Cancer Helper

During and after treatment for your anal cancer you may be able to hasten your recovery and improve your quality of life by taking an active role. Learn about the benefits and disadvantages of each of your treatment options, and ask questions of your cancer care team if there is anything you do not understand. Learn about and look out for side effects of treatment, and report these promptly to your cancer care team so that they can take steps to minimize them and shorten their duration.

Your body is as unique as your personality and your fingerprints. Although understanding your cancer’s stage and learning about the effectiveness of your treatment options can help predict what health problems you may face, no one can say precisely how you will respond to cancer or its treatment.

You may have special strengths such as a history of excellent nutrition and physical activity, a strong family support system, or a deep faith, and these strengths may make a difference in how you respond to cancer. In fact, behavioral scientists have recently found that some people who took advantage of a social support system, such as a cancer support group, survived with a better quality of life. There are also experienced professionals in mental health services, social work services and pastoral services who may assist you in coping with your illness.

You can help in your own recovery from cancer by making healthy lifestyle choices. If you use tobacco, stop now. Quitting will improve your overall health and the full return of the sense of smell may help you enjoy a healthy diet during recovery. If you use alcohol, limit how much you drink. Have no more than 1 or 2 drinks per day. Good nutrition can help you get better after treatment. Eat a nutritious and balanced diet, with plenty of fruits, vegetables, and whole grain foods. Ask your cancer care team if you could benefit from a special diet - they may have specific recommendations for people who have had radiation therapy or a colostomy.

If you are being treated for cancer, be aware of the battle that is going on in your body. Radiation therapy and chemotherapy add to the fatigue caused by the disease itself. Give your body all the rest it needs so that you will feel better as time goes on, and ask your doctor if and when an exercise program may be right for you.

Surgery and radiation therapy may sometimes affect the way you feel about your body, and may lead to specific physical problems that affect sexuality. Your cancer care team can help with these concerns, so don’t hesitate to discuss them.

A cancer diagnosis and its treatment are major life challenges that impact you and everyone who cares for you. Before you get to the point where you feel overwhelmed, consider attending a counseling session or meeting of a local support group. If you need individual assistance in other ways, contact your hospital’s social service department or the American Cancer Society for help in contacting counselors or other services.

Follow-up Care: For years after treatment ends, regular follow-up exams will be very important for you. Your health care team will explain what tests you need and how often they should be done. The most important tests will involve biopsies of your anal area to make sure the tumor has disappeared. This may occur over several months so don’t be discouraged if early biopsies still show cancer. You may need blood tests as well as x-rays, CT scans, and other imaging studies to detect recurrence, metastasis, or a new tumor. Make a special effort to keep all appointments with your cancer care team and follow their instructions carefully. Report any new or recurring symptoms to your doctor right away.

For patients with colostomies: Few permanent colostomies are needed now in the treatment of anal cancer. If you have a colostomy, follow-up is an important concern. You may feel worried or isolated from normal activities. An enterostomal therapist (a health care professional trained to help people with their colostomies) can teach you about the care of your colostomy. Ask the American Cancer Society about programs offering information and support in your area. For more information about your colostomy care, please contact the United Ostomy Association, Inc.

As you deal with your cancer and the process of treatment, you need to have honest, open discussions with your cancer care team. You should feel free to ask any question that’s on your mind, no matter how trivial it might seem. Among the questions you might want to ask are:

• What kind of anal cancer do I have?
• Has my cancer spread beyond the primary site?
• What is the stage of my cancer? What does the staging mean in my case?
• What treatment choices do I have?
• What treatment would you recommend for me?
• Based on what you’ve learned about my cancer, what is my prognosis?
• What side effects can I expect from my treatment?
• What are the other risks of treatment?
• How long will it take me to recover from treatment?
• When can I go back to work after treatment?
• How soon after treatment can I return to my normal activities, such as work, school, exercise, or sex?
• Will I have to have a colostomy?
• What are the chances that my cancer will recur?
• Does one type of treatment reduce the risk of recurrence more than another?
• What should I do to be ready for treatment?
• Should I get a second opinion?

You will no doubt have other questions about your own personal situation. Be sure and write your questions down so you will remember to ask them during each visit with your cancer care team. Keep in mind, too, that doctors are not the only ones who can provide you with information. Other health care professionals, such as nurses and social workers, may have the answers you seek.

How Is Anal Cancer Treated?

No matter what cell type or stage of anal cancer you have, treatment is available. The choice of treatment you receive depends on many factors. The location, type, and the stage (extent of spread) of the tumor are important. In creating your treatment plan, you and your cancer-care team will also take into account your age, the general state of your health, your personal preferences, and your social circumstances.

The 3 main methods of treatment for anal cancer are surgery, radiation therapy, and chemotherapy. Often the best approach uses 2 or more of these strategies. In the past, surgery was the only treatment. But experience has shown that most anal cancers can be successfully treated with radiation and chemotherapy combined. This treatment called chemoradiotherapy is the most widely used approach.

Your recovery is the goal of your cancer care team. If a cure is not possible, the goal may be to remove or destroy as much of the cancer as possible and to prevent the tumor from growing, spreading, or returning for as long as possible. Sometimes treatment is aimed at relieving such symptoms as pain or bleeding, even if a cure will not result. Another important goal is to treat the anal cancer without affecting your ability to control the passage of feces.

Surgery

Studies show that when surgery is the appropriate option, half of patients with anal cancer enjoy long-term survival. The kind of surgery used depends on the type and location of the tumor.

Local resection: One surgical procedure for anal cancer is called a local resection. This operation removes only the tumor, plus a small margin of noncancerous tissue around the tumor. Local resection is used if the cancer is small and has not spread to nearby tissues or lymph nodes. In most cases, local resection preserves the sphincter (the muscular ring that opens and closes the anus). If the sphincter is saved, then after the operation you will be able to move your bowels the same way you did before. Most small tumors that develop in the anal margin (the lower part of the anus) can be treated with local resection.

Abdominoperineal resection (APR): The other surgical method is a more extensive operation known as an abdominoperineal resection. The term means that the surgeon opens the body through the abdomen and through the perineum (the space between the anus and the external genitals) and removes the anus and part of the rectum. The surgeon may also take out some of the lymph nodes during this operation, although this step (called a lymph node dissection) can also be done later. This surgery was commonly done in the past for cancers of the anal canal, but it can often be avoided by treating the patient with combined radiation and chemotherapy instead.

The APR procedure does not preserve the anal sphincter. As a result, you will need to have a permanent opening made in your abdomen so that feces can exit the body. This opening is called a colostomy, or an ostomy. Feces passes through the opening into a collection bag attached to the body.

Radiation Therapy

Radiation therapy uses a beam of high-energy rays (or particles) to destroy cancer cells or slow their rate of growth. Sometimes doctors give radiation to shrink a tumor so that it can be removed more easily during surgery. This type of therapy can be given in several ways.

External-beam radiation: The most common way is to deliver a carefully focused beam of radiation from a machine outside the body. This is known as external beam radiation. Radiation treatment given this way can harm nearby healthy tissue along with the cancerous cells. Some people experience skin changes like a sunburn on the area that receives the radiation. You will also have temporary anal irritation and discomfort when having bowel movements. Side effects of radiation therapy vary depending on the area of the body that receives the treatment. Other possible side effects include fatigue, nausea, or diarrhea when the anal area is irradiated.

To reduce the risk of side effects, doctors carefully figure out the exact dose you need and aim the beam as accurately as they can. External-beam radiation therapy usually means having treatments 5 days a week for a period of 6 weeks or so.

Internal radiation, brachytherapy, or interstitial radiation: Another method of delivering radiation is to place tiny pellets that contain radioactive materials in or near the tumor. This method is also called internal radiation, brachytherapy, or interstitial radiation. The radioactive pellets, or “seeds,” release their dose slowly over a period of time. Although the pellets stop being radioactive after a while, they remain in place for the rest of your life. This method can be more convenient, since you will not need to make as many trips to the doctor. However, implanting the seeds requires surgery. Sometimes, both internal and external-beam radiation therapy are used together.

Damage to anal tissue by radiation may cause scar tissue to form. This scar tissue can keep the anal sphincter from working as it should.

Chemotherapy

Chemotherapy is the use of drugs for treating cancer. The drugs can be swallowed in pill form or they can be injected from a needle into a vein or muscle. Chemotherapy is usually a systemic therapy. This means that the drug enters the bloodstream and circulates throughout the body (through the whole system) to reach and destroy the cancer cells.

Some types of chemotherapy drugs kill cancer cells directly. Others act by making the cells more vulnerable to radiation. Chemotherapy often uses two or more drugs because one drug can boost the power of the other. Like radiation, chemotherapy can cause the tumor to shrink. In anal cancer, chemotherapy combined with radiation therapy can cure the cancer without the need for surgery. The main chemotherapy drug combinations used to treat anal cancer are 5-fluorouracil (5-FU) and mitomycin or 5-FU and cisplatin.

Chemotherapy drugs can reach just about any place inside the body. They are an effective way to destroy cancer cells that break off from the main tumor and travel in the bloodstream. Often doctors prescribe chemotherapy after surgery as a precaution, to make sure they destroy any remaining cancerous cells that may not have been detected.

Chemotherapy drugs kill cancer cells but also damage some normal cells. Careful attention must be given to avoid or minimize side effects, which depend on the specific drugs, the amount taken, and the length of treatment. Temporary side effects might include nausea and vomiting, loss of appetite, loss of hair, diarrhea, and mouth sores. Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can result in:

• an increased chance of infection (due to a shortage of white blood cells)
• bleeding or bruising after minor cuts or injuries (due to a shortage of blood platelets)
• fatigue or shortness of breath (due to low red blood cell counts)

It is important to tell your doctor or nurse about any side effects you experience. If you have side effects, your cancer care team can suggest steps to manage them. For example, anti-nausea drugs can help control nausea and vomiting. Sometimes changing the dosage or how you take your medications can reduce side effects. Fortunately, most side effects will stop when your course of treatment ends.

Clinical Trials

The purpose of clinical trials: Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

• Is the treatment helpful?
• How does this new type of treatment work?
• Does it work better than other treatments already available?
• What side effects does the treatment cause?
• Are the side effects greater or less than the standard treatment?
• Do the benefits outweigh the side effects?
• In which patients is the treatment most likely to be helpful?

Types of clinical trials: There are 3 phases of clinical trials in which a treatment is studied before it is eligible for approval by the FDA (Food and Drug Administration).

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. The cancer care team watches patients carefully for any harmful side effects. The treatment has been well tested in lab and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.

Phase II clinical trials: These studies are designed to see if the drug works. Patients are given the highest dose that doesn’t cause severe side effects (determined from the phase I study) and closely observed for an effect on the cancer. The cancer care team also looks for side effects.

Phase III clinical trials: Phase III studies involve large numbers of patient ??? often several hundred. One group (the control group) receives the standard (most accepted) treatment. The other group receives the new treatment. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better results than the others.

If you are in a clinical trial, you will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you.

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to find out. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.

Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study does not prevent you from getting other medical care you may need.

To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:

• Is there a clinical trial for which I would be eligible?
• What is the purpose of the study?
• What kinds of tests and treatments does the study involve?
• What does this treatment do? Has it been used before?
• Will I know which treatment I receive?
• What is likely to happen in my case with, or without, this new treatment?
• What are my other choices and their advantages and disadvantages?
• How could the study affect my daily life?
• What side effects can I expect from the study? Can the side effects be controlled?
• Will I have to be hospitalized? If so, how often and for how long?
• Will the study cost me anything? Will any of the treatment be free?
• If I am harmed as a result of the research, what treatment would I be entitled to?
• What type of long-term follow-up care is part of the study?
• Has the treatment been used to treat other types of cancers?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can reach this service at 1-800-303-5691 or on our Web site at http://clinicaltrials.cancer.org. Based on the information you provide about your cancer type, stage, and previous treatments, this service can compile a list of clinical trials that match your medical needs. In finding a center most convenient for you, the service can also take into account where you live and whether you are willing to travel.

You can also get a list of current clinical trials by calling the National Cancer Institute’s Cancer Information Service toll free at 1-800-4-CANCER or by visiting the NCI clinical trials Web site at http://www.cancer.gov/clinicaltrials.

Complementary and Alternative Therapies

Complementary and alternative therapies are a diverse group of health care practices, systems, and products that are not part of usual medical treatment. They may include products such as vitamins, herbs, or dietary supplements, or procedures such as acupuncture, massage, and a host of other types of treatment. There is a great deal of interest today in complementary and alternative treatments for cancer. Many are now being studied to find out if they are truly helpful to people with cancer.

You may hear about different treatments from family, friends, and others, which may be offered as a way to treat your cancer or to help you feel better. Some of these treatments are harmless in certain situations, while others have been shown to cause harm. Most of them are of unproven benefit.

The American Cancer Society defines complementary medicine or methods as those that are used along with your regular medical care. If these treatments are carefully managed, they may add to your comfort and well-being. Alternative medicines are defined as those that are used instead of your regular medical care. Some of them have been proven not to be useful or even to be harmful, but are still promoted as ?cures.? If you choose to use these alternatives, they may reduce your chance of fighting your cancer by delaying, replacing, or interfering with regular cancer treatment.

Before changing your treatment or adding any of these methods, discuss this openly with your doctor or nurse. Some methods can be safely used along with standard medical treatment. Others, however, can interfere with standard treatment or cause serious side effects. That is why it’s important to talk with your doctor.

Treatment Options by Stage

The type of treatment your cancer care team will recommend depends on the type of cancer and how far it has spread. This section summarizes the choices available for anal cancer treatment according to the stage. Anal tumors affecting the anal margin or the perianal skin are considered to be skin cancers and are not treated in the same way as anal canal cancers.

Stage 0: Because Stage 0 tumors do not penetrate beneath the epithelium of the anal canal, they usually can be completely removed through surgery (local resection). This surgery is an option if the tumor does not involve the sphincter.

Stages I and II: Local resection can remove small tumors (usually less than 1 centimeter or ? inch) that do not involve the sphincter.

If your cancer cannot be removed by a local resection without severely damaging the anal sphincter, you will be treated with a combination of radiation and chemotherapy. Even if it can be removed, many doctors recommend the chemotherapy and radiation as a safeguard. In the past, the standard treatment was a radical surgery called abdominoperineal (AP) resection that would leave you with a colostomy. Now, however, doctors have found that chemotherapy and external beam radiation given together work just as well and you don’t need a colostomy.

The combination of radiation and chemotherapy has been shown to be better than radiation alone. The radiation and the chemotherapy are given at the same time. The chemotherapy usually consists of 5-FU with either mitomycin C or cisplatin. The mitomycin or cisplatin are given as a short intravenous injection, usually at the beginning of radiation treatment and then near the end, at around 4 to 6 weeks. The 5-FU is given by a long intravenous infusion over 4 to 5 days and repeated in 4 to 6 weeks. In some cases, your doctor may suggest interstitial radiation in addition to the external beam radiation.

If your cancer hasn’t completely disappeared, surgery may be needed to remove the remaining cancer.

Stage IIIA: In most cases, the first choice of treatment is radiation therapy combined with chemotherapy as in Stages I and II.

Sometimes part of the tumor remains despite the use of chemotherapy or radiation or both. In that case, additional treatment may be given. In certain cases, surgery, either a local resection or a more extensive operation, can be done. If the cancer has spread to local lymph nodes, these may be removed with surgery.

Stage IIIB: Recovery is possible for Stage IIIB tumors, but it is more difficult to achieve. The most common approach is radiation plus chemotherapy to shrink the tumor, followed by surgery (local resection or abdominal perineal resection) to remove any remaining tumor. Surgical removal of the cancer-containing lymph nodes may be done during this operation or it may be done later as a separate procedure.

People with Stage IIIB anal cancers might benefit from taking part in a clinical trial, as described earlier.

Stage IV: In this advanced stage, treatment is aimed at controlling the disease and relieving symptoms as much as possible. Toward this end, depending on your needs, doctors may recommend surgery, radiation, or chemotherapy, or some combination of these methods. People with this stage of anal cancer might consider taking part in clinical trials.

Recurrent anal cancer: If your cancer returns after treatment, the choices available to you depend on what treatment you had the first time around. For example, if you had surgery, you may receive radiation and chemotherapy. If you first had radiation, then you may need surgery. At this time, an abdominal perineal resection may be needed. Again, clinical trials may prove to be valuable in controlling recurrent anal cancer.

HIV-positive patients: Most of the time treatment can be given the same as for people with HIV infection. Problems may arise with HIV patients with advanced stages of their disease. This usually requires decreasing the intensity of the treatment.

Staging, the process of finding out how far the cancer has spread, is very important because your treatment options and the outlook for your recovery and survival depend on the stage of your cancer. If you have anal cancer, ask your cancer care team to explain the staging in a way that you understand. Knowing all you can about staging lets you take a more active role in making informed decisions about your treatment.

Staging of anal cancer uses a system created by the American Joint Committee on Cancer (AJCC). The staging description that follows applies only to anal canal tumors.

The TNM System

The TNM system for staging contains three key pieces of information:

• T describes the size of the primary tumor, measured in centimeters (cm), and whether the cancer has spread to organs next to the tumor
• N describes the extent of spread (metastasis) to nearby (regional) lymph nodes
• M indicates whether the cancer has metastasized (spread) to other organs of the body

Additional letters or numbers appear after T, N, and M to provide more details about each of these factors:

• The numbers 0 through 4 indicate increasing severity.
• The letter X means “cannot be assessed” because the information is not available.
• The letters “i” and “s” mean “carcinoma in situ,” which means the tumor is contained within the layer of anal tissue in which it first developed (the epithelium) and has not yet penetrated to a deeper layer of tissue.

The possible values for T are:

TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: The tumor is 2.0 cm (about 4/5 inch) or smaller.
T2: Tumor is larger than 2.0 but smaller than 5.0 cm (2 inches).
T3: Tumor is larger than 5 cm.
T4: Tumor of any size that invades nearby organ(s), such as the vagina, urethra (the tube that carries urine out of the bladder), or bladder

The possible values for N are:

NX: Regional lymph nodes cannot be assessed.
N0: No regional lymph node spread
N1: Spread to lymph nodes near the rectum
N2: Spread to lymph nodes on one side of the groin and/or pelvis
N3: Spread to lymph nodes near the rectum and in the pelvis or groin, or to both sides of the groin or pelvis

The M values are:

MX: Presence of distant metastasis cannot be assessed
M0: No distant spread
M1: Distant spread to internal organs or lymph nodes of the abdomen is present.

Using the TNM system, a doctor will use each letter (T, N, and M) and a corresponding number. To make this information somewhat clearer, these TNM descriptions can be grouped together into a simpler set of stages, labeled stage 0 through stage IV.

Stage 0 (carcinoma in situ): Tis, N0, M0: Stage 0 is very early cancer that exists only in the top layer of anal tissue (epithelium).

Stage I: T1, N0, M0: The cancer has spread beyond the top layer of anal tissue but is less than 2 cm (about 4/5 inch) in size. It has not spread to distant sites.

Stage II: T2 or 3, N0, M0: The cancer is larger than 2 cm, but it has not spread to nearby organs or lymph nodes. It has not spread to distant sites.

Stage IIIA: T1, 2, or 3, N1, M0 or T4, N0, M0: The cancer can be any size and has spread to the lymph nodes around the rectum, or it has grown into nearby organs such as the vagina or the bladder but not spread to lymph nodes. It has not spread to distant sites.

Stage IIIB: T4, N1, M0, Any T, N2 or 3, M0: The cancer has grown into nearby organs such as the vagina or the bladder and has spread to lymph nodes around the rectum, or it can be of any size but has spread to lymph nodes in one groin or lymph nodes in both groins or lymph nodes in one groin and around the rectum. It has not spread to distant sites.

Stage IV: Any T, Any N, M1: Cancer can be any size and may or may not have spread to lymph nodes but has spread to organs in other parts of the body.

Recurrent: Recurrent anal cancer means that the cancer has come back (recurred) after treatment in either the anus or in another part of the body.

Five-Year Survival by Stage

Because anal cancer is uncommon, statistics on survival can only be approximate. They depend on reporting from institutions that only see a small number of patients.

The highest number of patients is collected by the SEER database of the National Cancer Institute. The SEER staging system looks at whether the cancer is localized (corresponds roughly to stages I and II), regional, (corresponds roughly to stage IIIA), or distant (corresponds roughly to stages IIIB and IV). The overall 5-year relative survival for all patients is 61% for men and 73% for women. If the cancer is localized, the relative 5-year survival is around 80%. If regional, it is 60%. It is 20% for those with distant disease. In all cases, the survival is slightly higher for women and lower for men.

The 5-year survival rate refers to the percentage of patients who live at least 5 years after their cancer is diagnosed. Although many of these patients live much longer than 5 years after diagnosis, 5-year rates are used to produce a standard way of discussing prognosis. Five-year relative survival rates don’t include patients dying of other diseases.

Five-year relative survival rates are considered to be a more accurate way to describe the prognosis for patients with a particular type and stage of cancer. Of course, 5-year survival rates are based on patients diagnosed and initially treated more than 5 years ago. Recent improvements in treatment often result in a more favorable outlook for recently diagnosed patients.

Anal cancer is relatively easy to diagnose because it is located in a very accessible site. Although some cases of anal cancer in people at high risk for that disease are diagnosed by screening tests, such as the digital rectal exam and/or anal cytology testing, as mentioned above, most people are diagnosed after their cancer starts to cause symptoms.

Signs and Symptoms of Anal Cancer

Some cases of anal cancer cause no symptoms at all. Bleeding occurs in more than half of patients and is usually the first sign of the disease. Often the bleeding is minor. At first, most people assume that hemorrhoids are the cause of their bleeding.

Other important symptoms of anal cancer include:

• pain in the anal area
• change in the diameter of stool
• abnormal discharge from the anus
• swollen lymph nodes in the anal or groin areas

There are a number of benign conditions, such as hemorrhoids, fissures, or anal warts, that can produce similar symptoms. In about 65% of anal cancers, benign anal conditions are present also. But if you have any of these signs or symptoms listed above, please discuss them with your doctor without delay. Remember, the sooner you receive a correct diagnosis, the sooner you can start treatment and the more effective your treatment will be.

Procedures Used to Diagnose Anal Cancer

Sometimes your doctor will detect anal cancer during a routine physical exam or during a minor procedure, such as removing a hemorrhoid. Treatment of cancers found in this way is often very effective because the tumors are found early in the course of the disease.

The digital rectal exam often reveals the presence of an unusual growth. However, since doctors cannot see what they feel, other steps are needed if you have symptoms or if your doctor suspects you have anal cancer.

Among the procedures used in diagnosing anal cancer are:

• anoscopy - use of a special device to view the anus
• proctoscopy - use of a lighted scope to view inside the anal canal
• transrectal ultrasound - use of a device that is inserted into the rectum and produces sound waves; echoes of these sound waves are detected and analyzed by a computer to create an image of the anus and nearby tissues

Your doctor also may ask you to have an exam using a sigmoidoscope or a colonoscope. These instruments allow the doctor to see inside the colon and look for abnormal growths, bleeding, or other signs of disease higher up.

If a suspicious growth is found, your doctor will want to do a biopsy. In this procedure, a small piece of the tissue is cut out and sent to a laboratory. A pathologist (a doctor specializing in laboratory diagnosis of diseases) will look at the tissue under a microscope. If cancer is present, the pathologist sends back a report describing the cell type and extent of the cancer. Usually, a biopsy causes only slight discomfort and you will not have to stay in the hospital. However, if you have pain or muscle spasms during the exam, an anesthetic can be given.

If the tumor is very small and has not grown below the surface of the anus into other tissues, your doctor may attempt to remove the entire tumor during the biopsy.

There is a risk that anal cancers, like other forms of cancer, can spread through the lymphatic system. Lymph nodes are bean-sized collections of immune system cells. Swollen lymph nodes in the groin are sometimes a sign of spreading anal cancer. These can also be a reaction to infections. To distinguish between these two causes, your doctor may use a thin needle to withdraw a small sample of fluid and tissue fragments from the lymph node. The lab will study this fluid to look for the presence of cancerous cells. This procedure is called a fine needle aspiration biopsy. In some cases, an operation to remove the lymph nodes may be done.

Sentinel node biopsy: Recently, a new way of examining local lymph nodes has been developed. In this method a radioactive tracer material is injected around the tumor. Then the groin lymph nodes are scanned to spot the radioactivity. The surgeon will then make a small incision over the radioactive area to remove the underlying lymph nodes. Often a blue dye will be injected into the tumor at the same time as the radioactive material. Then the surgeon will remove any blue-stained lymph nodes. Studies of other cancers have shown that if there has been spread of cancer to lymph nodes, the cancer has gone to the node that has picked up the blue dye or radioactivity.

Imaging Studies

If cancer is found, you will need to have certain tests to determine the stage (extent) of the disease.

Ultrasound: A transrectal ultrasound can show how far the cancer has invaded nearby tissues. Ultrasound uses sound waves and their echoes to produce a picture of internal organs or masses. A small microphone-like instrument called a transducer emits sound waves. These high-frequency sound waves are transmitted into the area of the body being studied and echoed back. The sound wave echoes are picked up by the transducer and converted by a computer into an image that is displayed on a computer screen.

Normally, ultrasound is a very easy procedure. It uses no radiation, which is why it is frequently used to look at developing fetuses. With endorectal ultrasound, the transducer is inserted directly into the rectum, which can be uncomfortable.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, as does a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take pictures of multiple slices of the part of your body that is being studied. This test can help tell if your anal cancer has spread into your liver or other organs. Often after the first set of pictures is taken you will receive an intravenous injection of a “dye” or radiocontrast agent that helps better outline structures in your body. A second set of pictures is then taken.

CT scans can also be used to precisely guide a biopsy needle into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table, while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine needle biopsy sample (tiny fragment of tissue) or a core needle biopsy sample (a thin cylinder of tissue about ?? inch long and less than 1/8 inch in diameter) is removed and examined under a microscope.

CT scans are more tedious than regular x-rays because they take longer and you usually need to lie still on a table for 15 to 30 minutes while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. You might feel a bit confined by the equipment while the pictures are being taken.

You will need an intravenous line through which the contrast “dye” is injected. The injection can cause some flushing. Some people are allergic and get hives or rarely more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays. You may be asked to drink 1 to 2 pints of a contrast solution. This helps outline the intestine so that it is not mistaken for tumors.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Like a CT scanner, this produces cross-sectional slices of the body. An MRI can produce slices that are parallel with the length of your body. Like a CT scan, a contrast material might be used, but not as often.

MRI scans are also very helpful in looking at the brain and spinal cord. MRI scans are a little more uncomfortable than CT scans. First, they take longer ??? often up to an hour. You have to be placed inside tube-like equipment, which is confining and can upset people with claustrophobia ( a fear of enclosed spaces). The machine makes a thumping noise that you may find disturbing. Some places will provide headphones with music to block this out.

Chest x-ray: This test may be done to determine whether anal cancer has spread to the lungs.

Positron emission tomography: Positron emission tomography (PET) uses glucose (a form of sugar) that contains a radioactive atom. Cancer cells in the body absorb large amounts of the radioactive sugar and a special camera can detect the radioactivity. PET is useful when your doctor thinks the cancer has spread, but doesn’t know where. PET scans can be used instead of several different x-rays because it scans your whole body.

Many cases of anal cancer can be found early in the course of the disease. Anal cancers develop in a part of the digestive tract that your doctor can see and reach. Many early anal cancers have symptoms that should make you see your doctor. Unfortunately, some anal cancers may not cause symptoms until they reach an advanced stage, and others may cause symptoms that appear to be due to a disease other than cancer.

A digital rectal exam will find some cases of anal carcinoma early. The American Cancer Society suggests that this be done yearly on all men over 50 to look for prostate cancer (because the prostate gland is next to the rectum). The rectal exam is done routinely as part of a pelvic exam on women. In this exam, the doctor inserts a gloved, lubricated finger into the anus to feel for unusual lumps or growths. If you are at high risk for anal cancer, ask your doctor if additional or more frequent examinations are needed.

The odds that anal cancer can be found early are influenced by the location and type of the cancer. Cancers that begin deeper in the anal canal are less likely to be found early. Melanomas tend to spread earlier than other cancers.

Recently doctors have tested people at high risk for sexually transmitted disease for anal intraepithelial neoplasia. The test is carried out much like a Pap smear for cervical cancer. The anal lining is swabbed and cells that come off on the swab are examined under the microscope. Some doctors have advocated doing this routinely on people at high risk for anal cancer, particularly HIV-positive men who have sex with men or HIV-positive women who have anal intercourse. Screening all HIV-positive people may also be helpful.

Since the cause of many cases of anal cancer is unknown and some people with anal cancer have no known risk factors, it is not possible to prevent this disease completely.

The best way to reduce your risk of anal cancer is to avoid sexual practices that carry a high risk of human papillomavirus (HPV) infection (particularly in the anal area) and HIV infection. This means not having unprotected sex.

Infection with HPV increases the risk of developing anal cancer. Until recently, it was thought that the use of condoms (”rubbers”) could prevent infection with HPV. But recent research shows that condoms might not offer protection. This is because you can pass HPV from person to person by skin-to-skin contact with any HPV-infected area of the body, such as skin of the genital or anal area not covered by the condom. You cannot base your decision about whether or not to be careful on the lack of visible warts, because HPV can be passed on to another person even when no warts or other symptoms can be observed. HPV can be present for years with no symptoms. For these reasons, it can be very difficult or impossible to know whether a person with whom you might have sex is infected with HPV. It is still very important, though, to use condoms to protect against AIDS and other sexually transmitted diseases that are passed on through body fluids.

If you stop smoking, you will also lower your risk of anal cancer, as well as many other cancers.

Sometimes there is nothing a person can do about certain diseases that affect their immune system. For many patients, a weakened immune system is an unavoidable side effect of treatment for some other disease.

Although the exact cause of most anal cancers is not known, most doctors tie it to infection with HPV. A great deal of research is now under way to learn how HPV causes anal cancer.

It is important to remember that some patients with anal cancers do not have any known risk factors and the causes of their cancers are not known.

There is good evidence that the human papillomavirus (HPV) causes many squamous cell anal carcinomas and transitional cell (cloacogenic) anal carcinomas. But, the role of this virus in causing anal adenocarcinomas is less certain. More than 100 types of HPV have been found by scientists. The type known as HPV-16 is often found in anal squamous-cell carcinoma and is also found in some anal warts. Another type, HPV 18 is found less often. Most anal warts are caused by HPV-6 and HPV-11. Warts containing HPV-6 or HPV-11 are much less likely to become cancerous than those containing HPV-16.

Research has recently shown that HPV produces proteins called E6 and E7 that can inactivate two important tumor suppressor proteins in normal cells. These 2 proteins, p53 and Rb, normally work to keep cells from growing out of control. When they are inactive, cells can become cancerous.

HIV, the virus that causes AIDS, weakens the body’s immune system. The immune system of patients with kidney, heart, liver, or other organ transplants is purposely weakened by medication to prevent rejection of their new organs. When the body is less able to fight off infections, viruses such as HPV may become more active and thus trigger the development of anal cancer. Also, a weakened immune system allows cancer to grow more readily.

Most people know that smoking is the main cause of lung cancer. But few realize that the cancer-causing chemicals in tobacco smoke are absorbed by the lungs and can spread through the bloodstream to the rest of the body. Many studies have noted an increased rate of anal cancer in smokers, and the effect of smoking is especially important in people with other anal cancer risk factors.

A risk factor is anything that increases a person’s chance of getting a disease such as cancer. Different cancers have different risk factors. For example, exposing skin to strong sunlight is a risk factor for skin cancer. Smoking is a risk factor for cancers of the lung, mouth, larynx, bladder, kidney, colon, anus, and several other organs. But having a risk factor, or even several, does not mean that a person will get the disease.

Human papillomavirus: Most doctors feel that squamous cell anal cancer is caused by the human papillomavirus (HPV), the same virus thought to be responsible for cervical cancer. There are several types of the virus but the one most likely to cause this cancer is called HPV-16. This virus is most often transmitted by sexual contact and more likely to be found in people who have had many sex partners.

One sign of infection by this virus is genital warts sometimes called condylomas. These are caused by HPV.

Sexual activity: Having multiple sexual partners is a risk factor for women. Another risk factor is anal intercourse for both men and women, particularly under the age of 30.

Smoking: Smoking also increases the risk of anal cancer. Current smokers are about 4 times more likely to have cancer of the anus compared with people who do not smoke. Quitting smoking will reduce the risk. People who used to smoke but have quit are only slightly more likely to develop this cancer compared with nonsmokers.

Lowered immunity/HIV infection: Higher rates of the disease occur among people with reduced immunity, such as organ transplant patients who must take medications that suppress their immune system. Another important risk factor is infection with the human immunodeficiency virus (HIV), the virus that causes AIDS.

Anal cancer is fairly rare. The American Cancer Society estimates that in 2005 about 3,990 new cases of anal cancer will be diagnosed in the United States. However, the number of new anal cancer cases has been increasing for many years.

The disease affects women somewhat more often than men. Of the 3,990 new cases, 2,240 will occur in women and 1,750 in men. Women are more likely to have cancers in the inner part of the anus (the anal canal), while anal tumors in men tend to develop on the outside of the anus.

Anal cancer can be a serious condition. An estimated 620 people (390 women and 230 men) will die of anal cancer in 2005. But treatment for anal cancer is very effective and most patients with this cancer will be cured.

Although anal cancer can affect adults at any age, it is more often found in people older than 50. Black men have a higher rate than white men.