Advancing Anal Cancer Care for Gay Men, Bisexual Men, and Transgender Women in Ambulatory Care: An RN-Led Quality Improvement Project

Purpose: According to the National Institutes of Health (NIH), anal cancer has become a concerning issue with an estimated 10,000 new cases and 1,870 annual deaths in the United States. However, medical providers often overlook the significance of anal cancer, particularly in high-risk populations like gay men, bisexual men, and transgender women. In 2022, the ANal Cancer/HSIL Outcomes Research (ANCHOR) study by Lee et al. revealed a high incidence rate of pre-anal cancer (14.1%) in these groups, emphasizing the need for early screening and prevention. This nurse-led project aims to establish standardized clinical protocols and care pathways to enhance anal cancer screening, particularly in HIV/STD clinics, and bridge the healthcare gap for equity and equality.

Significance: Gay men, bisexual men, and transgender women face disparities in cancer screening and sexual health prevention. The absence of specific guidelines from the Centers for Disease Control and Prevention (CDC) for these groups highlights the importance of this nurse-led project, which focuses on implementing standardized anal cancer screening and testing in HIV/STD clinics. The primary goal is to improve the quality of care and outcomes for high-risk populations by introducing anal pap smears into ambulatory care. This project seeks to facilitate early screening, testing, and referrals to specialty oncology care for gay men, bisexual men, and transgender women. The nurse-led project hypothesizes that implementing rectal cancer screening and testing will result in over 30% of pre-cancer findings within a year of implementation, thereby increasing testing rates, reducing wait times for treatment, lowering access barriers, and improving early diagnosis.

Methods: This nurse-led project employs the plan-do-study-act (PDSA) framework. In phase one, an interdisciplinary team developed an anal pap screening tool for targeted patients. Phase two involved creating clinical protocols and educational materials for anal pap screening tool utilization. All patients receive screening questionnaires before their appointments, with positive results triggering anal pap smear orders. Phases three and four consist of audits to collect data and implement interventions to improve the protocol.

Results: From November 2022 to September 2023, 719 patients completed anal pap screening questionnaires out of a total of 1,486. The response rate was 48%, with 109 eligible for anal pap smear tests. Among them, 38 tested positive, resulting in a 35% positivity rate. Post-implementation showed a fivefold increase in anal pap smear performance compared to pre-implementation. Abnormal cells included ASCUS, LSIL, and HSIL, with referrals made for further evaluation. Data collection continues until November 2023.

Conclusions: Utilizing the PDSA framework, the RN-led rectal cancer screening and testing protocol shows promise in improving the health outcomes of high-risk populations. The nurse-led project is set to continue its PDSA cycles in 2023, expanding standardized sexual health care for these populations. Key success factors include the adoption of opt-out screening questionnaires, stakeholder involvement, and effective education and training. This project aims to inspire primary care settings to adopt these strategies and contribute to closing gaps in equality, equity, and inclusion in health care.