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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Localised anal cancer is squamous cell cancer of the anal canal that has not spread beyond the pelvis and groin, one of the few cancers cured mainly by chemotherapy and radiotherapy together rather than by surgery. Fluorouracil with mitomycin during radiotherapy has been standard since the ACT II trial; surgery to remove the anus is kept for the minority whose cancer persists or returns.
Anal squamous cell carcinoma confined to the anal canal, the pelvic nodes and the groin nodes is treated to keep the anus. Before 1974 the standard was abdominoperineal resection with a permanent colostomy; Norman Nigro then showed that fluorouracil and mitomycin given during radiotherapy made most tumours disappear, and the UKCCCR ACT I and EORTC trials in the 1990s proved chemoradiotherapy beat radiotherapy alone. ACT II (Lancet Oncology 2013), the largest anal cancer trial with 940 patients, found that cisplatin was no better than mitomycin alongside fluorouracil and radiotherapy, that maintenance chemotherapy added nothing, and that tumours keep regressing for months, so response should be judged at 26 weeks rather than 11 before anyone is sent for surgery. RTOG 98-11 had likewise found induction cisplatin inferior to mitomycin-based treatment.
Today's treatment is intensity-modulated radiotherapy with concurrent fluorouracil (or capecitabine) and mitomycin, with the dose scaled to stage; very small well-differentiated perianal tumours can be excised alone. Salvage abdominoperineal resection is offered when biopsy confirms persistent or recurrent disease. HPV or p16 status is favourable and HIV is no longer a bar to full-dose treatment when CD4 counts are adequate. The UK PLATO programme (ACT3, ACT4 and ACT5) is testing lower doses for early tumours and higher doses for locally advanced ones, EA2165 tests nivolumab after chemoradiotherapy for high-risk disease, and circulating HPV DNA is being studied as a way to tell early who is cured.
| Setting | Approach | Guideline |
|---|---|---|
| Staging | Pelvic MRI, PET-CT, examination of the groins, HIV testing and HPV or p16 status; biopsy of suspicious groin nodes. | not mapped |
| Stage I to III | Intensity-modulated radiotherapy with concurrent fluorouracil (or capecitabine) and mitomycin, dose scaled to stage (ACT II, RTOG 98-11); small perianal tumours may be excised alone. | not mapped |
| Response assessment | Clinical assessment at 26 weeks; biopsy only if disease persists or grows, because regression continues for months (ACT II). | not mapped |
| Persistent or recurrent disease | Salvage abdominoperineal resection with permanent colostomy; inguinal node dissection or radiotherapy for isolated groin recurrence. | not mapped |
| High-risk locally advanced disease | Trials of dose escalation (PLATO ACT5) and adjuvant nivolumab (EA2165); standard care remains chemoradiotherapy alone. | not mapped |