examined by a board-certified pathologist.
The sample will then be interpreted using the Bethesda System: negative for intraepithelial lesion or malignancy (NILM), ASCUS, LSIL, ASC-H, or HSIL.
Pathologists interpreting the anal cytology will be blinded from hrHPV testing and biopsy histology.
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
To identify the infecting HPV genotype, DNA will be extracted from swab samples collected with the MagNA Pure LC DNA Isolation Kit III and an LC MagNA Pure system (Roche Diagnostics GmbH, Mannheim, Germany), followed by HPV typing using the TypeSeq assay, a laboratory prepared high-throughput next-generation sequencing assay developed by NCI will be performed as described.
The assay uses three sequential PCR steps resulting in barcoded L1 amplicons sequenced and submitted to a bioinformatics pipeline for typing.
This TypeSeq assay qualitatively detects and identifies 51 HPV genotypes (HPV types 3, 6, 11, 13, 16, 18, 26, 28, 30, 31, 32, 33, 34, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 61, 62, 66, 67, 68, 69, 70, 71, 72, 73, 74, 76, 81, 82, 83, 84, 85, 86, 87, 89, 90, 91, 97, and 114), including 14 high-risk (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68)
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
Dual immunostaining with p16/Ki-67 will be performed on the residual cytologic specimen by Roche MTM Laboratories (Heidelberg, Germany), using the CINtec®PLUS Kit according to the manufacturer's instructions.
The anal cytology material will be stained with a mouse monoclonal antibody directed against human p16INKa (p16) protein (clone E6H4) and recombinant rabbit monoclonal antibody directed against human Ki-67 protein (clone 274-11AC3V1), using the BenchMark ULTRA instrument (Ventana Roche).
Samples with insufficient cellularity will be excluded from the evaluation.
A trained cytotechnologist will review all cases for cells staining positively with both markers.
A slide will be considered positive if 1 or more squamous epithelial cell(s) stained positive for both p16 and Ki-67 and dual stain-positive cells will be semi-quantitatively assessed (0, 1, 2-5, 6-50, >50).
Other Names:
|
|
Other: Women with impaired immune status and and lower genital tract neoplasia (LGTN)
At each study visit, participants will receive a digital anorectal examination followed by HRA, with directed biopsies of suspicious lesions.
An HRA-certified physician will collect anal swabs and HRA-directed biopsies for histological confirmation of disease and biomarker assays.
|
High-Resolution Anoscopy, or HRA, is a standard of care procedure for screening and detection of premalignant lesions of the anus.
Using a small, thin round tube called an anoscope, the anal canal is examined with a high-resolution magnifying instrument called a colposcope.
The application of a mildly acidic liquid on the anal canal facilitates the evaluation of abnormal tissue such as anal dysplasia.
Biopsies for histological confirmation of disease will be taken.
Biopsies' reporting will follow the terminology, criteria, and recommendations of the Lower Anogenital Squamous Terminology (LAST) project.
Histology results will be reported as benign, condyloma acuminatum, AIN grades 1-3, or cancer.
For the proposed project, aHSIL+ will be defined as AIN2 (p16 block-positive), AIN3, and cancer at the HRA encounter.
All other cases will be classified as
Other Names:
Anal cytology collection (swab samples) will be performed as part of the standard of care during this study.
The collected cells, suspended in the SurePath liquid-based medium, will be placed on a slide and microscopically examined by a board-certified pathologist.
The sample will then be interpreted using the Bethesda System: negative for intraepithelial lesion or malignancy (NILM), ASCUS, LSIL, ASC-H, or HSIL.
Pathologists interpreting the anal cytology will be blinded from hrHPV testing and biopsy histology.
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
To identify the infecting HPV genotype, DNA will be extracted from swab samples collected with the MagNA Pure LC DNA Isolation Kit III and an LC MagNA Pure system (Roche Diagnostics GmbH, Mannheim, Germany), followed by HPV typing using the TypeSeq assay, a laboratory prepared high-throughput next-generation sequencing assay developed by NCI will be performed as described.
The assay uses three sequential PCR steps resulting in barcoded L1 amplicons sequenced and submitted to a bioinformatics pipeline for typing.
This TypeSeq assay qualitatively detects and identifies 51 HPV genotypes (HPV types 3, 6, 11, 13, 16, 18, 26, 28, 30, 31, 32, 33, 34, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 61, 62, 66, 67, 68, 69, 70, 71, 72, 73, 74, 76, 81, 82, 83, 84, 85, 86, 87, 89, 90, 91, 97, and 114), including 14 high-risk (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68)
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
Dual immunostaining with p16/Ki-67 will be performed on the residual cytologic specimen by Roche MTM Laboratories (Heidelberg, Germany), using the CINtec®PLUS Kit according to the manufacturer's instructions.
The anal cytology material will be stained with a mouse monoclonal antibody directed against human p16INKa (p16) protein (clone E6H4) and recombinant rabbit monoclonal antibody directed against human Ki-67 protein (clone 274-11AC3V1), using the BenchMark ULTRA instrument (Ventana Roche).
Samples with insufficient cellularity will be excluded from the evaluation.
A trained cytotechnologist will review all cases for cells staining positively with both markers.
A slide will be considered positive if 1 or more squamous epithelial cell(s) stained positive for both p16 and Ki-67 and dual stain-positive cells will be semi-quantitatively assessed (0, 1, 2-5, 6-50, >50).
Other Names:
|
|
Other: Women without impaired immune status and lower genital tract neoplasia (LGTN)
At each study visit, participants will receive a digital anorectal examination followed by HRA, with directed biopsies of suspicious lesions.
An HRA-certified physician will collect anal swabs and HRA-directed biopsies for histological confirmation of disease and biomarker assays.
|
High-Resolution Anoscopy, or HRA, is a standard of care procedure for screening and detection of premalignant lesions of the anus.
Using a small, thin round tube called an anoscope, the anal canal is examined with a high-resolution magnifying instrument called a colposcope.
The application of a mildly acidic liquid on the anal canal facilitates the evaluation of abnormal tissue such as anal dysplasia.
Biopsies for histological confirmation of disease will be taken.
Biopsies' reporting will follow the terminology, criteria, and recommendations of the Lower Anogenital Squamous Terminology (LAST) project.
Histology results will be reported as benign, condyloma acuminatum, AIN grades 1-3, or cancer.
For the proposed project, aHSIL+ will be defined as AIN2 (p16 block-positive), AIN3, and cancer at the HRA encounter.
All other cases will be classified as
Other Names:
Anal cytology collection (swab samples) will be performed as part of the standard of care during this study.
The collected cells, suspended in the SurePath liquid-based medium, will be placed on a slide and microscopically examined by a board-certified pathologist.
The sample will then be interpreted using the Bethesda System: negative for intraepithelial lesion or malignancy (NILM), ASCUS, LSIL, ASC-H, or HSIL.
Pathologists interpreting the anal cytology will be blinded from hrHPV testing and biopsy histology.
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
To identify the infecting HPV genotype, DNA will be extracted from swab samples collected with the MagNA Pure LC DNA Isolation Kit III and an LC MagNA Pure system (Roche Diagnostics GmbH, Mannheim, Germany), followed by HPV typing using the TypeSeq assay, a laboratory prepared high-throughput next-generation sequencing assay developed by NCI will be performed as described.
The assay uses three sequential PCR steps resulting in barcoded L1 amplicons sequenced and submitted to a bioinformatics pipeline for typing.
This TypeSeq assay qualitatively detects and identifies 51 HPV genotypes (HPV types 3, 6, 11, 13, 16, 18, 26, 28, 30, 31, 32, 33, 34, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 61, 62, 66, 67, 68, 69, 70, 71, 72, 73, 74, 76, 81, 82, 83, 84, 85, 86, 87, 89, 90, 91, 97, and 114), including 14 high-risk (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68)
Other Names:
Samples of exfoliated cells from the anal canal will be collected with Dacron swabs.
Dual immunostaining with p16/Ki-67 will be performed on the residual cytologic specimen by Roche MTM Laboratories (Heidelberg, Germany), using the CINtec®PLUS Kit according to the manufacturer's instructions.
The anal cytology material will be stained with a mouse monoclonal antibody directed against human p16INKa (p16) protein (clone E6H4) and recombinant rabbit monoclonal antibody directed against human Ki-67 protein (clone 274-11AC3V1), using the BenchMark ULTRA instrument (Ventana Roche).
Samples with insufficient cellularity will be excluded from the evaluation.
A trained cytotechnologist will review all cases for cells staining positively with both markers.
A slide will be considered positive if 1 or more squamous epithelial cell(s) stained positive for both p16 and Ki-67 and dual stain-positive cells will be semi-quantitatively assessed (0, 1, 2-5, 6-50, >50).
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
Specificity and Sensitivity of screening markers
Time Frame: Baseline
|
Sensitivity and specificity will be calculated for each of the proposed screening markers separately and a combination of two and three markers for the detection of aHSIL at baseline.
The combination of the two and three markers of primary interest includes CINtec®PLUS +hrHPV, CINtec®PLUS+anal cytology, hrHPV+anal cytology, and CINtec®PLUS+hrHPV+anal cytology.
The analysis will be performed for the four high-risk groups together and stratified by the four high-risk categories.
|
Baseline
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
|---|---|---|
|
DNA methylation markers
Time Frame: Baseline, 1 year, 2 years
|
In these models, aHSIL status at baseline will be considered as the response, and each anal DNA methylation marker will be the predictor.
Separate models will be performed for each methylation marker (ZNF582, ASCL1, ZIC1, SST, LHX8, WDR17, and ST6GALNAC5)
|
Baseline, 1 year, 2 years
|
|
Anal immune modulations
Time Frame: Baseline, 1 year, 2 years
|
High-risk HPV 16 persistent patients (N=10) vs. patients with no HPV at least two consecutive times (N=10).
Each of the groups will also include aHSIL+ (N=5) vs. <aLSIL (N=5).
|
Baseline, 1 year, 2 years
|
|
aHSIL prevalence
Time Frame: Baseline
|
The prevalence of HSIL will be estimated as the proportion of participants who are HRA positive for HSIL at entry and its 95% confidence interval.
Logistic regression analysis will be used to evaluate the association of potential risk factors with diagnosis of HSIL.
|
Baseline
|
|
aHSIL clearance
Time Frame: 1 year, 2 years
|
Only people treated with aHSIL will be used for the clearance analysis.
Clearance (HRA biopsy-proven) will be defined as no detectable aHSIL at the immediate one-year (for those with baseline aHSIL) or two-year (for those with newly diagnosed aHSIL cases at the one-year visit) follow-up visit after aHSIL treatment.
|
1 year, 2 years
|
|
Inflammatory Markers (Il-1RA, IL1β, IL6, IL6sr, TNF-α, and IL-10)
Time Frame: Baseline, 1 year, 2 years
|
Anal swab concentrations of inflammatory markers (IL1ra, IL1β, IL6, IL6sr, TNF-α, and IL-10) will be determined using multiplex assays (Meso Scale Discovery, Rockville, MD) according to the manufacturer's protocol.
All samples will be run in duplicates, and mean intra- and inter-assay CVs will be calculated and expected to be <10%.
These inflammatory markers have been reliably found to be elevated in inflammatory-associated diseases including anal inflammation.
|
Baseline, 1 year, 2 years
|
|
Inflammatory Markers (sTNFR2 and interferon (IFN)-γ)
Time Frame: Baseline, 1 year, 2 years
|
Anal swab concentrations of inflammatory markers of inflammatory markers (sTNFR2 and interferon (IFN)-γ) will be determined using multiplex assays (Meso Scale Discovery, Rockville, MD) according to the manufacturer's protocol.
|
Baseline, 1 year, 2 years
|
|
Inflammatory Marker (CRP)
Time Frame: Baseline, 1 year, 2 years
|
Anal swab concentrations of inflammatory markers (CRP) will be determined using multiplex assays (Meso Scale Discovery, Rockville, MD) according to the manufacturer's protocol.
All samples will be run in duplicates, and mean intra- and inter-assay CVs will be calculated and expected to be <10%.
|
Baseline, 1 year, 2 years
|
Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Sponsor
Collaborators
Investigators
- Principal Investigator: Lisa Flowers, MD, MPH, Emory University
- Principal Investigator: Canhua Xiao, PhD, RN, Emory University
Study record dates
These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.
Study Major Dates
Study Start (Actual)
December 16, 2024
Primary Completion (Estimated)
September 30, 2027
Study Completion (Estimated)
August 31, 2028
Study Registration Dates
First Submitted
October 3, 2024
First Submitted That Met QC Criteria
October 3, 2024
First Posted (Actual)
October 8, 2024
Study Record Updates
Last Update Posted (Actual)
August 26, 2026
Last Update Submitted That Met QC Criteria
August 24, 2026
Last Verified
August 1, 2026
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Neoplasms by Site
- Neoplasms
- Intestinal Diseases
- Gastrointestinal Neoplasms
- Digestive System Neoplasms
- Digestive System Diseases
- Gastrointestinal Diseases
- Colorectal Neoplasms
- Intestinal Neoplasms
- Rectal Diseases
- Anus Diseases
- Rectal Neoplasms
- Neoplasms
- Investigative Techniques
- Specimen Handling
- Clinical Laboratory Techniques
- Diagnostic Techniques and Procedures
- Diagnosis
- Surgical Procedures, Operative
- Cytological Techniques
- Cytodiagnosis
- Diagnostic Techniques, Surgical
- Biopsy
Other Study ID Numbers
- STUDY00006091
- R01CA285198 (U.S. NIH Grant/Contract)
- 2025P011462 (Other Identifier: Emory Insight Humans IRB)
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
YES
IPD Plan Description
All of the individual participant data collected from study participation will be available for sharing after deidentification
IPD Sharing Time Frame
Data will be available for sharing after publication.
IPD Sharing Access Criteria
Data will be shared upon request with researchers who provide a methodologically sound proposal to achieve the aims in the approved proposal.
To gain access, data requesters will need to sign a data access agreement.
IPD Sharing Supporting Information Type
- STUDY_PROTOCOL
- SAP
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
No
Studies a U.S. FDA-regulated device product
No
product manufactured in and exported from the U.S.
No
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.