High-resolution anoscopy in HIV-infected men: Assessment of the learning curve and factors that improve the performance

Abstract

Objective: To determine the required learning time for high-resolution anoscopy (HRA)-guided biopsy to detect histological high-risk squamous intraepithelial lesions (hHSIL) and to identify factors that impact on the training process.

Methods: All HIV-infected, screening-naïve men-who-have-sex-with-men who underwent HRA conducted by one single observer from 2010 to 2017 in a Spanish HIV-outpatient clinic were analysed.

Results: Eighty-five (14.7%) of the 581 patients included presented hHSIL. The factors associated with the capacity to detect hHSIL [adjusted odds ratio (aOR), 95% confidence interval (95%CI)] were the presence of cytological HSIL (3.04, 1.78-5.21; p < 0.001), infection with high-risk human papilloma virus (HR-HPV) (2.89, 1.38-6.05; p = 0.005), the number of biopsies taken/HRA (aOR: 1.28, 1.07-1.52; p = 0.006) and tobacco smoking (1.75; 1.12-2.73; p = 0.014). Two events independently augmented the detection rate of hHSIL: one single experienced pathologist interpreted biopsies after 409 HRA (2.80, 1.74-4.48; p = 0.035) and the anoscopist underwent an additional training after 536 HRA (2.57, 1.07-6.16; p = 0.035). A learning process could be observed throughout the whole study with stable HR-HPV prevalence.

Conclusion: The data support the growing evidence that the proposed training volume of 50-200 performances is underestimated. Extensive training of both anoscopist and pathologist is warranted and the development of tools to support the diagnostic performance may be considered.

Keywords: Anal squamous cell carcinoma; High-resolution anoscopy; Human papillomavirus; Learning curve; Liquid-based cytology; Operator experience.

Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.

Figures

Fig. 1

Binominal linear models to identify independent predictors for the detection of high-grade squamous intraepithelial lesions (HSIL) in high resolution anoscopies (HRA) with subsequent biopsy considering the number of HRA performed (Model 1, Fig. 2A) and the events that showed an impact on slope steepness of the learning curve (Model 2, Fig. 2B) in HIV-infected men who have sex with men seen between 2010 and 2017 in an HIV outpatient clinic of a tertiary care centre in Seville, Spain. AOR: adjusted odds ratio; CI: confidence interval; HR-HPV: high-risk human papillomavirus; Event #1: One single expert pathologist responsible for biopsy interpretation; Event #2: Observer participates at additional one week expert training. Akaike Information Criteria were 389,398 for Model 1 and 380.526 for Model 2, respectively.

Fig. 2

Accumulated high-grade anal squamous neoplasias (HSIL) according to the total number of high resolution anoscopies (HRA) with subsequent biopsy (black line) and the prevalence of high-risk human papillomavirus (HR-HPV) (grey line) in 581 HIV-infected men who have sex with men seen between 2010 and 2017 in an HIV outpatient clinic of a tertiary care centre in Seville, Spain. Event #1: One single expert pathologist responsible for biopsy interpretation; Event #2: Observer participates at additional one week expert training. The slope of the HR-HPV curve from the hundredth HRA onwards was −0.0003 (r2 = 0.97).