Chemo and radiation for Anal Cancer – pro

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.

1.American College of Radiology (ACR), Expert Panel on Radiation Oncology-Rectal/Anal Cancer. Anal cancer. Reston (VA): American College of Radiology (ACR); 2002. 11 p. (ACR appropriateness criteria). [31 references]

2.NCCN.ORG, Anal Cancer 2013

3.Abeloff: Clinical Oncology 3rd Ed.-2004 , Ch. 82

4.Anal cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up

5.R. Glynne-Jones,  J. M. A. Northover,  A. Cervantes,  On behalf of the ESMO Guidelines Working Group,  Ann Oncol (2010) 21 (suppl 5): v87-v92.

6. Poggi MM, Konski AA, Suh WW, Blackstock AW, Herman JM, Hong TS, Rodriguez-Bigas M, Small W Jr, Thomas CR Jr, Venook AP, Zook J, Expert Panel on Radiation Oncology-Rectal/Anal Cancer. ACR Appropriateness Criteria® anal cancer. [online publication]. Reston (VA): American College of Radiology (ACR); 2010. 11 p. [43 references]

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


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