Anal Cancer.docx

7/27/2019 Anal Cancer.docx

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Anal Cancer

click for larger picture

The anus consists ofa mucosa-lined analcanal and anepidermis-lined analmargin. Theproximal end of theanal canal beginsanatomically at the

junction of the

puborectalis portionof the levator animuscle and theexternal analsphincter, andextends distally tothe anal verge, adistance ofapproximately 4 cm.The anal canal isdivided by the

dentate line, whichoverlies thetransition fromglandular (columnar)to squamousmucosa that is oftenreferred to as thetransitional zone.
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The anal marginbeginsapproximately at theanal verge, whichcorresponds to the

introitus of the analorifice. It representsthe transition fromthe squamousmucosa to theepidermis-linedperianal skin, andextends to theperianal skin.

At initial

presentation, mostpatients have a T1or T2 lesion andfewer than 20percent are node-positive. In a seriesof 270 patients withanal canal SCC, thedistribution of stageat diagnosis was asfollows

T19percent

T251percent

T330percent

T410percent

Node-positive

13 percent

In the above seriesof 270 patients, thefive-year survival bystage was

T186


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percent T286

percent T360

percent

T4

45percent

N076percent

Node-positive54 percent


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patients with squamous cell carcinoma of the anal canal are generally treated with widelocal excision for in-situ cases (if margins are negative) or with radiation. The more

advanced cases get radiation usually combined with chemotherapy (see NCCN

guidelines for anal canal). Patients with cancer of the anal marginmay be treated withlocal surgery (see guidelines for anal margin). Following this, patients are checkedevery few months (without biopsy unless there is a suspicious area,see NCCN follow-

up guidelines.)Gohere for NCCN anal site
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Radiation for Cancer of the Anal Canal

anatomy contouring hereorhere

Based on the studies below, it appears thatradiation combined with chemoRx (5FU +Mitomycinsee data,or perhaps new regimensthat contain Platinol,see dataproduce the bestresults. Other recent data ishere.(Cisplatin maybe less toxic than Mitomycin,see MD Andersonstudy.) The proper dose of radiation is unknown.The original trials (Nigro) used low doses (30Gy)but the standard has become 45-50Gy plus orminus a boost dose (9Gy if + bx or in some

protocols a routine dose of 15-20Gy is added.)See recent MDA paper on techniquehere.

The RTOG tried to use higher doses (5940 with 2w break) but had worse results than in studieswith previous lower doses (50Gy continuous.)The anal region tolerates radiochemoRx poorlyand we generally are lucky to get in 5040cGy at180cGy/fx. The necessity of a boost is unclearbut if the response is poor, pushing to total doseto 54-59Gy is standard (see thecurrent NCCN

guidelines.)

The approach at theU of Florida seems quitereasonable.(The current NCI page notes: "Theoptimal dose of radiation with concurrentchemotherapy to optimize local control andminimize sphincter toxic effects is underevaluation but appears to be in the 45 Gy to 60Gy range.") See details ofRTOG anal trial 9811andRTOG 0529and the resultshere.

Typical results using modern chemoradiation withIMRT arehereandhere. Some of the olderstudies arehere
http://atc.wustl.edu/protocols/rtog-closed/0529/ANAL_Ca_CTVs_5-21-07_Final.pdfhttp://atc.wustl.edu/protocols/rtog-closed/0529/ANAL_Ca_CTVs_5-21-07_Final.pdfhttp://rtog.org/pdf_file2.html?pdf_document=AnorectalContouringGuidelines.pdfhttp://rtog.org/pdf_file2.html?pdf_document=AnorectalContouringGuidelines.pdfhttp://rtog.org/pdf_file2.html?pdf_document=AnorectalContouringGuidelines.pdfhttp://www.aboutcancer.com/anal_perez_data1.jpghttp://www.aboutcancer.com/anal_perez_data1.jpghttp://www.aboutcancer.com/anal_perez_data1.jpghttp://www.aboutcancer.com/anal_perez_data2.jpghttp://www.aboutcancer.com/anal_perez_data2.jpghttp://www.aboutcancer.com/anal_perez_data2.jpghttp://www.aboutcancer.com/anal_vuong.htmhttp://www.aboutcancer.com/anal_vuong.htmhttp://www.aboutcancer.com/anal_vuong.htmhttp://www.aboutcancer.com/anal_cisplatin.htmhttp://www.aboutcancer.com/anal_cisplatin.htmhttp://www.aboutcancer.com/anal_cisplatin.htmhttp://www.aboutcancer.com/anal_cisplatin.htmhttp://www.aboutcancer.com/anus_das_707.htmhttp://www.aboutcancer.com/anus_das_707.htmhttp://www.aboutcancer.com/anus_das_707.htmhttp://www.nccn.org/professionals/physician_gls/PDF/anal.pdfhttp://www.nccn.org/professionals/physician_gls/PDF/anal.pdfhttp://www.nccn.org/professionals/physician_gls/PDF/anal.pdfhttp://www.nccn.org/professionals/physician_gls/PDF/anal.pdfhttp://www.geocities.com/doctorbobm/anal_canal_mendenhall.htmhttp://www.geocities.com/doctorbobm/anal_canal_mendenhall.htmhttp://www.geocities.com/doctorbobm/anal_canal_mendenhall.htmhttp://www.geocities.com/doctorbobm/anal_canal_mendenhall.htmhttp://www.aboutcancer.com/rtog_anal_trial.htmhttp://www.aboutcancer.com/rtog_anal_trial.htmhttp://www.aboutcancer.com/rtog_anal_trial.htmhttp://www.aboutcancer.com/rtog_0529.htmhttp://www.aboutcancer.com/rtog_0529.htmhttp://www.aboutcancer.com/rtog_0529.htmhttp://www.aboutcancer.com/RTOG_9811_PRELIM_RESULTS.htmhttp://www.aboutcancer.com/RTOG_9811_PRELIM_RESULTS.htmhttp://www.aboutcancer.com/RTOG_9811_PRELIM_RESULTS.htmhttp://www.aboutcancer.com/anal_salama_1007.htmhttp://www.aboutcancer.com/anal_salama_1007.htmhttp://www.aboutcancer.com/anal_salama_1007.htmhttp://www.aboutcancer.com/anal_imrt_0211.htmhttp://www.aboutcancer.com/anal_imrt_0211.htmhttp://www.aboutcancer.com/anal_imrt_0211.htmhttp://www.aboutcancer.com/anal_studies_old.htmhttp://www.aboutcancer.com/anal_studies_old.htmhttp://www.aboutcancer.com/anal_studies_old.htmhttp://www.aboutcancer.com/anal_studies_old.htmhttp://www.aboutcancer.com/anal_imrt_0211.htmhttp://www.aboutcancer.com/anal_salama_1007.htmhttp://www.aboutcancer.com/RTOG_9811_PRELIM_RESULTS.htmhttp://www.aboutcancer.com/rtog_0529.htmhttp://www.aboutcancer.com/rtog_anal_trial.htmhttp://www.geocities.com/doctorbobm/anal_canal_mendenhall.htmhttp://www.geocities.com/doctorbobm/anal_canal_mendenhall.htmhttp://www.nccn.org/professionals/physician_gls/PDF/anal.pdfhttp://www.nccn.org/professionals/physician_gls/PDF/anal.pdfhttp://www.aboutcancer.com/anus_das_707.htmhttp://www.aboutcancer.com/anal_cisplatin.htmhttp://www.aboutcancer.com/anal_cisplatin.htmhttp://www.aboutcancer.com/anal_vuong.htmhttp://www.aboutcancer.com/anal_perez_data2.jpghttp://www.aboutcancer.com/anal_perez_data1.jpghttp://rtog.org/pdf_file2.html?pdf_document=AnorectalContouringGuidelines.pdfhttp://atc.wustl.edu/protocols/rtog-closed/0529/ANAL_Ca_CTVs_5-21-07_Final.pdf


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Anal Cancer Treatment Results

Treatment Local Control Survival

Radiation 49 - 92% 60-93%Radiation plus

Chemotherapy60-92% 51-90%


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What is anal cancer?

The anus

The anus is the body's opening at the lower end of the intestines. The anal canal is the tube that

connects the lower part of the large intestine (rectum) to the anus and the outside of the body. As

food is digested, it passes from the stomach to the small intestine. It then travels from the smallintestine into the large intestine (colon). The colon absorbs water and liquid from the digested

food. The waste matter that is left after going through the colon is known asfecesorstool. Fecesare stored in the rectum, the final 6 inches of the digestive system. From there, they pass out of

the body through the anus as a bowel movement.


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The anal canal is about an inch and a half long. Its inner lining (called the mucosa) is made up of

several different kinds of cells. Learning a little about these cells is helpful in understanding the

kinds of cancer that develop in various parts of the anal canal. Glands and ducts (tubes leadingfrom the glands) are found under the mucosa. These glands make mucus, which acts as a

lubricating fluid.

The anal canalgoes from the rectum to the anal verge(where the canal meets the outside skin at

the anus). About midway down the anal canal is the dentate line, which is where most of these

anal glandsempty into the anus.

Cells above the anal canal (in the rectum) and in the part of the anal canal close to the rectum are

shaped like tiny columns. Most cells near the middle of the anal canal and around the dentate lineare shaped like cubes and are called transitional cells. This area is called the transitional zone.

Below the dentate line are flat (squamous) cells. At the anal verge, the squamous cells of thelower anal canal merge with the skin just outside the anus. This skin around the anal verge(called the perianal skin or the anal margin) is also made up of squamous cells, but it also

contains sweat glands and hair follicles; the lining of the lower anal canal does not. Cancers of

the anal canal (above the anal verge) and cancers of the anal margin (below the anal verge) are

treated very differently.


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The anal canal is surrounded by a sphincter, which is a circular muscle that keeps feces from

coming out until it is relaxed during a bowel movement.

Anal tumors

Many types of tumors can develop in the anus. Not all of these tumors are cancers -- some arebenign (non-cancerous). There are also some growths that start off as benign but over time can

develop into cancer. These are called pre-cancerous conditions. This section discusses all of

these types of abnormal growths.

Benign (non-cancerous) anal tumors

Polyps:Polyps are small, bumpy, or mushroom-like growths that develop in the mucosa or just

under it. There are several kinds, depending on their cause and location.

Inflammatory polypsarise because of inflammation from injury or infection.

Lymphoid polypsare caused by an overgrowth of lymph tissue (which is part of theimmune system). Small nodules of lymph tissue are normally present under the anal inner

lining.

Hypertrophied anal papillaeare benign growths of connective tissue that are covered bysquamous cells. They are simply an enlargement of the normal papillae, which are small

folds of mucosa found at the dentate line. Hypertrophied anal papillae are also called

fibroepithelial polyps.

Skin tags: Skin tags are benign growths of connective tissue that are covered by squamous cells.

Skin tags are often mistaken for hemorrhoids but they are not truly hemorrhoids.

Condylomas:Condylomas (also called warts) are growths that occur just outside the anus and inthe lower anal canal below the dentate line. Occasionally condylomas can be found just abovethe dentate line. They are caused by infection with the human papilloma virus(HPV). People

who have had condylomas are more likely to develop anal cancer (see "Potentially pre-cancerous

anal conditions" below and the section What are the risk factors for anal cancer?).

Other benign tumors:In rare cases, benign tumors can grow in other tissues of the anus. These

include:

Adnexal tumors -- usually benign growths that start in hair follicles or sweat glands of the

skin just outside of the anus. These tumors stay in the perianal skin area and do not grow

into the anal region. Leiomyomas -- develop from smooth muscle cells

Granular cell tumors -- develop from nerve cells and are composed of cells that containlots of tiny spots (granules)

Hemangiomas -- start in the lining cells of blood vessels

Lipomas -- start from fat cells

Schwannomas -- develop from cells that cover nerves
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Potentially pre-cancerous anal conditions

Some changes in the anal mucosa are harmless in their early stages but might later develop into a

cancer. A common term for these potentially pre-cancerous conditions is dysplasia. Some warts,for example, contain areas of dysplasia that can develop into cancer.

Dysplasia occurring in the anus is also known asanal intraepithelial neoplasia(AIN) and as

anal squamous intraepithelial lesions (SILs). Depending on how the cells look under the

microscope, AIN (or anal SIL) can be divided into 2 groups: low-grade and high-grade. The cells

in low-grade AIN resemble normal cells while the cells in high-grade AIN look much moreabnormal. Low-grade AIN often goes away without treatment. It has a low chance of turning into

cancer. High-grade AIN is less likely to go away without treatment. Left untreated, high-grade

AIN could eventually become cancer, and so it needs to be watched closely. Some cases of high-

grade AIN need to be treated.

Carcinoma in situ

Sometimes abnormal cells on the surface layer of the anus look like cancer cells but have not

grown into any of the deeper layers. This condition is known as carcinoma in situ, (pronounced

"in SY-too"), or CIS. Another name for this condition isBowen's disease. Some doctors viewthis as the earliest form of anal cancer and others consider it the most advanced type of AIN,

which is considered a pre-cancer but not a true cancer.

Invasive anal cancers

Squamous cell carcinomas: Most anal cancers in the United States are squamous cell

carcinomas. These tumors come from the squamous cells that line the anal margin and most of

the anal canal.

Cells of invasivesquamous cell carcinomas have already spread beyond the surface to the deeperlayers of the lining. Squamous cell carcinomas of the anal canal are discussed in detail in this

document. Squamous cell carcinomas of the anal margin (perianal skin) are treated similarly to

squamous cell carcinomas of the skin elsewhere in the body. For more information, see ourdocument,Skin Cancer: Basal and Squamous Cell.

Cloacogenic carcinomas(also called basaloid or transitional cell carcinomas) are sometimes

listed as a subclass of squamous cell cancers. They develop in the transitional zone, also calledthe cloaca. These cancers look slightly different under the microscope but they behave and are

treated like other squamous cell carcinomas of the anal canal.

Adenocarcinomas:A small number of anal cancers are known as adenocarcinomas. These can

develop in cells that line the upper part of the anus near the rectum, or in glands located underthe anal mucosa that release their secretions into the anal canal. These anal adenocarcinomas, are

treated the same way as rectal carcinomas. For more information, see our document,Colorectal

Cancer.
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Adenocarcinomas can also start in apocrine glands (a type of sweat gland of the perianal skin).

Paget's diseaseis a type of apocrine gland carcinoma that spreads through the surface layer of

the skin. Paget's disease can affect skin anywhere in the body but most often affects skin of theperianal area, vulva, or breast. This condition should not be confused with Paget's disease of the

bone, which is a different disease.

Basal cell carcinomas:Basal cell carcinomas are a type of skin cancer that can develop in the

perianal skin. These tumors are much more common in areas of skin that are exposed to sun,

such as the face and hands, and account for only a small number of anal cancers. They are oftentreated with surgery to remove the cancer. For more information, see our document,Skin

Cancer: Basal and Squamous Cell.

Malignant melanoma:This cancer develops from cells in the skin or anal lining that make thebrown pigment called melanin. Only about 1% to 2% of anal cancers are melanomas.

Melanomas are far more common on parts of the body that are exposed to sun. If melanomas are

found at an early stage (before they have grown deeply into the skin or spread to lymph nodes)

they can be removed with surgery and the outlook (prognosis) for long-term survival is verygood. But because they are hard to see, most anal melanomas are found at a later stage. If

possible, the entire tumor is removed with surgery. If all of the tumor can be removed, a cure ispossible. If the melanoma has spread too far to be removed completely, other treatments may be

given. For more information, see our document,Melanoma Skin Cancer.

Gastrointestinal stromal tumors:These are rare anal cancers that are much more commonly

found in the stomach or small intestine. When these are found at an early stage, they are removed

with surgery. If they have spread beyond the anus, they can be treated with drug therapy. For

more information, see our document,Gastrointestinal Stromal Tumor (GIST).

After anal cancer has been diagnosed, tests are done to find out if cancer cells have spread withinthe anus or to other parts of the body.

The process used to find out ifcancerhas spread within theanusor to other parts of the body iscalledstaging.The information gathered from the staging process determines thestageof 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, such as theabdomenor chest, taken from different angles. The pictures are

made by a computer linked to anx-raymachine. Adyemay beinjectedinto aveinorswallowed to help theorgansortissuesshow up more clearly. This procedure is also

called computed tomography, computerized tomography, or computerized axial

tomography. Foranal cancer,a CT scan of thepelvisand 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.
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MRI(magnetic resonance imaging): A procedure that uses a magnet,radio waves,and

a computer to make a series of detailed pictures of areas inside the body. This procedure

is also called nuclear magnetic resonance imaging (NMRI).

PET scan(positron emission tomography scan): A procedure to findmalignanttumor

cellsin the body. A small amount ofradioactiveglucose(sugar) is injected into a vein.

The PETscannerrotates around the body and makes a picture of where glucose is beingused in the body. Malignant tumor cells show up brighter in the picture because they aremore active and take up more glucose than normal cells do.

There are three ways that cancer spreads in the body.

The three ways that cancer spreads in the body are:

Throughtissue.Cancerinvadesthe surrounding normal tissue.

Through thelymph system.Cancer invades the lymph system and travels through thelymph vesselsto other places in the body.

Through theblood.Cancer invades theveinsandcapillariesand travels through the bloodto other places in the body.

When cancercellsbreak away from theprimary(original)tumorand travel through thelymphor

blood to other places in the body, another (secondary) tumor may form. This process is calledmetastasis.The secondary (metastatic) tumor is the same type of cancer as the primary tumor.For example, ifbreast cancerspreads to the bones, the cancer cells in the bones are actually

breast cancer cells. The disease is metastatic breast cancer, notbone cancer.

The following stages are used for anal cancer:

Stage 0 (Carcinoma in Situ)

Instage 0,abnormalcellsare found in the innermost lining of theanus.These abnormal cellsmay becomecancerand spread into nearby normaltissue.Stage 0 is also calledcarcinoma in

situ.

Enlarge

Pea, peanut, walnut, and lime show tumor sizes.

Stage I
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13/20

Instage I,cancerhas formed and thetumoris 2centimetersor smaller.

Stage II

Instage II,thetumoris larger than 2centimeters.

Stage IIIA

Instage IIIA,thetumormay be any size and has spread to either:

lymph nodesnear therectum;or

nearbyorgans,such as thevagina,urethra,andbladder.

Stage IIIB

Instage IIIB,thetumormay be any size and has spread:

to nearbyorgansand tolymph nodesnear therectum;or

to lymph nodes on one side of thepelvisand/orgroin,and may have spread to nearbyorgans; 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

Instage IV,thetumormay be any size andcancermay have spread tolymph nodesor nearby

organsand has spread to distant parts of the body.

Recurrent Anal Cancer

Recurrentanal canceris cancer that hasrecurred(come back) after it has been treated. Thecancer may come back in theanusor in other parts of the body.

Treatment Option Overview

Key Points for This Section

There are different types of treatment for patients with anal cancer. Three types of standard treatment are used:

o Radiation therapy

o Chemotherapy

o Surgery

Having the human immunodeficiency virus can affect treatment of anal cancer.

New types of treatment are being tested in clinical trials.

o Radiosensitizers
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Patients may want to think about taking part in a clinical trial.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Follow-up tests may be needed.

There are different types of treatment for patients with anal cancer.

Different types of treatments are available for patients withanal cancer.Some treatments arestandard(the currently used treatment), and some are being tested inclinical trials.A treatment

clinical trial is aresearch studymeant to help improve current treatments or obtain information

on new treatments for patients withcancer.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 therapyis a cancer treatment that uses high-energyx-raysor other types ofradiationtokill cancercells.There are two types of radiation therapy.External radiation therapyuses a

machine outside the body to send radiation toward the cancer.Internal radiation therapyuses a

radioactivesubstance sealed in needles,seeds,wires, orcathetersthat are placed directly into or

near the cancer. The way the radiation therapy is given depends on the type andstageof the

cancer being treated.

Chemotherapy

Chemotherapyis a cancer treatment that usesdrugsto stop the growth of cancer cells, either by

killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth orinjectedinto aveinor muscle, the drugs enter the bloodstream and can reach cancer cells

throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the

cerebrospinal fluid,anorgan,or a bodycavitysuch as theabdomen,the drugs mainly affect

cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given dependson the type and stage of the cancer being treated.

Surgery

Localresection:Asurgicalprocedure in which thetumoris cut from theanusalong withsome of the healthytissuearound it. Local resection may be used if the cancer is small

and has not spread. This procedure may save thesphinctermuscles so the patient can still

controlbowelmovements. Tumors that form in the lower part of the anus can often beremoved with local resection.
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Abdominoperineal resection:A surgical procedure in which the anus, therectum,and

part of thesigmoid colonare removed through anincisionmade in the abdomen. The

doctor sews the end of theintestineto an opening, called astoma,made in the surface ofthe abdomen so body waste can be collected in a disposable bag outside of the body. This

is called acolostomy.Lymph nodesthat contain cancer may also be removed during this

operation.

Enlarge

Resection of the colon with colostomy. Part of the colon containing the cancer andnearby healthy tissue 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.

Cancertherapycan further damage the already weakenedimmune systemsof patients who havethehuman immunodeficiency virus(HIV). For this reason, patients who have anal cancer and

HIV are usually treated with lowerdosesof 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

Radiosensitizersare 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.
http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=377733&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=377733&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46555&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46555&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46555&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=357588&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=357588&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=357588&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46353&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46353&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46353&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46335&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46335&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46335&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45104&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45104&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45104&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46464&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46464&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46464&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45762&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45762&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45762&version=Patient&language=Englishhttp://www.cancer.gov/PublishedContent/MediaLinks/514973.htmlhttp://www.cancer.gov/PublishedContent/MediaLinks/514973.htmlhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44737&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44737&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44737&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46356&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46356&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46356&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44366&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44366&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44366&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44664&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44664&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44664&version=Patient&language=Englishhttp://cancer.gov/clinicaltrialshttp://cancer.gov/clinicaltrialshttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46553&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46553&version=Patient&language=Englishhttp://www.cancer.gov/PublishedContent/MediaLinks/514973.htmlhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46553&version=Patient&language=Englishhttp://cancer.gov/clinicaltrialshttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44664&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44366&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46356&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44737&version=Patient&language=Englishhttp://www.cancer.gov/PublishedContent/MediaLinks/514973.htmlhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45762&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46464&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45104&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46335&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46353&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=357588&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinit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For some patients, taking part in aclinical trialmay 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 thestandard 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 anew treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in thefuture. 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 testtreatments for patients whose cancer has not gotten better. There are also clinical trials that test

new ways to stop cancer fromrecurring(coming back) or reduce theside effectsof cancertreatment.

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 fromNCI'slisting of clinical trials.

Follow-up tests may be needed.

Some of the tests that were done todiagnosethe cancer or to find out thestageof 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 ofthese 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 yourconditionhas changed or if the cancer hasrecurred(come

back). These tests are sometimes calledfollow-uptests or check-ups.

Treatment Options by Stage

Stage 0 (Carcinoma in Situ)

Stage I Anal Cancer

Stage II Anal CancerStage IIIA Anal CancerStage IIIB Anal Cancer

Stage IV Anal Cancer

A link to a list of currentclinical trialsis included for each treatment section. For some types or

stagesofcancer,there may not be any trials listed. Check with your doctor for clinical trials thatare not listed here but may be right for you.
http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45961&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45961&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45961&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44930&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44930&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44930&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46556&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46556&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46556&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46580&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46580&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46580&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44267&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44267&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44267&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46450&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46450&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46450&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45885&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45885&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45885&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=651193&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=651193&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=651193&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46556&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46556&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46556&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44671&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44671&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44671&version=Patient&language=Englishhttp://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_139http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_139http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_140http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_140http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_98http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_98http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_144http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_144http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_127http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_127http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_106http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_106http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45961&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45961&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45961&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45885&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45885&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45333&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45333&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45333&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45333&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45885&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45961&version=Patient&language=Englishhttp://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_106http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_127http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_144http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_98http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_140http://www.cancer.gov/cancertopics/pdq/treatment/anal/Patient/page5#Section_139http://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=44671&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46556&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=651193&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=45885&version=Patient&language=Englishhttp://www.cancer.gov/Common/PopUps/popDefinition.aspx?id=46450&version=Patient&language=Englishhttp://www.c

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