KERRY’S STORY
Kerry was a 42-year-old female executive who was in excellent health. She was married but had no children and had never been pregnant. She was a non-smoker, with no medical history or family history of cancer. Specifically, she Kerry had no history of sexually transmitted diseases and she was HIV negative. When she noticed blood on the toilet paper after a bowel movement, she first thought the problem was due to hemorrhoids. However, after two weeks, the bleeding increased and she was accompanied by pain and itching around her anus. She went to her GP whose examination revealed a 2 x 2 inch mass in the anal sphincter. Her doctor did not feel any abnormal lymph nodes in her snout. She referred her to a colorectal surgeon who performed a colonoscopy. That exam confirmed the mass seen by her GP, but no other lesions. The biopsy revealed a squamous cell carcinoma, anal cancer.

After her diagnosis, Kerry’s surgeon sent her for a PET/CT scan that revealed abnormalities in the anal mass only. There was no distant activity to suggest metastatic (distant, incurable) spread of her cancer. Her surgeon referred her to a radiation oncologist and a medical oncologist. They recommended radiation therapy (RT) and chemotherapy given together (concurrent chemoRT) which she underwent over a 6-week period. Kerry was treated with intensity-modulated radiation therapy (IMRT) to minimize RT dose to critical organs, including the small intestine and bladder, while treating possible microscopic cancer cells within the pelvic and groin lymph nodes and the tumor. anal. She received concurrent mitomycin and fluoruracial chemotherapy via IV infusion as an outpatient. Kerry expected side effects from the treatment, such as severe irritation and redness of the skin in her groin and anus, but she did not need a break during the IMRT. She had significant fatigue that kept her out of work for most of her chemotherapy. She had some loose bowels which were well controlled after adjusting her diet. Near the completion of her treatment, there was no evidence that any tumor remained. She recovered from the side effects of the treatment for about six weeks. Kerry has seen one of her oncologists every three to six months for the past five years and she remains cancer free!

THE ESSENTIAL
Although it is one of the less common cancers of the GI tract, about 5,000 cases of anal cancer are still diagnosed in the US each year. There are more women than men diagnosed. The average age at diagnosis is around 60 years, but it can occur in patients in their 30s and 40s. If the disease is localized, which is the case in 50% of patients, the cure rate is approximately 80%.

RISKS AND CAUSES
Most patients diagnosed with anal cancer do not have a clearly defined risk factor. However, factors that increase the risk of developing anal cancer are associated with the risk of human papillomavirus (HPV) infection. This virus is the same type that causes genital warts. Certain strains of the HPV virus are associated with a high risk of developing anal cancer, as well as cervical cancer and some types of throat cancer. Activities that put people at risk of getting HPV, such as receptive anal sex, also put them at risk of developing anal cancer later on.

SIGNS AND SYMPTOMS
Patients often go to their doctors with complaints of anal pain or bleeding. Many patients ignore or downplay the symptoms, often initially attributing them to hemorrhoids. Although most people who have these symptoms do not have anal cancer, persistent pain or bleeding should always seek medical attention. Less commonly, patients complain of itching or a painless mass in the groin. A groin lump can develop as a result of anal cancer spreading to the lymph nodes and causing them to become enlarged.

DIAGNOSIS
The diagnosis of anal cancer is usually made by biopsy of the anal mass or area of ​​ulceration. This procedure is usually performed by a gastroenterology doctor or surgeon. These doctors can look directly at the anal canal and rectum by proctoscopy (or the entire colon by colonoscopy) with special instruments after administering the medications to minimize discomfort. Biopsies are taken during these procedures, after sedation and/or injection of an anesthetic medication. Most anal cancers (80%) are squamous cell carcinomas. A thorough evaluation of a person suspected of having anal cancer should also include an examination of the pelvis, particularly of both groins. If the lymph nodes are enlarged, they may also be biopsied. Many enlarged lymph nodes are just swollen, with no evidence of cancer. Blood tests that may be ordered include a complete blood count, kidney function tests, and possibly HIV tests, depending on the patients’ risk factors for the virus.

STAGING
The American Joint Committee on Cancer (AJCC) TNM staging system is used to determine whether anal cancer is localized (early stage) or has spread to other sites (advanced or late stage). Early-stage disease is limited to the anus, while advanced disease refers to cancers that have invaded nearby organs or lymph nodes in the pelvis or groin. Imaging studies should include a CT scan of the abdomen and pelvis and a chest x-ray at a minimum. Staging may also include a PET/CT scan. This imaging test allows the radiologist, as well as the cancer specialists treating you, to see if the anal cancer has spread to involve lymph nodes in the groin or pelvis, or has metastasized to other sites. of the body, such as the liver or lungs.

TREATMENT
Standard treatment for anal cancer does not involve surgery, which is a surprise and a relief for many patients. Since most anal cancers invade the sphincter that controls bowel movement, surgery to remove such cancer would require removal of the sphincter and creation of a colostomy. Therefore, surgery is generally avoided in favor of a treatment that will keep the anal sphincter intact. An exception would be very early cancers of the anal margin, on the skin outside the anus.

Concurrent chemoRT is the standard treatment for most patients with anal cancer, to obtain the best chance of sphincter-sparing cure. RT administered for approximately 6 weeks with concurrent IV chemotherapy with fluorouracil (5FU) and mitomycin-C (MMC) gives patients the best chance of cure. RT is administered in daily fractions using 3D conformal RT or IMRT. The latter technique can be used to minimize the amount of normal intestine and/or genitalia receiving the full dose of RT (and thus minimize side effects).

The main possible side effects during RT to the anus and pelvis include a skin reaction that can be severe around the anus and skin folds in the groin, as well as intestinal irritation and diarrhea. Most patients will have these acute symptoms resolved within 1 to 2 months after completing treatment. Extremely rare (<1%) but serious side effects include intestinal obstruction or fistula (a hole between the anus and the bladder or urethra). 5FU can also cause intestinal irritation, diarrhea, mouth or lip irritation, loss of appetite, and fatigue. Infrequently, discoloration of the skin or nails or severe scaling of the hands and feet (hand-foot syndrome) or other serious side effects may occur. In rare cases, heart problems can occur, including a heart attack. MMC can cause a drop in blood counts, mouth sores, poor appetite, and fatigue. Nausea, vomiting, and urinary irritation may also occur. Rarely, life-threatening lung or kidney damage may occur.