Treatment options for different stages of anal cancer
After a thorough investigational workup, the when the diagnosis and stage of anal canal cancer is confirmed, the next step is the treatment. The anal cancer treatment may depends on various factors including stage of the disease, age, performance status of the patient, patient’s preference along with other factors.
Stage 0 (Tis N0 M0)
Stage 0 anal cancer can be treated by removal of the pre-cancerous lesion by local excision with the negative margins
Stage I and II (T1-3 N0 M0)
In the case of Stage I to II anal cancer, chemotherapy along with radiotherapy is considered the preferred treatment.
Stage III (Any T N0-1 M0)
In the case of Stage III anal cancer, chemotherapy along with radiotherapy is considered the first-line treatment.
Stage IV (Any T Any N M1)
In the case of Stage IV anal cancer, chemotherapy is the mainstay of treatment.
Anal Cancer Treatment Options
Surgery is the first choice of treatment for early-stage anal cancer. Precancerous lesions or lesions that are present only in the superficial layer can be treated by local resection. In abdominoperineal resection (APR), the anus and rectum are surgically removed along with regional lymph nodes. An artificial opening (stoma) is created in the abdomen to collect stools in a bag attached to it.
Radiation therapy (or radiotherapy) uses high-energy x-rays or other high-energy radiations which are directed to the affected area to kill cancerous cells. Radiotherapy can be employed either by using an external radiation source (external beam radiation therapy) or by directly placing the source of radiation near the cancer tissue (brachytherapy). Radiotherapy (along with chemotherapy) is commonly used as first-line treatment of most anal cancers. It is also sometimes used for palliation of symptoms of the advanced-stage disease such as pain, bleeding, obstruction, etc.
Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly growing cancer cells. Chemotherapy (in conjunction with radiotherapy) is considered the first-line treatment for most locoregionally advanced anal cancers. Also, chemotherapy is the mainstay of treatment for the advanced-stage disease that has spread to distant body parts. It may be associated with side effects like nausea/vomiting, hair loss, fatigue, etc due to its effect on normal body cells apart from cancerous cells.
Cancer cells utilize certain mechanisms to escape from the immune system of the patient from attacking these cells. Immunotherapeutic agents activate the immune system to recognize and kill cancer cells. Nivolumab and pembrolizumab target the PD-1 protein on T-cells and activate them to kill cancerous cells. The immunotherapy is generally used for the treatment of advanced-stage disease unresponsive to primary treatment.
This may help in improving the overall quality of life by providing relief from the symptoms caused by anal cancer. However, they do not directly treat anal cancer. They are generally given as supportive care for advanced-stage cancer. These include but are not limited to using drugs to reduce pain and other symptoms such as vomiting, fatigue or external-beam radiation therapy for bleeding or pain, etc.
It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes the patient’s choice and health condition are also important to make a treatment choice.
Following are goals of treating anal cancer:
- Prolongation of life
- Reduction of symptoms
- Improvement of overall quality of life
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