General Information About Anal Cancer
Anal cancer is a disease in which malignant (cancer) cells form in
the tissues of the anus.
The anus is the end of the large intestine, below the rectum, through which stool (solid waste) leaves the body. The anus is formed partly from the outer, skin layers of the body and partly from the intestine. Two ring-like muscles, called sphincter muscles, open and close the anal opening to let stool pass out of the body. The anal canal, the part of the anus between the rectum and the anal opening, is about 1½ inches long.
 |
| Anatomy of the lower digestive system, showing the colon and other organs. |
The skin around the outside of the anus is called the perianal area. Tumors in this area are skin tumors, not analcancer.
Being infected with the human papillomavirus (HPV) can affect the risk of developing anal
cancer.
Risk factors include the following:
- Being over 50 years old.
- Being infected with human papillomavirus (HPV).
- Having many sexual partners.
- Having receptive anal intercourse (anal sex).
- Frequent anal redness, swelling, and soreness.
- Having anal fistulas (abnormal openings).
- Smoking cigarettes.
Possible signs of anal cancer include bleeding from the anus or rectum or a lump near the anus.
These and other symptoms may be caused by anal cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur:
- Bleeding from the anus or rectum.
- Pain or pressure in the area around the anus.
- Itching or discharge from the anus.
- A lump near the anus.
- A change in bowel habits.
Tests that examine the rectum and anus are used to detect (find) and diagnose anal cancer.
The following tests and procedures may be used:
- Physical exam and history: An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
- Digital rectal examination (DRE): An exam of the anus and rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual.
- Anoscopy: An exam of the anus and lower rectum using a short, lighted tube called an anoscope.
- Proctoscopy: An exam of the rectum using a short, lighted tube called a proctoscope.
- Endo-anal or endorectal ultrasound: A procedure in which an ultrasound transducer (probe) is inserted into the anus or rectum and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
- Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist to check for signs of cancer. If an abnormal area is seen during the anoscopy, a biopsy may be done at that time.
Certain factors affect the prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) depends on the following:
- The size of the tumor.
- Where the tumor is in the anus.
- Whether the cancer has spread to the lymph nodes.
The treatment options depend on the following:
- The stage of the cancer.
- Where the tumor is in the anus.
- Whether the patient has human immunodeficiency virus (HIV).
- Whether cancer remains after initial treatment or has recurred.
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Stages of Anal Cancer
After anal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the anus or to other parts of the body.
The process used to find out if cancer has spread within the anus or to other
parts of the body is called staging. The information gathered from the
staging process determines the stage of the disease. It is important to know
the stage in order to plan treatment. The following tests may be used in the staging process:
- CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography. For anal cancer, a CT scan of the pelvis and abdomen may be done.
- Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
- Endo-anal or endorectal ultrasound: A procedure in which an ultrasound transducer (probe) is inserted into the anus or rectum and used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram.
There are three ways that cancer spreads in the body.
The three ways that cancer spreads in the body are:
- Through tissue. Cancer invades the surrounding normal tissue.
- Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
- Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.
When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
The following stages are used for anal cancer:
Stage 0 (Carcinoma in Situ)
In stage 0, abnormalcells are found in the innermost lining of the anus. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
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| Pea, peanut, walnut, and lime show tumor sizes. |
Stage I
In stage I, cancer has formed and the tumor is 2 centimeters or smaller.
Stage II
In stage II, the tumor is larger than 2 centimeters.
Stage IIIA
In stage IIIA, the tumor may be any size and has spread to either:
- lymph nodes near the rectum; or
- nearby organs, such as the vagina, urethra, and bladder.
Stage IIIB
In stage IIIB, the tumor may be any size and has spread:
- to nearby organs and to lymph nodes near the rectum; or
- to lymph nodes on one side of the pelvis and/or groin, and may have spread to nearby organs; or
- to lymph nodes near the rectum and in the groin, and/or to lymph nodes on both sides of the pelvis and/or groin, and may have spread to nearby organs.
Stage IV
In stage IV, the tumor may be any size and cancer may have spread to lymph nodes or nearby organs and has spread to distant parts of the body.
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Recurrent Anal Cancer
Recurrentanalcancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the anus or in other parts of the body.
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Treatment Option Overview
There are different types of treatment for patients with anal cancer.
Different types of treatments are available for patients with analcancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Three types of standard treatment are used:
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Surgery
- Localresection: A surgical procedure in which the tumor is cut from the anus along with some of the healthy tissue around it. Local resection may be used if the cancer is small and has not spread. This procedure may save the sphincter muscles so the patient can still control bowel movements. Tumors that develop in the lower part of the anus can often be removed with local resection.
- Abdominoperineal resection: A surgical procedure in which the anus, the rectum, and part of the sigmoid colon are removed through an incision made in the abdomen. The doctor sews the end of the intestine to an opening, called a stoma, made in the surface of the abdomen so body waste can be collected in a disposable bag outside of the body. This is called a colostomy. Lymph nodes that contain cancer may also be removed during this operation.
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| Anal cancer surgery with colostomy. The anus, rectum, and part of the colon are removed, a stoma is created, and a colostomy bag is attached to the stoma. |
Having the human immunodeficiency virus can affect treatment of anal cancer.
Cancer therapy can further damage the already weakened immune systems of patients who have the human immunodeficiency virus (HIV). For this reason, patients who have anal cancer and HIV are usually treated with lower doses of anticancer drugs and radiation than patients who do not have HIV.
New types of treatment are being tested in clinical trials.
This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied.
Information about clinical trials is available from the NCI Web site.
Radiosensitizers
Radiosensitizers are drugs that make tumor cells more sensitive to radiation therapy. Combining radiation therapy with radiosensitizers may kill more tumor cells.
Patients may want to think about taking part in a clinical trial.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's clinical trials database.
Follow-up tests may be needed.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
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Treatment Options by Stage
A link to a list of current clinical trials is included for each treatment section. For some types or stages of cancer, there may not be any trials listed. Check with your doctor for clinical trials that are not listed here but may be right for you.
Stage 0 (Carcinoma in Situ)
Treatment of stage 0 is usually localresection.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage 0 anal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
Stage I Anal Cancer
Treatment of stage I anal cancer may include the following:
- Localresection.
- External-beam radiation therapy with or without chemotherapy. If cancer remains after treatment, additional chemotherapy and radiation therapy may be given to avoid the need for a permanent colostomy.
- Internal radiation therapy.
- Abdominoperineal resection, if cancer remains or comes back after treatment with radiation therapy and chemotherapy.
- Internal radiation therapy for cancer that remains after treatment with external-beam radiation therapy.
Patients who have had treatment that saves the sphincter muscles may receive follow-up exams every 3 months for the first 2 years, including rectal exams with endoscopy and biopsy, as needed.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage I anal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
Stage II Anal Cancer
Treatment of stage II anal cancer may include the following:
- Localresection.
- External-beam radiation therapy with chemotherapy. If cancer remains after treatment, additional chemotherapy and radiation therapy may be given to avoid the need for a permanent colostomy.
- Internal radiation therapy.
- Abdominoperineal resection, if cancer remains or comes back after treatment with radiation therapy and chemotherapy.
- A clinical trial of new treatment options.
Patients who have had treatment that saves the sphincter muscles may receive follow-up exams every 3 months for the first 2 years, including rectal exams with endoscopy and biopsy, as needed.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage II anal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
Stage IIIA Anal Cancer
Treatment of stage IIIA anal cancer may include the following:
- External-beam radiation therapy with chemotherapy. If cancer remains after treatment, additional chemotherapy and radiation therapy may be given to avoid the need for a permanent colostomy.
- Internal radiation therapy.
- Abdominoperineal resection, if cancer remains or comes back after treatment with chemotherapy and radiation therapy.
- A clinical trial of new treatment options.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IIIA anal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
Stage IIIB Anal Cancer
Treatment of stage IIIB anal cancer may include the following:
- External-beam radiation therapy with chemotherapy.
- Localresection or abdominoperineal resection, if cancer remains or comes back after treatment with chemotherapy and radiation therapy. Lymph nodes may also be removed.
- A clinical trial of new treatment options.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IIIB anal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
Stage IV Anal Cancer
Treatment of stage IV anal cancer may include the following:
- Surgery as palliative therapy to relieve symptoms and improve the quality of life.
- Radiation therapy as palliative therapy.
- Chemotherapy with radiation therapy as palliative therapy.
- A clinical trial of new treatment options.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with stage IV anal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
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Treatment Options for Recurrent Anal Cancer
Treatment of recurrentanalcancer may include the following:
- Radiation therapy and chemotherapy, for recurrence after surgery.
- Surgery, for recurrence after radiation therapy and/or chemotherapy.
- A clinical trial of radiation therapy with chemotherapy and/or radiosensitizers.
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with recurrent anal cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.
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To Learn More About Anal Cancer
For more information from the National Cancer Institute about anal cancer, see the following:
For general cancer information and other resources from the National Cancer Institute, see the following:
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This information is provided by the National Cancer Institute.
This information was last updated on June 13, 2008.
Purpose of This PDQ Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of anal cancer. This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board.
Information about the following is included in this summary:
- Prognostic factors.
- Cellular classification.
- Staging.
- Treatment options by cancer stage.
This summary is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Some of the reference citations in the summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations. Based on the strength of the available evidence, treatment options are described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for reimbursement determinations.
This summary is available in a patient version, written in less technical language, and in Spanish.
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General Information
Note: Estimated new cases and deaths from anal cancer in the United States in 2009:[1]
- New cases: 5,290.
- Deaths: 710.
Anal cancer is usually curable. The three major prognostic factors are
site (anal canal vs. perianal skin), size (primary tumors <2
cm in size have better prognoses), and nodal status.
Anal cancer is an uncommon malignancy and accounts for only a small percentage
(4%) of all cancers of the lower alimentary tract. Clinical trials such as E-7283R, for example, have
evaluated the roles of chemotherapy, radiation therapy, and surgery in the
treatment of this disease.[2][3] Information about ongoing clinical trials is
available from the NCI Web site.
Overall, the risk of anal cancer is rising, with data suggesting that
persons engaging in certain sexual practices, such as receptive anal intercourse, or persons with a high lifetime number of sexual partners are at increased risk of anal cancer. These practices may have led to an increase in the number of individuals at risk for infection with human papillomavirus (HPV); HPV infection is strongly associated with anal cancer development and may be a necessary step in its carcinogenesis.[4][5][6][7]
References:
American Cancer Society.: Cancer Facts and Figures 2009. Atlanta, Ga: American Cancer Society, 2009. Also available online. Last accessed January 6, 2010.
Martenson JA, Lipsitz SR, Lefkopoulou M, et al.: Results of combined modality therapy for patients with anal cancer (E7283). An Eastern Cooperative Oncology Group study. Cancer 76 (10): 1731-6, 1995.
Fuchshuber PR, Rodriguez-Bigas M, Weber T, et al.: Anal canal and perianal epidermoid cancers. J Am Coll Surg 185 (5): 494-505, 1997.
Johnson LG, Madeleine MM, Newcomer LM, et al.: Anal cancer incidence and survival: the surveillance, epidemiology, and end results experience, 1973-2000. Cancer 101 (2): 281-8, 2004.
Daling JR, Weiss NS, Hislop TG, et al.: Sexual practices, sexually transmitted diseases, and the incidence of anal cancer. N Engl J Med 317 (16): 973-7, 1987.
Palefsky JM, Holly EA, Gonzales J, et al.: Detection of human papillomavirus DNA in anal intraepithelial neoplasia and anal cancer. Cancer Res 51 (3): 1014-9, 1991.
Ryan DP, Compton CC, Mayer RJ: Carcinoma of the anal canal. N Engl J Med 342 (11): 792-800, 2000.
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Cellular Classification
Squamous cell (epidermoid) carcinomas make up the majority of all primary
cancers of the anus. The important subset of cloacogenic (basaloid
transitional cell) tumors constitutes the remainder. These two histologic
variants are associated with human papillomavirus infection.[1]
Adenocarcinomas from anal glands or fistulae formation and melanomas are rare.
Treatment of anal melanoma is not included in this summary.
References:
Palefsky JM, Holly EA, Gonzales J, et al.: Detection of human papillomavirus DNA in anal intraepithelial neoplasia and anal cancer. Cancer Res 51 (3): 1014-9, 1991.
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Stage Information
The anal canal extends from the rectum to the perianal skin and is lined by a
mucous membrane that covers the internal sphincter. The following is a staging
system for anal canal cancer that has been described by the American Joint
Committee on Cancer (AJCC) and the International Union Against Cancer.[1]
Tumors of the anal margin (below the anal verge and involving the perianal
hair-bearing skin) are classified with skin tumors.
TNM Definitions
Primary tumor (T)
- TX: Primary tumor cannot be assessed
- T0: No evidence of primary tumor
- Tis: Carcinoma in situ
- T1: Tumor 2 cm or less in greatest dimension
- T2: Tumor more than 2 cm but not more than 5 cm in greatest dimension
- T3: Tumor more than 5 cm in greatest dimension
- T4: Tumor of any size that invades adjacent organ(s), e.g., vagina,
urethra, bladder*
*Direct invasion of the rectal wall, perirectal skin, subcutaneous tissue, or the sphincter muscle(s) is not classified as T4.
Regional lymph nodes (N)
- NX: Regional lymph nodes cannot be assessed
- N0: No regional lymph node metastasis
- N1: Metastasis in perirectal lymph node(s)
- N2: Metastasis in unilateral internal iliac and/or inguinal lymph node(s)
- N3: Metastasis in perirectal and inguinal lymph nodes and/or bilateral
internal iliac and/or inguinal lymph nodes
Distant metastasis (M)
- MX: Distant metastasis cannot be assessed
- M0: No distant metastasis
- M1: Distant metastasis
AJCC Stage Groupings
Stage 0
Stage I
Stage II
Stage IIIA
- T1, N1, M0
- T2, N1, M0
- T3, N1, M0
- T4, N0, M0
Stage IIIB
- T4, N1, M0
- Any T, N2, M0
- Any T, N3, M0
Stage IV
References:
Anal canal. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 125-130.
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Treatment Option Overview
Abdominoperineal resection leading to permanent colostomy was previously
thought to be required for all but small anal cancers below the dentate line,
with approximately 70% of patients surviving 5 or more years in single
institutions,[1] but such surgery is no longer the treatment of choice.[2][3]
Radiation therapy alone may lead to a 5-year survival rate in excess of 70%,
though high doses (≥60 Gy) may yield necrosis or fibrosis.[4]
Chemotherapy concurrent with lower-dose radiation therapy as evidenced in the RTOG-8314 trial, for example, has a 5-year
survival rate in excess of 70% with low levels of acute and chronic morbidity,
and few patients require surgery for dermal or sphincter toxic effects.[5][6][7][8][9][10]
The optimal dose of radiation with concurrent chemotherapy to optimize local
control and minimize sphincter toxic effects is under evaluation as evidenced in the RTOG-9208 trial, for example, but appears to
be in the 45 Gy to 60 Gy range.[11][12] Analysis of an intergroup trial that
compared radiation therapy plus fluorouracil/mitomycin with radiation therapy
plus fluorouracil alone in patients with anal cancer has shown improved results
(lower colostomy rates and higher colostomy-free and disease-free survival)
with the addition of mitomycin.[13] Radiation with continuous infusion of
fluorouracil plus cisplatin is also under evaluation as seen in the RTOG 9811 trial.[14] Standard salvage
therapy for those patients with either gross or microscopic residual disease
following chemoradiation therapy has been abdominoperineal resection. Alternately,
patients may be treated with additional salvage chemoradiation therapy in the form
of fluorouracil, cisplatin, and a radiation boost to potentially avoid
permanent colostomy.[13]
Because of the small number of cases, information that can only come from
patient participation in well-designed clinical trials is needed to improve the
management of anal cancer. Patients with stages II, III, and IV disease should
be considered candidates for clinical trials.
Information about ongoing clinical trials is available from the NCI Web site.
HIV and Anal Cancer
The tolerance of patients with human immunodeficiency virus (HIV) and anal
carcinoma to standard fluorouracil/mitomycin chemoradiation is not well
defined.[15][16] Patients with pretreatment CD4 counts of less than 200 may
have increased acute and late toxic effects;[17][18] chemoradiation doses may
require modification in this subset of patients.
References:
Boman BM, Moertel CG, O'Connell MJ, et al.: Carcinoma of the anal canal. A clinical and pathologic study of 188 cases. Cancer 54 (1): 114-25, 1984.
Stearns MW Jr, Quan SH: Epidermoid carcinoma of the anorectum. Surg Gynecol Obstet 131 (5): 953-7, 1970.
Cummings BJ: The Role of Radiation Therapy With 5-Fluorouracil in Anal Cancer. Semin Radiat Oncol 7 (4): 306-312, 1997.
Cantril ST, Green JP, Schall GL, et al.: Primary radiation therapy in the treatment of anal carcinoma. Int J Radiat Oncol Biol Phys 9 (9): 1271-8, 1983.
Leichman L, Nigro N, Vaitkevicius VK, et al.: Cancer of the anal canal. Model for preoperative adjuvant combined modality therapy. Am J Med 78 (2): 211-5, 1985.
Sischy B: The use of radiation therapy combined with chemotherapy in the management of squamous cell carcinoma of the anus and marginally resectable adenocarcinoma of the rectum. Int J Radiat Oncol Biol Phys 11 (9): 1587-93, 1985.
Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and chemotherapy for radiosensitization in management of anal carcinoma: interim report on Radiation Therapy Oncology Group study no. 8314. J Natl Cancer Inst 81 (11): 850-6, 1989.
Cummings BJ: Anal cancer. Int J Radiat Oncol Biol Phys 19 (5): 1309-15, 1990.
Zucali R, Doci R, Bombelli L: Combined chemotherapy--radiotherapy of anal cancer. Int J Radiat Oncol Biol Phys 19 (5): 1221-3, 1990.
Fuchshuber PR, Rodriguez-Bigas M, Weber T, et al.: Anal canal and perianal epidermoid cancers. J Am Coll Surg 185 (5): 494-505, 1997.
Fung CY, Willett CG, Efird JT, et al.: Chemoradiotherapy for anal carcinoma: what is the optimal radiation dose? Radiat Oncol Investig 2(3): 152-6, 1994.
John M, Pajak T, Flam M, et al.: Dose Escalation in Chemoradiation for Anal Cancer: Preliminary Results of RTOG 92-08 Cancer J Sci Am 2 (4): 205-11, 1996.
Flam M, John M, Pajak TF, et al.: Role of mitomycin in combination with fluorouracil and radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study. J Clin Oncol 14 (9): 2527-39, 1996.
Rich TA, Ajani JA, Morrison WH, et al.: Chemoradiation therapy for anal cancer: radiation plus continuous infusion of 5-fluorouracil with or without cisplatin. Radiother Oncol 27 (3): 209-15, 1993.
Holland JM, Swift PS: Tolerance of patients with human immunodeficiency virus and anal carcinoma to treatment with combined chemotherapy and radiation therapy. Radiology 193 (1): 251-4, 1994.
Peddada AV, Smith DE, Rao AR, et al.: Chemotherapy and low-dose radiotherapy in the treatment of HIV-infected patients with carcinoma of the anal canal. Int J Radiat Oncol Biol Phys 37 (5): 1101-5, 1997.
Hoffman R, Welton ML, Klencke B, et al.: The significance of pretreatment CD4 count on the outcome and treatment tolerance of HIV-positive patients with anal cancer. Int J Radiat Oncol Biol Phys 44 (1): 127-31, 1999.
Place RJ, Gregorcyk SG, Huber PJ, et al.: Outcome analysis of HIV-positive patients with anal squamous cell carcinoma. Dis Colon Rectum 44 (4): 506-12, 2001.
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Stage 0 Anal Cancer
Stage 0 anal cancer is carcinoma in situ. Rarely diagnosed, it is a very early
cancer that has not spread below the limiting membrane of the first layer of
anal tissue.
Standard treatment options:
Surgical resection is used for treatment of lesions of the perianal area not
involving the anal sphincter (approach depends on the location of the lesion in
the anal canal).
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
stage 0 anal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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Stage I Anal Cancer
Stage I anal cancer was formerly treated with abdominoperineal resection.
Current sphincter-sparing therapies include wide local excision for small
tumors of the perianal skin or anal margin, or definitive chemoradiation
(fluorouracil and mitomycin) for cancers of the anal canal. Salvage
chemoradiation therapy (fluorouracil and cisplatin plus a radiation boost) may avoid
permanent colostomy in patients with residual tumor following initial
nonoperative therapy.[1] Radical resection is reserved for patients with
incomplete responses or recurrent disease. Continued surveillance
with rectal examination every 3 months for the first 2 years and
endoscopy/biopsy when indicated after completion of sphincter-preserving
therapy is important.
Standard treatment options:
- Small tumors of the perianal skin or anal margin not involving the anal
sphincter may be adequately treated with local resection.[2]
- As evidenced in RTOG-9208 and RTOG-8314 trials, for example, all other stage I cancers of the anal canal that involve the anal sphincter
or are too large for complete local excision are treated with external-beam
radiation therapy (EBRT) with or without chemotherapy.[1][3][4][5][6][7][8][9]
Chemotherapy with fluorouracil and mitomycin combined with primary radiation
therapy appears to be more effective than radiation therapy alone.[10] The
optimal dose of radiation with concurrent chemotherapy is under
evaluation as seen in the RTOG 9811 trial, for example.[11][12]
Selected tumors are also suitable for interstitial radiation therapy.[4]
- Radical resection is reserved for residual or recurrent cancer in the anal
canal after nonoperative therapy.
- Alternately, salvage chemotherapy with fluorouracil and cisplatin combined
with a radiation boost may avoid a permanent colostomy in selected patients
with small amounts of residual tumor following initial nonoperative therapy.[1]
- Interstitial iridium 192 after EBRT may convert some
patients with residual disease into complete responders.[13]
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
stage I anal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Flam M, John M, Pajak TF, et al.: Role of mitomycin in combination with fluorouracil and radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study. J Clin Oncol 14 (9): 2527-39, 1996.
Enker WE, Heilwell M, Janov AJ, et al.: Improved survival in epidermoid carcinoma of the anus in association with preoperative multidisciplinary therapy. Arch Surg 121 (12): 1386-90, 1986.
Papillon J, Mayer M, Montbarbon JF, et al.: A new approach to the management of epidermoid carcinoma of the anal canal. Cancer 51 (10): 1830-7, 1983.
Cummings B, Keane T, Thomas G, et al.: Results and toxicity of the treatment of anal canal carcinoma by radiation therapy or radiation therapy and chemotherapy. Cancer 54 (10): 2062-8, 1984.
Leichman L, Nigro N, Vaitkevicius VK, et al.: Cancer of the anal canal. Model for preoperative adjuvant combined modality therapy. Am J Med 78 (2): 211-5, 1985.
James RD, Pointon RS, Martin S: Local radiotherapy in the management of squamous carcinoma of the anus. Br J Surg 72 (4): 282-5, 1985.
Sischy B: The use of radiation therapy combined with chemotherapy in the management of squamous cell carcinoma of the anus and marginally resectable adenocarcinoma of the rectum. Int J Radiat Oncol Biol Phys 11 (9): 1587-93, 1985.
Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and chemotherapy for radiosensitization in management of anal carcinoma: interim report on Radiation Therapy Oncology Group study no. 8314. J Natl Cancer Inst 81 (11): 850-6, 1989.
Mitchell SE, Mendenhall WM, Zlotecki RA, et al.: Squamous cell carcinoma of the anal canal. Int J Radiat Oncol Biol Phys 49 (4): 1007-13, 2001.
Epidermoid anal cancer: results from the UKCCCR randomised trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. UKCCCR Anal Cancer Trial Working Party. UK Co-ordinating Committee on Cancer Research. Lancet 348 (9034): 1049-54, 1996.
Fung CY, Willett CG, Efird JT, et al.: Chemoradiotherapy for anal carcinoma: what is the optimal radiation dose? Radiat Oncol Investig 2(3): 152-6, 1994.
John M, Pajak T, Flam M, et al.: Dose Escalation in Chemoradiation for Anal Cancer: Preliminary Results of RTOG 92-08 Cancer J Sci Am 2 (4): 205-11, 1996.
Sandhu AP, Symonds RP, Robertson AG, et al.: Interstitial iridium-192 implantation combined with external radiotherapy in anal cancer: ten years experience. Int J Radiat Oncol Biol Phys 40 (3): 575-81, 1998.
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Stage II Anal Cancer
Stage II anal cancer was formerly treated with abdominoperineal resection.
Current sphincter-sparing therapies include wide local excision for small
tumors of the perianal skin or anal margin, or definitive chemoradiation
(fluorouracil and mitomycin) for cancers of the anal canal. Salvage
chemotherapy (fluorouracil with cisplatin plus a radiation boost) may avoid
permanent colostomy in patients with residual tumor following initial
nonoperative therapy. Radical resection is reserved for patients with
incomplete responses or recurrent disease. Therefore, continued surveillance
with rectal examination every 3 months for the first 2 years and
endoscopy/biopsy when indicated after completion of sphincter-preserving
therapy is important.
Standard treatment options:
- Small tumors of the perianal skin or anal margin not involving the anal
sphincter may be adequately treated with local resection.[1]
- All other stage II cancers of the anal canal that involve the anal sphincter
or are too large for complete local excision are treated with external-beam
radiation therapy plus chemotherapy as evidenced in the RTOG-8314 trial, for example.[2][3][4][5][6][7][8]
Chemotherapy with fluorouracil and mitomycin combined with primary radiation
therapy appears to be more effective than radiation therapy alone.[9] The
optimal dose of radiation with concurrent chemotherapy is under
evaluation as seen in the RTOG-9811 and RTOG-9208 trials, for example.[10][11]
Selected tumors are also suitable for interstitial radiation therapy.[3][12]
- Radical resection is reserved for continued residual or recurrent cancer
in the anal canal after nonoperative therapy.
- Alternately, salvage chemotherapy with fluorouracil and cisplatin combined
with a radiation boost may avoid a permanent colostomy in selected patients
with small amounts of residual tumor following initial nonoperative therapy.[8]
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
stage II anal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Enker WE, Heilwell M, Janov AJ, et al.: Improved survival in epidermoid carcinoma of the anus in association with preoperative multidisciplinary therapy. Arch Surg 121 (12): 1386-90, 1986.
Papillon J, Mayer M, Montbarbon JF, et al.: A new approach to the management of epidermoid carcinoma of the anal canal. Cancer 51 (10): 1830-7, 1983.
Cummings B, Keane T, Thomas G, et al.: Results and toxicity of the treatment of anal canal carcinoma by radiation therapy or radiation therapy and chemotherapy. Cancer 54 (10): 2062-8, 1984.
Leichman L, Nigro N, Vaitkevicius VK, et al.: Cancer of the anal canal. Model for preoperative adjuvant combined modality therapy. Am J Med 78 (2): 211-5, 1985.
James RD, Pointon RS, Martin S: Local radiotherapy in the management of squamous carcinoma of the anus. Br J Surg 72 (4): 282-5, 1985.
Sischy B: The use of radiation therapy combined with chemotherapy in the management of squamous cell carcinoma of the anus and marginally resectable adenocarcinoma of the rectum. Int J Radiat Oncol Biol Phys 11 (9): 1587-93, 1985.
Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and chemotherapy for radiosensitization in management of anal carcinoma: interim report on Radiation Therapy Oncology Group study no. 8314. J Natl Cancer Inst 81 (11): 850-6, 1989.
Flam M, John M, Pajak TF, et al.: Role of mitomycin in combination with fluorouracil and radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study. J Clin Oncol 14 (9): 2527-39, 1996.
Epidermoid anal cancer: results from the UKCCCR randomised trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. UKCCCR Anal Cancer Trial Working Party. UK Co-ordinating Committee on Cancer Research. Lancet 348 (9034): 1049-54, 1996.
Fung CY, Willett CG, Efird JT, et al.: Chemoradiotherapy for anal carcinoma: what is the optimal radiation dose? Radiat Oncol Investig 2(3): 152-6, 1994.
John M, Pajak T, Flam M, et al.: Dose Escalation in Chemoradiation for Anal Cancer: Preliminary Results of RTOG 92-08 Cancer J Sci Am 2 (4): 205-11, 1996.
Sandhu AP, Symonds RP, Robertson AG, et al.: Interstitial iridium-192 implantation combined with external radiotherapy in anal cancer: ten years experience. Int J Radiat Oncol Biol Phys 40 (3): 575-81, 1998.
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Stage IIIA Anal Cancer
Stage IIIA anal cancer presents clinically as stage II in most instances and is
determined to be IIIA by clinically evident perirectal nodal disease or
adjacent organ involvement. Endorectal or endoanal ultrasound may aid in
pretreatment staging.
Standard treatment options:
- As evidenced in the RTOG-8314 trial, treatment used is the same as for stage I and II disease, including the use of radiation therapy plus
chemotherapy.[1][2]
- Radical resection is reserved for continued residual or recurrent cancer in the anal canal after nonoperative therapy.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
stage IIIA anal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and chemotherapy for radiosensitization in management of anal carcinoma: interim report on Radiation Therapy Oncology Group study no. 8314. J Natl Cancer Inst 81 (11): 850-6, 1989.
Flam M, John M, Pajak TF, et al.: Role of mitomycin in combination with fluorouracil and radiotherapy, and of salvage chemoradiation in the definitive nonsurgical treatment of epidermoid carcinoma of the anal canal: results of a phase III randomized intergroup study. J Clin Oncol 14 (9): 2527-39, 1996.
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Stage IIIB Anal Cancer
The presence of inguinal nodes that are involved with metastatic disease
(unilateral or bilateral) is a poor prognostic sign, though cure of this
stage of disease is possible. Because of the poor prognosis associated with
this stage, patients should be included in clinical trials whenever possible.
Standard treatment options:
- Radiation therapy plus chemotherapy (as described for stage II) with surgical
resection of residual disease at the primary site (local resection or
abdominoperineal resection) and unilateral or bilateral superficial and deep
inguinal node dissection for residual or recurrent tumor.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
stage IIIB anal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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Stage IV Anal Cancer
There is no standard chemotherapy for patients with metastatic disease.
Palliation of symptoms from the primary lesion is of major importance. Patients in this stage should be considered candidates for clinical trials.
Standard treatment options:
- Palliative surgery.
- Palliative radiation therapy.
- Palliative combined chemotherapy and radiation therapy.
- Clinical trials.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
stage IV anal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
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Recurrent Anal Cancer
Local recurrences and/or persistent disease after treatment with radiation therapy and chemotherapy or
surgery as the primary treatment may be controlled by using the alternate
treatment (surgical resection after radiation and vice versa).[1] Clinical
trials are exploring the use of radiation therapy with chemotherapy and/or
radiosensitizers to improve local control.
Current Clinical Trials
Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with
recurrent anal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
References:
Longo WE, Vernava AM 3rd, Wade TP, et al.: Recurrent squamous cell carcinoma of the anal canal. Predictors of initial treatment failure and results of salvage therapy. Ann Surg 220 (1): 40-9, 1994.
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More Information
About PDQ
Additional PDQ Summaries
Important:
This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).
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This information is provided by the National Cancer Institute.
This information was last updated on May 22, 2008.