What is anal cancer?
Anal cancer is a malignant tumor that starts in the cells around the anus. A malignant tumor means it can invade and destroy surrounding tissue. It can also spread (metastasize) to other parts of the body.
The anus is part of the digestive system. The anus is the opening at the end of the large intestine.
The stool is passed from the body through the anus. Located after the rectum, the anus is the opening at the end of the large intestine.
The area around the anus is called the anal region. It includes the anal canal, the short tube located just above the anus, as well as the perianal skin, which is the skin around the anus.
The anal canal and perianal skin cells sometimes undergo changes that make the way they grow or behave abnormally. These changes can lead to non-cancerous or benign conditions such as anal warts, polyps or skin tags.
Changes in cells in the anal area can also cause a precancerous condition called anal intraepithelial neoplasia (AIN). This means that the cells are not yet cancerous, but are at risk of becoming cancerous if left untreated.
In some cases, the altered cells in the anal canal or perianal skin can become cancerous. Anal cancer usually starts in round, flat cells called squamous cells, which are found inside the anal canal and make up the perianal skin. This type of cancer is called squamous cell carcinoma of the anus.
There are also other rare types of anal cancer, such as adenocarcinoma, basal cell carcinoma, melanoma, and gastrointestinal stromal tumor (TSGI).
Finding anal cancer in its early stages
Finding and treating anal cancer at an early stage increases the chances of successful treatment. Have a regular check-up and see your doctor if you experience any symptoms or are concerned about your health.
If your risk is above average, you may need to see your doctor more often to check for anal cancer. Talk to your doctor about tests that can help find early anal cancer, including the following:
digital rectal examination (DRE);
anoscopy (examination of the inside of the anal canal and the end of the rectum by the doctor using an anoscopy);
anal cytology (also called anal smear).
Symptoms of anal cancer
In its early stages, anal cancer may not cause any signs or symptoms because it is very small. Symptoms often appear after the tumor has grown or has invaded nearby tissue. Other medical conditions can cause the same symptoms as anal cancer. If you experience these symptoms, see your doctor.
The most common symptom of anal cancer is anal bleeding. This is also the symptom that usually appears first. Often this bleeding is minor. Sometimes blood is seen in the stool.
Other symptoms of anal cancer include:
- pain, discomfort, or a feeling of pressure in the anal area;
- itching in the anal area;
- discharge of mucus from the anus;
- lump or swelling near the anus or groin;
- change in bowel movement, for example narrowing of the stool.
Diagnosis of anal cancer
The diagnostic process for anal cancer usually begins with a visit to your family doctor. Your doctor will ask you about your symptoms and do a physical exam. Based on this information, your doctor may refer you to a specialist or order tests to check for anal cancer or other health problems.
The diagnostic process can seem long and overwhelming. It’s okay to worry, but try to remember that other medical conditions can cause anal cancer-like symptoms. It is important that the healthcare team rule out any other possible cause of the condition before making a diagnosis of anal cancer.
The following tests are commonly used to rule out or confirm a diagnosis of anal cancer. Many tests that can diagnose cancer are also used to determine the stage, that is, the extent of progression of the disease. Your doctor may also order other tests to assess your general health and help plan your treatment.
Health history and physical examination
Your health history consists of a checkup of your symptoms, risk factors, and any medical events and conditions you may have had in the past. When checking your medical history, your doctor will ask you questions about your personal history of:
symptoms that may indicate the presence of anal cancer;
human papillomavirus (HPV) infection;
certain sexual behaviors, including the number of sexual partners and anal sex;
risk factors or human immunodeficiency virus (HIV) infection.
Your doctor may also ask you questions about your family history of:
risk of anal cancer;
The physical exam allows the doctor to look for any signs of anal cancer. During the physical examination, the doctor may:
examine the anal area for any lump or area with abnormal skin;
do a digital rectal exam (DRE) to check for any lump or swelling;
palpate the groin for swollen lymph nodes;
do a pelvic exam and a Pap test to check the condition of the vagina and cervix.
Complete blood count (FSC)
The complete blood count (FSC) is used to assess the quantity and quality of white blood cells, red blood cells and platelets. It is done to check for anemia due to bleeding from the anus or rectum that has lasted for a long time (chronic).
Blood biochemical analyzes
A blood chemistry test measures the level of chemicals in the blood. They make it possible to evaluate the functioning of certain organs and to detect abnormalities. The following blood chemistry tests are among those done to determine the stage of anal cancer and to assess your overall health.
Liver function tests are used to assess how well the liver is working. High levels of some substances could mean that the anal cancer has spread to the liver.
Kidney function tests help assess how well the kidneys are working.
Endoscopy allows the doctor to observe the interior of the body cavities using a flexible tube, at the end of which are attached a lumen and a lens. This instrument is called an endoscope. Doctors usually do an endoscopy if they find anything abnormal during a digital rectal exam. They also use it to determine the cause of certain symptoms, such as bleeding from the anus or rectum. A biopsy can be done during an endoscopy.
Different types of endoscopy can be done to diagnose and stage anal cancer. Their names vary depending on the structures or organs they are used to examine.
The anoscopy allows the doctor to see the inside of the anal canal and the last part of the rectum using an anoscopy.
Rectoscopy allows you to see the entire rectum.
Sigmoidoscopy looks at the rectum and sigmoid colon (the last part of the colon).
Doctors may use proctoscopy or sigmoidoscopy instead of anoscopy to determine if anal cancer has invaded the rectum.
During a biopsy, the doctor removes tissue or cells from the body for analysis in the laboratory. The laboratory report confirms the presence or absence of cancer cells in the sample. The biopsy is usually done during an endoscopy (this is called an endoscopic biopsy). The doctor removes a small amount of tissue or polyps in the anus, rectum, or both.
A fine needle biopsy can be done to check for cancer in swollen lymph nodes in the groin. The doctor uses a very fine needle and syringe to remove a small amount of fluid or cells from a lymph node.
Transrectal ultrasound (ETR)
In an ultrasound, high-frequency sound waves are used to produce images of body structures. In a transrectal ultrasound (TRUS), an ultrasound transducer (probe) is inserted through the anus to the rectum. Sometimes the probe is placed in the anal canal only. This is called an endoanal ultrasound.
The ETR is used to determine the stage of anal cancer. It allows doctors to see the size of the tumor and whether the cancer has spread to the anal sphincter, vagina (in women) or to the prostate (in men).
Computed tomography (CT)
A computed tomography (CT) scan uses special x-ray machines to produce 3-dimensional and cross-sectional images of the body’s organs, tissues, bones and blood vessels. A computer assembles the photos into detailed images.
A CT scan is used to check if the anal cancer has spread to the lymph nodes or organs in the chest, abdomen or pelvis.
Magnetic resonance imaging (MRI) uses powerful magnetic forces and radio waves to produce cross-sectional images of the body’s organs, tissues, bones, and blood vessels. A computer assembles the images into 3-dimensional snapshots.
MRI can be used to check if the anal cancer has spread to the lymph nodes and organs in the abdomen and pelvis, especially the lymph nodes in the groin.
In an x-ray, low doses of radiation are used to produce images of the body’s structures on film. A chest x-ray is used to check if the anal cancer has spread to the lungs.
Positron emission tomography combined with computed tomography (PET / CT)
A positron emission tomography (PET) scan uses radioactive material (called radiopharmaceuticals) to detect changes in the metabolic activity of body tissues. A computer analyzes patterns of radioactivity distribution and produces 3-dimensional, color images of the region being examined.
PET / CT combines a PET with a CT. The two tests are done at the same time, with the same machine. A CT scan is used to check if the anal cancer has spread to the lymph nodes or organs in the chest, abdomen or pelvis. PET / CT can also help doctors plan surgery.
Human immunodeficiency virus (HIV) screening
Having an HIV infection is a risk factor for anal cancer. If doctors believe or confirm that a person has anal cancer, they may order a blood test to find out if they have HIV infection.
HIV infects CD4 cells, a type of T cell. T cells are a type of white blood cell (lymphocyte). Doctors usually order a CD4 cell count in people with anal cancer who are also infected with HIV. This CD4 cell count helps them plan treatment.
Questions to ask your healthcare team
Here are some questions you can ask members of the healthcare team about your risk of getting cancer. Choose the ones that apply to you or your child and add your own questions to them. It may be useful to bring this list to your next meeting to write down the answers.
What are the risk factors for this type of cancer?
What makes a person at higher than average risk of developing this type of cancer?
Does our family history make us more likely than average to one day develop this type of cancer?
If I have this type of cancer, are my children more likely to have it?
What are the chances of one day getting this type of cancer?
What aspects of lifestyle (such as diet, smoking, alcohol consumption or occupational exposures) affect the risk of one day developing this type of cancer?
What can I do to reduce the risk of one day getting this cancer?
Histological classification of anal cancer (grading)
To determine the grade of anal cancer, the pathologist examines a sample of tissue taken from the tumor under a microscope. The pathologist assigns a grade of 1 to 4 for anal cancer. The lower this number, the lower the rank.
The grade is the description of the differentiation of cancer cells. Differentiation refers to the appearance and behavior of cancer cells compared to normal cells.
Low-grade cancer cells are well differentiated. They look and behave very much like normal cells. They tend to grow slowly and are less likely to spread.
High-grade cancer cells are poorly differentiated or undifferentiated. Their appearance and behavior are less normal, or more abnormal. They tend to grow quickly and are more likely to spread.
Knowing the grade gives your healthcare team an idea of how quickly cancer can grow and how likely it is to spread. It helps him plan your treatment. Histological classification can also help the healthcare team predict how you might respond to treatment.
Stages of anal cancer
Staging describes or categorizes cancer based on how much cancer is in the body and where it was initially diagnosed. This is often referred to as the extent of cancer. Information from tests is used to find out how big the tumor is, what parts of the organ have cancer, if the cancer has spread from where it started and where it has spread. Your healthcare team uses the stage to plan your treatment and predict the outcome (your prognosis).
The anal cancer staging system only applies to carcinomas. In the case of perianal skin carcinomas, only tumors that are less than 5 cm from the anus are staged according to the system described below.
The most frequently used staging system for anal cancer is the TNM staging system. In anal cancer there are 5 stages, stage 0 followed by stages 1 to 4. For stages 1 to 4, the Roman numerals I, II, III and IV are often used. In general, the higher the number, the more cancer has spread. Talk to your doctor if you have questions about staging.
When doctors describe the stage, they can use the words local, regional, or distant. Local means the cancer is only found in the area around the anus (anal canal or perianal skin) and has not spread to other parts of the body. Regional means near or around the anus. Distant means in a part of the body farther from the anus.
Stage 0 (carcinoma in situ)
The tumor or abnormal cells are only present in the top layer of anal tissue. Stage 0 includes high-grade anal intraepithelial neoplasia (AIN) and Bowen’s disease anus.
The tumor is 2 cm or less.
The tumor measures more than 2 cm but not more than 5 cm.
The tumor is over 5 cm.
The tumor is 5 cm or less. The cancer has also spread to nearby lymph nodes, including nodes in the groin, nodes around the rectum, or nodes inside the pelvis.
The tumor has grown to nearby organs such as the bladder, the urethra or the vagina.
The tumor is more than 5 cm in size or has grown into nearby organs such as the bladder, urethra or vagina. The cancer has also spread to nearby lymph nodes, including nodes in the groin, nodes around the rectum, or nodes inside the pelvis.
The cancer has spread to other parts of the body (distant metastasis), such as to the liver, lungs or bones. It is also called metastatic anus cancer.
Recurrence of anal cancer
Recurrence of anal cancer means that the cancer comes back after treatment. If it reappears where it first started, it is called a local recurrence. If it reappears in tissues or lymph nodes near where it first started, it is called a regional recurrence. It can also reappear in another part of the body: this is called a recurrence or distant metastasis.
If anal cancer spreads
Cancer cells can spread from the anus to other parts of the body. This spread is called metastasis.
Understanding how a type of cancer usually grows and spreads helps your healthcare team plan for your treatment and future care. If anal cancer spreads, it can spread to the following structures:
- lymph nodes around the rectum (called perirectal lymph nodes);
- lymph nodes in the groin (called inguinal lymph nodes);
- lymph nodes in the pelvis (called internal iliac lymph nodes);
- vagina or prostate;
Prognosis and survival for anal cancer
If you have anal cancer, you may be wondering about your prognosis. A prognosis is the act by which the doctor best assesses how the cancer will affect a person and how they will respond to treatment. The prognosis and survival depend on many factors. Only a doctor who is familiar with your medical history, the type of cancer you have, the stage and characteristics of the disease, the treatments chosen and the response to the treatment can review all of this data together with the survival statistics to determine the results. arrive at a prognosis.
A prognostic factor is an aspect of the cancer or a characteristic of the person that the doctor takes into account when making a prognosis. The following are prognostic factors for anal cancer.
Tumors smaller than 2 cm have a better prognosis than larger tumors. The prognosis for tumors larger than 5 cm tends to be grim.
Spread to the lymph nodes
The prognosis for anal cancer that has not spread to the lymph nodes is better than that of cancer that has spread there.
Hemoglobin is a protein found in red blood cells. It carries oxygen and gives blood its red color. Low hemoglobin is usually associated with a poor prognosis.
Squamous cell carcinoma has a better prognosis than adenocarcinoma and other rare cancers of the anus.
Treatments for anal cancer
If you have anal cancer, your healthcare team will make a treatment plan especially for you. It will be based on your needs and specific cancer information. When your healthcare team decides which treatments to offer you for anal cancer, they take the following into consideration:
- the stage of the cancer;
- the size and location of the tumor;
- your general state of health;
- your personal preferences.
Type of Treatments
There are several types of cancer treatment, including surgery, radiation therapy, and chemotherapy. The type of treatment you will receive depends on the type of cancer you have, its stage, your preferences and your age.
Treatments for stage 1 anal cancer
Surgery or chemoradiation is the main treatment for stage 1 anal cancer. Ask about treatments, including radiation therapy, chemotherapy, and surgery.
Treatments for stage 2 anal cancer
Chemoradiation is the main treatment for stage 2 anal cancer. Ask about treatments, including radiation therapy, chemotherapy, and surgery.
Treatments for stage 3 anal cancer
Chemoradiation is the main treatment for stage 3 anal cancer. Ask about treatments, including radiation therapy, chemotherapy and surgery.
Treatments for stage 4 anal cancer
Chemotherapy, chemoradiotherapy, and surgery are treatment options for stage 4 anal cancer. Learn about treatments for stage 4 anal cancer.
Treatments for recurrent anal cancer
If the anal cancer has come back, the following treatment options may be used. Learn about treatments for local and distant recurrences.
Radiation therapy for anal cancer
In radiation therapy, high-energy rays or particles are used to destroy cancer cells. The standard treatment for anal cancer is radiation therapy, which is given at the same time as chemotherapy (chemoradiotherapy). Radiotherapy
Radiation therapy destroys cancer cells and damages their DNA, preventing them from dividing and growing. Radiation therapy may be used only to treat cancer or in combination with other treatments such as surgery and chemotherapy.
Chemotherapy for anal cancer
Chemotherapy is commonly used to treat anal cancer. Chemotherapy is given along with radiation therapy (chemoradiotherapy) as the standard treatment for anal cancer. In chemotherapy, one or more drugs are used to destroy cancer cells. Chemotherapy can also be combined with other treatments, such as radiation therapy or targeted therapy.
Surgery for anal cancer
Sometimes surgery is done to treat anal cancer. See wide local excision, abdominoperineal resection, inguinal lymph node dissection and the side effects of surgery. Surgery is a medical procedure to examine, remove, or repair tissue. Surgery can be used in the following ways as part of a cancer treatment plan.
The main goal of surgery for cancer treatment is to completely remove the tumor or cancerous tissue from a specific location in the body. Surgery is most effective when it removes completely a tumor that is at an early stage, is only where it started (localized), and has not spread to others. parts of the body.
Surgery can also be used to treat cancer that has spread from the place where it started (primary site, or primary tumor) to other parts of the body. The new tumor is called a metastasis, or secondary tumor.
In surgery to remove cancer, the surgeon also removes a small amount of normal tissue from all around the cancer (surgical margin). This is to make sure that there are no remaining cancer cells. If the cancer cells cannot be completely removed, the cancer could come back. The amount of normal tissue to remove depends on the type and location of the tumor. Surgeons use normal vision as well as visual aids such as a microscope to make sure all of the tissue affected by the cancer is removed as well as a safety margin.
Depending on the type of cancer, the surgeon sometimes also removes the lymph nodes located near the tumor. Surgery to remove lymph nodes is called a lymph node dissection. The lymph nodes are sent to the lab to be examined under a microscope to see if they contain cancer cells. If the lymph nodes are not removed and contain cancer cells, these cells could form new tumors or spread to other parts of the body.
Follow-up after treatment for anal cancer
Follow-up after treatment for anal cancer is important. Find out about the schedule for follow-up appointments, as well as exams and tests that can be done.
Don’t wait until your next scheduled appointment to report any new symptoms and any symptoms that don’t go away. Tell your healthcare team if you have:
- bleeding from the anus;
- pain or worsening of pain, especially in the groin, pelvis or abdomen;
- any new lump or swelling.
Follow-up is particularly important during the first 6 months after chemoradiotherapy. During follow-up visits, doctors assess how the cancer has responded to treatment. They are looking to see if the anal cancer is completely gone or if it continues to shrink (tumors may continue to shrink for several months after chemoradiation). The information collected helps doctors determine if more treatment is needed.
The risk of anal cancer coming back is highest for 2 years, so close follow-up is necessary during this time.
Planning of follow-up visits
The first follow-up visit is usually 8 to 12 weeks after chemoradiation. The doctor checks the cancer’s reaction to treatment.
Follow-up visits usually take place every 3 to 6 months for 5 years after the end of treatment.
Conduct of follow-up visits
During a follow-up visit, your healthcare team will usually ask you about the side effects of treatment and how well you are coping.
Your doctor may do a physical exam, during which he may:
- perform a digital rectal examination (DRE)
- feel the lymph nodes in the groin
Follow-up often involves examinations. The following tests could be ordered:
- anoscopy or rectoscopy to check if there is any cancer left or if it has come back after treatment
- computed tomography (CT) scan of the chest, abdomen, and pelvis
- biopsy to confirm, if cancer is found, that it is anal cancer
The anoscopy or proctoscopy is usually done at the same time as a physical exam. A CT scan is usually done every year for the first 3 years when the primary tumor is large or the cancer has spread to the lymph nodes.
If a recurrence is detected, your healthcare team will assess you to determine the best treatment options.
Supportive care for anal cancer
Supportive care empowers people with the physical, practical, emotional and spiritual barriers of anal cancer. It is an important component of the care of people with this disease. There are many programs and services that help meet the needs and improve the quality of life of these people and their loved ones, especially after treatment is over.
Recovering from anal cancer and adjusting to life after treatment is different for everyone. They depend on the stage, the treatments given and many other factors. The end of cancer treatment can lead to mixed emotions. Even if treatment is finished, there may be other issues to work out, such as coping with long-term side effects.
You may want to discuss the following aspects with your healthcare team.
Diarrhea is a common problem in people being treated for anal cancer because the anal area and intestines are very sensitive to treatments such as radiation therapy and chemotherapy. An abdominoperineal resection can also cause diarrhea. Usually, diarrhea goes away after treatment is finished, but it can sometimes last for several months or even years after treatment is finished.
Making changes to your diet can help you control diarrhea. Limiting your intake of certain foods and drinks, such as fatty or high-fiber foods, coffee, tea, and alcohol, can help prevent diarrhea. Ask your doctor to refer you to a registered dietitian if you have any questions or concerns about your diet. Your healthcare team can also recommend medicines to help relieve diarrhea.
In addition to having diarrhea, some people may not be able to control bowel movements. This condition, called incontinence, often occurs when the anal sphincter has been damaged by treatment. Tell your healthcare team if you have incontinence. You can wear special towels or panties that collect the stool. In some cases, surgery may be done to repair the anal sphincter. If the anal sphincter cannot be repaired, a colostomy may be performed.
Some treatments for anal cancer can cause sexual problems or make sex difficult. For example, loss of interest in sex is common at diagnosis and during treatment. Some people may not be able to have anal sex anymore because of cancer or treatments.
Men who have received radiation therapy or have had abdominoperineal resection may not be able to get or maintain an erection (a condition called erectile dysfunction). These treatments can also cause ejaculation problems, including non-ejaculation orgasms (no semen release).
Women may experience pain or discomfort during sex if scar tissue or adhesions have formed in the abdomen after abdominoperineal resection. Radiation therapy can cause vaginal irritation and dryness, which can make sex painful or uncomfortable.
Talk to your doctor or members of your healthcare team if you have sexual problems because of anal cancer or treatments. They can suggest ways to manage these problems, such as specific medications or devices. Some people find that counseling helps them cope with the effects of anal cancer and treatment on sex.
Living with a colostomy
With a colostomy, an artificial opening (called a stoma) is created in the colon that opens to the outside of the body through the abdominal wall. Since the anal sphincter is removed during abdominoperineal resection, a permanent colostomy is necessary in people who have this operation.
Specially trained healthcare professionals, called enterostomal therapists, will help you adjust to life with a colostomy. They will teach you how to take care of the stoma. Support and information can also be obtained from local or national ostomy associations and groups.
The word “cancer” is a generic term for a large group of diseases that can affect any part of the body. We also speak of malignant tumors or neoplasms. One of the hallmarks of cancer is the rapid multiplication of abnormal growing cells, which can invade nearby parts of the body and then migrate to other organs. This is called metastasis, which is the main cause of death from cancer. Types of cancer (in alphabetical order of the area concerned):
Information: Cleverly Smart is not a substitute for a doctor. Always consult a doctor to treat your health condition.
Sources: PinterPandai, Cancer Center, Web MD, American Cancer Society, European Society for Medical Oncology (ESMO), Cancer Council Australia, National Cancer Institute (NIH), International Agency for Research on Cancer, National Cancer Centre Singapore
Photo explanation: a squamous cell carcinoma is seen from the anus (anal cancer). Article: Anal (Anal) Cancer – Signs Symptoms, Causes, Diagnosis, Treatment, Prevention.
Photo credit: Wikimedia Commons