09 June 2026
Anal cancer is rare, almost always linked to HPV, and in many cases preventable — if we detect precancerous lesions in time. In an in-depth interview, Dr. Magali Surmont (UZ Brussels) shares how Belgium is taking action against anal cancer. She points to three key areas where we can truly make a difference: prevention, screening, and treatment.
“It’s a question I’m sometimes asked — and one I used to ask myself too,” admits Dr. Magali Surmont, gastroenterologist at UZ Brussels, specializing in proctology (disorders of the rectum and anus) and pelvic floor pathology.
“Anal cancer is officially considered a rare disease. In 2023, 274 new cases were diagnosed in Belgium. To put that in context: every year, more than 8,000 Belgians are diagnosed with colorectal cancer,” she explains.
But the label ‘rare’ doesn’t tell the whole story.
For example, anal cancer occurs twice as often in women as in men.
“Still, when you look at women as a group, it remains a rare cancer,” says Dr. Surmont.
The picture changes, however, for certain populations.
“Take HIV-positive men who have sex with men (MSM) — their risk of developing anal cancer is a hundred times higher than in the general population. In that group, anal cancer is not rare.”
“In fact,” she adds, “an HIV-positive MSM has a higher risk of developing anal cancer than the average person over 50 has of getting colorectal cancer — or the average woman of developing cervical cancer.”
Dr. Surmont deliberately draws the comparison with those two cancers. Like anal cancer, they have precancerous stages that can be detected and treated — making targeted screening worthwhile.
“The investments we make in population screening for colorectal and cervical cancer are completely justified,” she says. “So why leave anal cancer out in the cold?”
UZ Brussels has submitted a proposal for a study on anal cancer screening in people living with HIV.
“But we shouldn’t forget that most people diagnosed with anal cancer don’t actually belong to a known risk group,” she emphasizes.
“That’s why, in our communication, we shouldn’t focus solely on risk groups,” Dr. Surmont adds.
“Otherwise, we risk sending the wrong message — that others don’t need to worry. What we really need to say is this: if you have symptoms, get checked.”
In addition to HIV-positive MSM, women with HPV-related gynaecological cancers or precancers and transplant patients also belong to the high-risk groups.
“The common factor,” explains Dr. Surmont, “is a weakened immune system. This makes them more vulnerable to chronic infection with the human papillomavirus — and HPV is responsible for around 90% of all anal cancers.”
Because HPV is sexually transmitted, it’s often surrounded by taboo.
“But that really isn’t necessary,” she says. “Between 80 and 90% of sexually active people will contract HPV at some point. In most cases, the body clears the virus on its own. Sometimes, however, it doesn’t — for example when someone’s immune system is weakened or due to an underlying sensitivity.”
There are low-risk and high-risk types of HPV.
Low-risk types can cause anogenital warts, while high-risk types can lead to several cancers, including anal cancer.
“If your body doesn’t naturally clear a high-risk HPV infection, the virus can remain dormant for years — and eventually lead to precancerous lesions,” Dr. Surmont explains.
The stigma around HPV can sometimes stop parents from having their children vaccinated. Dr. Surmont points to the United States as an example.
“The vaccine protects against both high-risk and low-risk types of HPV. But in the U.S., vaccination campaigns deliberately focus on the high-risk variant — and call it an ‘anti-cancer vaccine’. They want to avoid the association with an ‘anti-wart vaccine’ at all costs,” she explains.
“Because many parents think, ‘My child isn’t sexually active — why would they need that?’”
“The best thing, of course, is to make sure people never get infected with HPV in the first place,” Dr. Surmont continues.
“How? By vaccinating at a young age, before the first sexual contact. For nearly twenty years, we’ve been vaccinating girls to protect them against cervical cancer. Today, we know that HPV is gender-neutral and can cause other types of cancer as well. That’s why, in recent years, boys have also been included in the HPV vaccination programme in Belgium.”
In Belgium, HPV vaccination is fully reimbursed for all boys and girls in the first year of secondary school. Those who miss the vaccine that year can still receive it up to the third year. This policy follows the recommendation of the Superior Health Council (HGR) to vaccinate girls and boys between 9 and 14 years old.
Still, Belgium doesn’t get a perfect score.
“The policy only follows part of the scientific advice,” notes Dr. Surmont.
In addition to general vaccination between ages 9 and 14, the HGR also recommends catch-up vaccination for adolescents and young adults aged 15 to 26 who haven’t yet received the vaccine. However, catch-up vaccination is not — or only partially — reimbursed.
“Up to the age of 18, you pay €36.30 yourself — that’s €12.10 per dose. But once you’re over 18, you have to pay the full amount, which comes to almost €400,” Dr. Surmont explains.
“That’s a lot of money, especially at a time when young people are just starting out in adult life. Because of that financial barrier, many adolescents and young adults decide not to get vaccinated.”
Dr. Surmont hopes Belgium’s vaccination policy will continue to evolve in the coming years. But she’s clear: vaccination alone isn’t enough.
“The real impact of the vaccines we’re giving today won’t become visible for another fifty years,” she explains. “By then, the young people we’re vaccinating now will be in their fifties or sixties — the age when anal cancer incidence peaks. In the meantime, it’s our duty to care for those for whom the vaccine came too late. We can’t let them become lost generations.”
For these people, the solution lies in stepwise screening.
Today, the process starts with an anal HPV swab. If that test comes back positive, it’s followed by a High-Resolution Anoscopy (HRA) — a specialized examination to detect and treat precancerous lesions.
“When I started my clinic in 2019, it wasn’t yet clear whether treating precancerous lesions would make a real difference,” Dr. Surmont recalls.
“That changed with the ANCHOR study, a landmark publication in 2022 that showed, in black and white: treating precancerous lesions significantly reduces the risk of developing anal cancer.
That finding was a huge relief for everyone working on anal HPV and screening,” she adds.
“We now know for sure — we’re truly making a difference for people.”
Dr. Surmont stresses the importance of approaching screening responsibly.
“HRA capacity in Belgium is limited. You can’t start collecting large numbers of anal HPV swabs and then fail to follow up positive results with HRA. That would be unethical,” she warns.
That’s why she advocates for a targeted approach, focusing on high-risk groups and using cytological tests and, where possible, biomarkers to triage.
“If those results are positive, an HRA can follow,” she explains.
“In this way, we use our limited HRA capacity where it will have the greatest impact.”
At the same time, Belgium needs to gradually expand its HRA capacity — which requires investment in both medical equipment and training for healthcare professionals.
“HRA isn’t reimbursed in Belgium,” Dr. Surmont notes. “That makes it a less attractive activity for hospitals, and it limits training opportunities for clinicians. The result? Long waiting times for patients, a lot of ad hoc work, and variation in how care is delivered.”
“This isn’t just a Belgian issue,” she adds.
“Across Europe, we’re seeing the same challenges. Through the International Anal Neoplasia Society (IANS), we’re currently collecting as much information as possible on how different countries handle HRA, so we can learn from each other and help structure national approaches.
We also organize HRA crash courses at medical conferences — not to train people fully in two hours, of course, but to raise awareness of the importance of HRA and to inspire more professionals to get involved.”
The International Anal Neoplasia Society (IANS) doesn’t focus on one single medical specialty. “What’s unique about anal cancer is that the first point of care can differ greatly depending on the country or setting,” Dr. Surmont explains.
“In Belgium, patients often arrive through gastroenterology, in the Netherlands through dermatology, and in the UK through surgery or infectious diseases.
Which door a patient enters through doesn’t really matter — what’s important is that we have strong multidisciplinary care pathways where specialists work together.”
Screening plays a crucial role in those pathways — although sometimes, it comes too late to detect precancerous stages.
“Fortunately, we’ve made major progress in the treatment of anal cancer over the past years,” says Dr. Surmont.
“The mutilating surgeries of the past are now largely behind us. Chemoradiotherapy has become the much less invasive standard, and outcomes are strong: five-year survival rates reach 85% for localized disease.
When the cancer has spread, survival drops to around 36% — so early detection remains key.”
Even though treatment is far less invasive today, its impact on patients remains significant.
“Because of the toxicity of chemoradiotherapy, many people experience sexual dysfunction and bowel problems,” Dr. Surmont explains.
“That’s a heavy burden to carry. That’s why early detection isn’t only about survival — it’s also about quality of life.”
When asked about her hopes for the future, Dr. Surmont doesn’t hesitate:
“My hope is that anal cancer will be virtually eliminated within fifty years — thanks to gender-neutral HPV vaccination. And in the meantime, that we continue to care for those for whom the vaccine came too late.
We already have the tools — now it’s up to us to use them as effectively as possible.”
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