Latest news with #KlintPeebles
Medscape
06-08-2025
- Health
- Medscape
Detecting Anal Cancer in Vulnerable Patients
WASHINGTON — Anal cancer is a major issue in the older adult population, especially for those identifying as sexually diverse, and it is 'not yet talked about enough,' Klint Peebles, MD, said at the ElderDerm 2025 conference on dermatology in the older patient population. Between 2001 and 2015, the incidence of anal squamous cell carcinoma rose 2.7% per year in the US, according to a published analysis of the US Cancer Statistics dataset, with statistically significant increases in people aged 50 years or older, especially in women. Moreover, deaths from anal cancer rose 3.1% each year during that period. 'Not only are rates rising, but we're seeing later-stage diagnoses rise as well,' said Peebles, a dermatologist with Kaiser Permanente, Mid-Atlantic Permanente Medical Group, in Washington, DC, and suburban Maryland. 'We're not catching them early in certain groups.' Peebles discussed this issue in a presentation titled 'Intersection of aging, gender & sexual diversity, and dermatology' at the meeting hosted by the George Washington School of Medicine and Health Sciences, Washington, DC. Klint Peebles, MD In 2024, there were an estimated 10,540 new cases of anal cancer (0.5% of all new cancer cases), with higher rates in women than in men. Notably, in women aged 65-74 years or older, anal cancer is more common than cervical cancer. Cervical cancer screening generally ends at age 65 for women at average risk. But anal cancer hasn't even peaked in this population by then, Peebles noted, referring to a 2021 report from the HPV Information Centre. 'For men, it starts to peak at age 60 or so and then never comes down.' Among subpopulations, people living with HIV — and especially men who have sex with men (MSM) who are living with HIV — have the highest rates of anal cancer. 'Men who have sex with men and living with HIV are 80 times more likely to develop anal cancer than HIV-negative individuals,' Peebles said. One in 10 MSM living with HIV will get anal cancer over their lifetime, and 'we're seeing this happen regardless of antiretroviral therapy.' Challenges, Disparities of a Growing Population Understanding the epidemiology of anal cancer is part of the broader need for dermatologists to recognize the health challenges faced by LGBTQ older adults, said Peebles, chair of the American Academy of Dermatology (AAD)'s Access to Dermatologic Care Committee and past chair of the AAD's LGBTQ/Sexual and Gender Minority Expert Resource Group. An estimated 250,000 US adults older than 65 years identify as transgender, about 0.5% of that age group, mirroring the proportion in the general population. An estimated 3 million LGBTQ adults older than 50 years currently live in the US, and that's expected to grow to 7 million by 2030. Many LGBTQ older adults face significant economic, housing, and healthcare barriers rooted in a lifetime of discrimination. More than half report employment and/or housing discrimination, and one third live at or below the federal poverty level. Among LGBTQ seniors, 'there are many concerns about long-term care settings,' Peebles added, 'with many trans older adults being forced, for instance, to hide their identify in order to get accepted' into long-term care and to feel safe and secure there. These disparities can directly influence dermatologic care, emphasized Peebles, who urged dermatologists to provide trauma-informed care, which is a distinct evidence-based model that acknowledges the substantial impact of trauma while offering the necessary support for healing. In addition, it is important to differentiate between sex/sex assigned at birth, gender identity, gender expression, sexual orientation, and sexual behavior. 'All of these are very different,' Peebles said. An Important Start on Anal Cancer Screening The ANCHOR trial conducted at 25 US clinical sites and published in The New England Journal of Medicine in 2022, demonstrated that routine screening for and removal of anal high-grade squamous intraepithelial lesions could significantly lower the risk for anal cancer in people living with HIV. The findings informed the first federal screening guidelines released in 2024, co-sponsored by the Office of AIDS Research at the National Institutes of Health, the CDC, and the HIV Medicine Association affiliated with the Infectious Diseases Society of America. The guidelines recommend that all adults living with HIV be assessed at least once a year for anal abnormalities and undergo digital anorectal examination. Those younger than 35 years with anal symptoms or abnormalities on examination should undergo standard anoscopy, people older than 35 years should have laboratory-based screening (with follow-up high-resolution anoscopy, if indicated) if they are MSM, transgender women, or aged 45 years or older. Consensus screening guidelines from the International Anal Neoplasia Society similarly recommend screening in all MSM and transgender women living with HIV who are aged 35 years or older. A lower risk category for screening requiring shared decision-making recommends screening for those with perinatal warts who are 45 years or older. 'I've helped to identify a handful of invasive anal cancers over the last year alone in the older adult population who are living with HIV and identify as MSM,' Peebles said at the meeting. 'This was only after I initiated the conversation about their risk factors for anal cancer, which then led to appropriate screening,' Peebles explained after the meeting. A 2018 survey sponsored by the American Association of Retired Persons and the University of Michigan found that about 40% of people aged 65-80 years are sexually active, condom use is low, and only 17% had discussed sexual health with their healthcare provider in the prior 2 years. 'It is important to remember this context, to gather relevant information about sexual behaviors, and to remember that sexual behaviors are entirely distinct from sexual orientation and attraction,' Peebles told Medscape Medical News after the meeting.
Medscape
29-05-2025
- General
- Medscape
Advocating for Consistent Health Plan Coverage for Vitiligo
Anxiety, depression, social isolation, and stigma are the daily struggles of people living with vitiligo. Yet coverage of prescribed medication is often denied under the rationale that the condition is 'cosmetic.' The problem persists for Medicaid and TRICARE recipients in particular and varies by state. Klint Peebles, MD Vitiligo is an autoimmune disease in which patients' immune systems destroy melanocytes, causing depigmented or white patches of lesions on the skin. While vitiligo is visible, it is hardly a cosmetic condition, because its negative effects are more than skin deep. Given its high visibility, many patients with vitiligo experience social stigma, low self-esteem, and discrimination. Across all age groups, vitiligo can cause significant insecurity and fear of social rejection, which can lead to social withdrawal and feelings of isolation. The impact of the disease can be even more profound in cultural contexts that idealize uniform, consistent pigmentation. Studies have found that vitiligo has significant negative psychosocial impacts, with patients experiencing higher rates of anxiety, depression and social isolation. The wide range of negative health effects warrants classification of vitiligo as a medical condition deserving of proper treatment. Vitiligo is associated with other medical conditions and physiologic effects. Studies have found that around 20% of patients with vitiligo have other autoimmune conditions, such as thyroid disorders, type 1 diabetes, and rheumatoid arthritis, among others. And because patients' immune systems attack melanocytes in the retina, uvea, and cochlea, patients also can experience vision and hearing loss. Medicaid Challenges 'Part D drugs indicated for the treatment of…vitiligo are not considered cosmetic,' the Centers for Medicare & Medicaid Services' (CMS) Medicare Prescription Drug Benefit Manual clearly states. But although vitiligo is correctly classified as a progressive autoimmune condition by CMS, many patients continue to be denied coverage for their treatment because of discrepancies at the state level. At least 11 states have Medicaid plans classifying vitiligo as a cosmetic condition, which prevents patients from accessing the medications they need. Seven states (Arizona, Hawaii, Iowa, New Hampshire, New York, Rhode Island, and Virginia) have formal exclusion policies that deny coverage of the first US Food and Drug Administration (FDA)–approved vitiligo treatment, whereas providers in Alabama, North Dakota, South Dakota, and West Virginia have received letters of denial for Medicaid coverage of treatments. In fact, only 20 states have policies explicitly stating that they cover vitiligo treatments. The discrepancy in classification between CMS and state Medicaid services directly blocks patients from accessing treatment and further compounds disparities in the vitiligo community. TRICARE Challenges TRICARE, the government health program for active service members, retirees, and their families, also fails to correctly classify vitiligo as a medical condition. The approach does not align with CMS and other government health agencies' classification. In contrast, the Blue Cross Blue Shield Federal Employee Program and the Department of Veterans Affairs correctly classify the disease and provide their beneficiaries access to vitiligo treatments. The Department of Veterans Affairs even provides veterans with vitiligo a 10% disability rating, placing further emphasis on the severity of the impact of vitiligo on a patient's overall health and ability to function. Inconsistencies are all the more troubling because new treatment options could offer patients relief. The FDA recently approved topical ruxolitinib for treating nonsegmental vitiligo, the first and only drug approved for vitiligo. Repigmentation with treatment not only reduces the risk for skin cancer but also alleviates the psychological burden of having visible discolored skin patches. Yet, TRICARE's formulary lists this medication as a 'non-formulary drug' based on the incorrect perception that the drug serves only cosmetic use. The only way beneficiaries can access this medication is by submitting forms for prior authorization and proof of medical necessity. What Dermatologists, Other Healthcare Providers, and Patients Can Do There are many ways in which physicians and other healthcare providers can advocate for individuals impacted by vitiligo. First, it is essential to engage with the policymaking process, encouraging legislation and insurance coverage provisions that classify vitiligo appropriately as a medical condition (ie, as a chronic autoimmune disorder) rather than a cosmetic concern. In addition, physicians can work across organized medicine and with regulatory agencies to ensure that evidence-based standards are promoted and amplified. In all of these contexts, physicians can participate in public hearings, testifying about the psychosocial impact of vitiligo and the need for better treatment options and high-quality research. Moreover, inclusive research should be encouraged such that diverse patient populations are appropriately represented. It is also essential to advocate for the creation of standardized treatment protocols to help improve patient outcomes. Finally, physicians can participate in broader educational efforts, ensuring that others are aware of the impact of vitiligo and dispel misinformation about the condition. It is also crucial to partner with patients in advocacy groups, nonprofits, and awareness campaigns. By engaging with the regulatory and policy spaces, physicians can compel systemic changes that lead to higher-quality care, access, improved treatment options, and reduced stigma. The Derma Care Access Network (DCAN) recently sent letters to CMS and TRICARE urging them to correct these issues. Medical professionals and patients can also take action by contacting their state's Medicaid Director and the DHA's TRICARE Pharmacy Operations Division and urging them to address these problems. Until health policymakers and regulators standardize the definition of vitiligo as a medical condition, treatment barriers will continue to present a challenge for Medicaid patients and service members living with vitiligo. Dr Peebles is a board-certified dermatologist at Kaiser Permanente, Washington, DC, and suburban Maryland, a member of the editorial board of the Journal of the American Academy of Dermatology (JAAD), co-chair of JAAD's Diversity, Equity, and Inclusion Work Group, vice chair of the American Medical Association Dermatology Section Council, and chair of the AAD Access to Dermatologic Care Committee and Basic Dermatology Curriculum Work Group. Dr Peebles is also on the board of directors and is the advocacy committee chair of the Medical Society of the District of Columbia, and a member of the Medical Advisory Board for Derma Care Access Network (DCAN).
