Anal cancer: ESMO–ESSO–ESTRO clinical practice guidelines for diagnosis, treatment and follow-up

Abstract

Squamous cell carcinoma of the anus (SCCA) is a rare cancer but its incidence is increasing throughout the world, and is particularly high in the human immunodeficiency virus positive (HIV+) population. A multidisciplinary approach is mandatory (involving radiation therapists, medical oncologists, surgeons, radiologists and pathologists). SCCA usually spreads in a loco-regional manner within and outside the anal canal. Lymph node involvement at diagnosis is observed in 30–40% of cases while systemic spread is uncommon with distant extrapelvic metastases recorded in 5–8% at onset, and rates of metastatic progression after primary treatment between 10% and 20%. SCCA is strongly associated with human papilloma virus (HPV, types 16–18) infection. The primary aim of treatment is to achieve cure with loco-regional control and preservation of anal function, with the best possible quality of life. Treatment dramatically differs from adenocarcinomas of the lower rectum. Combinations of 5FU-based chemoradiation and other cytotoxic agents (mitomycin C) have been established as the standard of care, leading to complete tumour regression in 80–90% of patients with locoregional failures in the region of 15%. There is an accepted role for surgical salvage. Assessment and treatment should be carried out in specialised centres treating a high number of patients as early as possible in the clinical diagnosis. To date, the limited evidence from only 6 randomised trials [1Jemal A. Simard E.P. Dorell C. et al.Annual report to the nation on the status of cancer, 1975–2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels.J Natl Cancer Inst. 2013; 105: 175-201Crossref PubMed Scopus (840) Google Scholar, 2Palefsky J.M. Giuliano A.R. Goldstone S. et al.HPV vaccine against anal HPV infection and anal intraepithelial neoplasia.N Engl J Med. 2011; 365: 1576-1585Crossref PubMed Scopus (726) Google Scholar, 3Goh V. Gollub F.K. Liaw J. et al.Magnetic resonance imaging assessment of squamous cell carcinoma of the anal canal before and after chemoradiation: can MRI predict for eventual clinical outcome?.Int J Radiat Oncol Biol Phys. 2010; 78: 715-721Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 4Bartelink H. Roelofsen F. Eschwege F. et al.Concomitant radiotherapy and chemotherapy is superior to radiotherapy alone in the treatment of locally advanced anal cancer: results of a phase III randomized trial of the European Organization for Research and Treatment of Cancer Radiotherapy and Gastrointestinal Cooperative Groups.J Clin Oncol. 1997; 15: 2040-2049Crossref PubMed Scopus (1089) Google Scholar, 6Oehler-Jänne C. Huguet F. Provencher S. et al.HIV-specific differences in outcome of squamous cell carcinoma of the anal canal: a multicentric cohort study of HIV-positive patients receiving highly active antiretroviral therapy.J Clin Oncol. 2008; 26: 2550-2557Crossref PubMed Scopus (161) Google Scholar, 7Wexler A. Berson A.M. Goldstone S.E. et al.Invasive anal squamous-cell carcinoma in the HIV-positive patient: outcome in the era of highly active antiretroviral therapy.Dis Colon Rectum. 2008; 51: 73-81Crossref PubMed Scopus (119) Google Scholar], the rarity of the cancer, and the different behaviour/natural history depending on the predominant site of origin, (the anal margin, anal canal or above the dentate line) provide scanty direction for any individual oncologist. Here we aim to provide guidelines which can assist medical, radiation and surgical oncologists in the practical management of this unusual cancer.