119 The International Anal Neoplasia Society (IANS) has released new guidelines recommending targeted anal cancer screening for high-risk populations. These guidelines are set to reshape the approach to early detection and prevention of anal cancer, particularly among men who have sex with men (MSM), transgender women (TW), and individuals living with HIV. The guidelines are based on extensive research and consensus among international experts, addressing a critical gap in the early detection of a cancer type that, although rare in the general population, poses a significant risk to specific groups. The guidelines advocate for a more tailored approach to anal cancer screening, recognising that certain populations are at a much higher risk of developing the disease. For instance, MSM and TW living with HIV are recommended to begin screening at the age of 35, given their heightened risk. This recommendation is grounded in evidence showing that these groups have a significantly higher incidence of anal cancer compared to the general population, with rates exceeding 70 per 100,000 person-years for those aged 30 to 44. This figure rises even further in older age groups. For MSM and TW without HIV, the recommended age for screening is 45. Similarly, women and heterosexual men with HIV are also advised to begin screening at 45. The guidelines underscore the importance of early detection in these high-risk groups, where the incidence of anal cancer is considerably higher than in the general population. The task force behind these guidelines also addressed other groups with elevated risks, such as individuals with a history of vulvar cancer or precancer, as well as solid organ transplant recipients. For these populations, screening is recommended to start within one year of a vulvar cancer diagnosis or ten years post-transplant, respectively. The new guidelines emphasise the need for shared decision-making in populations with a slightly elevated risk, but not to the same extent as those in the highest risk categories. For example, people with autoimmune conditions or a history of cervical cancer may be considered for screening, but this decision should be made jointly by the patient and healthcare provider, taking into account the capacity to perform diagnostic procedures like high-resolution anoscopy (HRA). The IANS guidelines provide clear thresholds for when to refer patients for further testing, such as HRA, which is crucial in confirming the presence of high-grade squamous intraepithelial lesions (HSIL), a precursor to anal cancer. The guidelines propose using anal cytology, high-risk HPV testing, or a combination of both as effective screening methods. However, they acknowledge the need for more data on the long-term effectiveness of these approaches. While the guidelines represent a significant step forward in the prevention of anal cancer, they also highlight the challenges in implementing such screening programmes, particularly in regions with limited resources. The availability of HRA, which is essential for diagnosing HSIL, remains a significant barrier. Most HRA providers are concentrated in large urban centres in high-income countries, leaving vast areas, especially in low- and middle-income countries, without access to this crucial service. The guidelines call for increased investment in HRA infrastructure and training to ensure that at-risk populations worldwide can benefit from early detection and treatment. The IANS stresses that without addressing these disparities, the full potential of the guidelines to reduce anal cancer incidence cannot be realised. The release of these guidelines marks a pivotal moment in the fight against anal cancer, but the IANS acknowledges that this is just the beginning. The task force has identified several areas where further research is needed, including the impact of HPV vaccination on anal cancer risk and the long-term outcomes of different screening strategies. Moreover, the guidelines will need to evolve as new data becomes available, particularly concerning the effectiveness of screening in populations other than those with HIV. As more robust longitudinal studies are conducted, it is expected that the guidelines will be updated to reflect the latest evidence, ensuring that screening practices remain aligned with the best available science. In the meantime, these guidelines offer a clear roadmap for healthcare providers and policymakers aiming to reduce the burden of anal cancer in high-risk populations. By prioritising early detection and targeted screening, the IANS hopes to significantly lower the incidence of this often-overlooked cancer, ultimately saving lives.