Anal Cancer are a group of malignancies that includes cancers of the anal canal which may be extending up into the rectum or down onto the perianal skin, and also carcinomas of the anal margin which are extending into the canal. The preferred treatment is external irradiation, combined with chemotherapy if the tumor is large or there is nodal involvement. Combined modality therapy has a high likelihood of curing the disease while maintaining sphincter function.
Randomized trials of radiation versus chemoradiation (with 5-fluorouracil and mitomycin) show better complete response rates, event free survival, colostomy-free survival, but higher early toxicity with the combined approach. No survival difference was observed between these modalities, presumably because surgery is good salvage therapy for locally recurrent disease. A further randomized trial has shown improved disease free survival but higher toxicity with the use of both 5-fluorouracil and mitomycin combined with radiation compared with 5-fluorouracil and radiation alone. An ongoing randomized trial is exploring the relative merits of 5-fluorouracil versus 5-fluorouracil plus cisplatin, both combined with concurrent radiation, based on promising phase II data. Other ongoing trials are also exploring the role of cisplatin in the neoadjuvant, concurrent and adjuvant settings. Until the results of these phase III trials are available, the inclusion of cisplatin in the chemotherapy regimen is controversial, although NCCN, while not listing it in the body of recommendations (it recommends mitomycin and 5FU), mentions it in a footnote and cites a phase II study.
The Evaluation of Xeloda Treatment with Radiotherapy in Anal cancer (EXTRA) trial of capecitabine and mitomycin C showed a high complete response rate in 31 patients. Four weeks following completion of chemoradiation, 24 patients (77%) had a complete clinical response, and 4 (16%) a partial response. With a median follow-up of 14 months, three locoregional relapses occurred. There was acceptable toxicity.
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Guideline Summary NGC:010675 1998 (revised 2014)
ACR Appropriateness Criteria® recurrent rectal cancer.
R. Glynne et al, Anal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol (2010) 21 (suppl 5): v87-v92
DCF (docetaxel, cisplatin and 5-fluorouracil) chemotherapy is a promising treatment for recurrent advanced squamous cell anal carcinoma. Ann Oncol (2013) 24 (12): 3045-3050