• This manual is not a substitute for consultation with an appropriate specialist.
• The contents of this manual have been developed through consensus of a Provincial Tumour Group. Please note the various update dates for each section as some of the content of the manual may not be up to date.

Revised 26 Sept 2012

The anal canal should be examined by digital rectal examination during a yearly physical exam.

Anal canal cancer is known to be associated with human papillomavirus (HPV) infection. People at higher than average risk for anal cancer who should be considered for anal cytology testing and anoscopy are those who:

• are HPV- or HIV-positive
  
• have receptive anal intercourse
  
• have had multiple sexual partners
  

Patients with anal dysplasia or carcinoma in situ   should be referred for assessment by colposcopy and subsequent treatment and follow up at the Anal Dysplasia Clinic at St. Paul's Hospital where the appropriate diagnostic and therapeutic equipment is available.

Revised 26 Sept 2012

• Digital rectal examination​ to determine local involvement
• Anoscopy or sigmoidoscopy with biopsy
• CT scan of the chest, abdomen and pelvis is recommended to assess of local, regional involvement and to exclude distant metastases.
• Consider pelvic MRI and PET/CT for staging locally advanced cases.
• Female patients should have a gynecologic examination (with Pap smear) to exclude a synchronous cervical cancer, as both types of cancer are related to human papilloma virus (HPV) infection
• ​If suspected, human immunodeficiency virus (HIV) serology and CD4 count

Revised 26 Sept 2012

Wide local excision is appropriate for early stage disease.

Abdominoperineal resection (APR) is indicated in patients who have previous pelvic radiation or other contraindications to chemoradiotherapy. APR is also indicated in resistant or recurrent anal cancer.

Revised 26 Sept 2012

(per College of American Pathologists, Updated June 2012)

Specimen: specify

• Type
• Procedure
• Integrity

Tumour: specify

• Site
• Size
• Histologic type
• Histologic grade
• Microscopic tumour extension
• Margins: proximal, distal, radial, deep (for endoscopic resections)
• Treatment effect (if neo-adjuvant therapy given)
• Lymphovascular invasion
• Perineural invasion
• pTNM (Lymph nodes: number examined, number involved)

Additional pathologic findings

Revised 16 October 2012

Please refer to the American Joint Committee on Cancer (AJCC) staging guidelines or download the BCCA Staging Dia​gram and Classification Criteria (TNM).

Revised 26 Sept 2012

Stage 0: cancer is limited to mucosa without invasion of the lamina propria

• If no sphincter involvement, wide local excision with negative margins
• If sphincter is involved, primary radiation therapy with or without chemotherapy​

Stage I: T1, N0, M0

• If no sphincter involvement, wide local excision with negative margins
• If sphincter is involved, primary radiation therapy with or without chemotherapy

Stage II – Stage IIIA: T2-4, N0, M0 or T1-3, N1, M0

• Primary chemoradiotherapy (GICART, GICPART, GIFUART, GIFUPART)
• Consider treatment on a clinical trial, if available.

Stage IIIB: T4, N1, M0 or any T, N2-3, M0

• Primary chemoradiotherapy (GICART, GICPART, GIFUART, GIFUPART) followed by resection of residual disease (local resection or APR of primary site with or without inguinal lymph node dissection)
• Consider treatment on a clinical trial, if available.

Stage IV: any T, any N, M1 (Metastatic disease)

• Palliative surgical resection or bypass of obstructing or bleeding primary lesions in selected patients
• Palliative radiation therapy with or without chemotherapy
• Palliative chemotherapy may be given to help improve symptoms and quality of life, and extend survival in appropriately selected patients.
• Currently approved chemotherapeutic agents for advanced anal cancer include: 5-fluorouracil (5-FU) and cisplatin (GIFUC)
• Please refer to current treatment protocols for indications, dosing and eligibility criteria
• Consider treatment on a clinical trial, if available.
• Symptom management, best supportive care, and involvement of palliative care services as indicated by patient’s clinical status.

Recurrent disease:

• Local recurrences or persistent disease after primary chemoradiotherapy may be controlled with APR with permanent colostomy.
• If no previous chemoradiotherapy, consider radical chemoradiotherapy with or without surgery.

Revised 26 Sept 2012

Follow-up after curative treatment:

• Digital rectal examination six to eight weeks after completion of therapy
• Consider biopsy of any suspicious lesions at three months after completion of therapy, recognizing that tumours may continue to respond up to six months after radiation
• After a complete response: rectal examination, anoscopy and examination of inguinal lymph nodes every two to three months for two years and then every four to six months for three additional years
• For tumours with extensive rectal involvement and/or pelvic nodal involvement, consider using CT, MRI or PET/CT as an adjunct to clinical examination.