CANCER

What is anal cancer?

The anus

The anus is the body's opening at the lower end of the intestines. The anal canal is the tube that connects the lower part of the large intestine (rectum) to the anus and the outside of the body. As food is digested, it passes from the stomach to the small intestine. It then travels from the small intestine into the large intestine (colon). The colon absorbs water and liquid from the digested food. The waste matter that is left after going through the colon is known asfeces or stool. Feces are stored in the rectum, the final 6 inches of the digestive system. From there, they pass out of the body through the anus as a bowel movement.

The anal canal is about an inch and a half long. Its inner lining (called the mucosa) is made up of several different kinds of cells. Learning a little about these cells is helpful in understanding the kinds of cancer that develop in various parts of the anal canal. Glands and ducts (tubes leading from the glands) are found under the mucosa. These glands make mucus, which acts as a lubricating fluid.

The anal canal goes from the rectum to the anal verge (where the canal meets the outside skin at the anus). About midway down the anal canal is the dentate line, which is where most of these anal glands empty into the anus.

Cells above the anal canal (in the rectum) and in the part of the anal canal close to the rectum are shaped like tiny columns. Most cells near the middle of the anal canal and around the dentate line are shaped like cubes and are called transitional cells. This area is called the transitional zone. Below the dentate line are flat (squamous) cells. At the anal verge, the squamous cells of the lower anal canal merge with the skin just outside the anus. This skin around the anal verge (called the perianal skin or the anal margin) is also made up of squamous cells, but it also contains sweat glands and hair follicles; the lining of the lower anal canal does not. Cancers of the anal canal (above the anal verge) and cancers of the anal margin (below the anal verge) are treated very differently.

The anal canal is surrounded by a sphincter, which is a circular muscle that keeps feces from coming out until it is relaxed during a bowel movement.

Anal tumors

Many types of tumors can develop in the anus. Not all of these tumors are cancers -- some are benign (non-cancerous). There are also some growths that start off as benign but over time can develop into cancer. These are called pre-cancerous conditions. This section discusses all of these types of abnormal growths.

Benign (non-cancerous) anal tumors

Polyps: Polyps are small, bumpy, or mushroom-like growths that develop in the mucosa or just under it. There are several kinds, depending on their cause and location.

§  Inflammatory polyps arise because of inflammation from injury or infection.

§  Lymphoid polyps are caused by an overgrowth of lymph tissue (which is part of the immune system). Small nodules of lymph tissue are normally present under the anal inner lining.

§  Hypertrophied anal papillae are benign growths of connective tissue that are covered by squamous cells. They are simply an enlargement of the normal papillae, which are small folds of mucosa found at the dentate line. Hypertrophied anal papillae are also called fibroepithelial polyps.

Skin tags: Skin tags are benign growths of connective tissue that are covered by squamous cells. Skin tags are often mistaken for hemorrhoids but they are not truly hemorrhoids.

Condylomas: Condylomas (also called warts) are growths that occur just outside the anus and in the lower anal canal below the dentate line. Occasionally condylomas can be found just above the dentate line. They are caused by infection with the human papilloma virus (HPV). People who have had condylomas are more likely to develop anal cancer (see "Potentially pre-cancerous anal conditions" below and the section “What are the risk factors for anal cancer?”).

Other benign tumors: In rare cases, benign tumors can grow in other tissues of the anus. These include:

§  Adnexal tumors -- usually benign growths that start in hair follicles or sweat glands of the skin just outside of the anus. These tumors stay in the perianal skin area and do not grow into the anal region.

§  Leiomyomas -- develop from smooth muscle cells

§  Granular cell tumors -- develop from nerve cells and are composed of cells that contain lots of tiny spots (granules)

§  Hemangiomas -- start in the lining cells of blood vessels

§  Lipomas -- start from fat cells

§  Schwannomas -- develop from cells that cover nerves

Potentially pre-cancerous anal conditions

Some changes in the anal mucosa are harmless in their early stages but might later develop into a cancer. A common term for these potentially pre-cancerous conditions is dysplasia. Some warts, for example, contain areas of dysplasia that can develop into cancer.

Dysplasia occurring in the anus is also known as anal intraepithelial neoplasia (AIN) and as anal squamous intraepithelial lesions (SILs). Depending on how the cells look under the microscope, AIN (or anal SIL) can be divided into 2 groups: low-grade and high-grade. The cells in low-grade AIN resemble normal cells while the cells in high-grade AIN look much more abnormal. Low-grade AIN often goes away without treatment. It has a low chance of turning into cancer. High-grade AIN is less likely to go away without treatment. Left untreated, high-grade AIN could eventually become cancer, and so it needs to be watched closely. Some cases of high-grade AIN need to be treated.

Carcinoma in situ

Sometimes abnormal cells on the surface layer of the anus look like cancer cells but have not grown into any of the deeper layers. This condition is known as carcinoma in situ, (pronounced "in SY-too"), or CIS. Another name for this condition is Bowen's disease. Some doctors view this as the earliest form of anal cancer and others consider it the most advanced type of AIN, which is considered a pre-cancer but not a true cancer.

Invasive anal cancers

Squamous cell carcinomas: Most anal cancers in the United States are squamous cell carcinomas. These tumors come from the squamous cells that line the anal margin and most of the anal canal.

Cells of invasive squamous cell carcinomas have already spread beyond the surface to the deeper layers of the lining. Squamous cell carcinomas of the anal canal are discussed in detail in this document. Squamous cell carcinomas of the anal margin (perianal skin) are treated similarly to squamous cell carcinomas of the skin elsewhere in the body. For more information, see our document, Skin Cancer: Basal and Squamous Cell.

Cloacogenic carcinomas (also called basaloid or transitional cell carcinomas) are sometimes listed as a subclass of squamous cell cancers. They develop in the transitional zone, also called the cloaca. These cancers look slightly different under the microscope but they behave and are treated like other squamous cell carcinomas of the anal canal.

Adenocarcinomas: A small number of anal cancers are known as adenocarcinomas. These can develop in cells that line the upper part of the anus near the rectum, or in glands located under the anal mucosa that release their secretions into the anal canal. These anal adenocarcinomas, are treated the same way as rectal carcinomas. For more information, see our document, Colorectal Cancer.

Adenocarcinomas can also start in apocrine glands (a type of sweat gland of the perianal skin). Paget's disease is a type of apocrine gland carcinoma that spreads through the surface layer of the skin. Paget's disease can affect skin anywhere in the body but most often affects skin of the perianal area, vulva, or breast. This condition should not be confused with Paget's disease of the bone, which is a different disease.

Basal cell carcinomas: Basal cell carcinomas are a type of skin cancer that can develop in the perianal skin. These tumors are much more common in areas of skin that are exposed to sun, such as the face and hands, and account for only a small number of anal cancers. They are often treated with surgery to remove the cancer. For more information, see our document, Skin Cancer: Basal and Squamous Cell.

Malignant melanoma: This cancer develops from cells in the skin or anal lining that make the brown pigment called melanin. Only about 1% to 2% of anal cancers are melanomas. Melanomas are far more common on parts of the body that are exposed to sun. If melanomas are found at an early stage (before they have grown deeply into the skin or spread to lymph nodes) they can be removed with surgery and the outlook (prognosis) for long-term survival is very good. But because they are hard to see, most anal melanomas are found at a later stage. If possible, the entire tumor is removed with surgery. If all of the tumor can be removed, a cure is possible. If the melanoma has spread too far to be removed completely, other treatments may be given. For more information, see our document, Melanoma Skin Cancer.

Gastrointestinal stromal tumors: These are rare anal cancers that are much more commonly found in the stomach or small intestine. When these are found at an early stage, they are removed with surgery. If they have spread beyond the anus, they can be treated with drug therapy. For more information, see our document, Gastrointestinal Stromal Tumor (GIST).

How is anal cancer treated?

This information represents the views of the doctors and nurses serving on the American Cancer Society's Cancer Information Database Editorial Board. These views are based on their interpretation of studies published in medical journals, as well as their own professional experience.

The treatment information in this document is not official policy of the Society and is not intended as medical advice to replace the expertise and judgment of your cancer care team. It is intended to help you and your family make informed decisions, together with your doctor.

Your doctor may have reasons for suggesting a treatment plan different from these general treatment options. Don't hesitate to ask him or her questions about your treatment options.

General treatment information

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 choosing your treatment plan, you and your cancer care team will also take into account your age, the general state of your health, and your personal preferences.

The 3 main methods of treatment for anal cancer are:

§  Surgery

§  Radiation therapy

§  Chemotherapy

Often the best approach combines 2 or more of these strategies. In the past, surgery was the only treatment that could cure anal cancer, but now most anal cancers are treated with radiation and chemotherapy combined (calledchemoradiation or chemoradiotherapy). This approach often eliminates the need for surgery.

For information about some of the most common approaches used based on the extent of the disease, see the section “Treatment of anal cancer by stage.”

Your recovery is the goal of your cancer care team. If the cancer can't be cured, the goal may be to help you live as well as possible for as long as possible. This may involve treatment 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 symptoms such as pain or bleeding and improving the person's quality of life, even if it will not result in a cure.

It is important to discuss all of your treatment options, including their goals and possible side effects, with your doctors to help make the decision that best fits your needs. It’s also very important to ask questions if there is anything you’re not sure about. You can find some good questions to ask in the section, “What should you ask your doctor about anal cancer?”

Surgery for anal cancer

Surgery is no longer the standard option for most people with anal cancer. In people who do need surgery, the type of operation depends on the type and location of the tumor.

Local resection

Local resection is used most commonly to treat cancers of the anal margin. A local resection is an operation that removes only the tumor, plus a small margin of the normal tissue around the tumor. Local resection can be 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). This allows the bowels to move (and be controlled) normally after the surgery. Many small tumors of the anal margin can be treated with local resection.

Abdominoperineal resection

Abdominoperineal resection (APR) is a more extensive operation. In this surgery, the surgeon makes incisions in the abdomen and around the anus to remove the anus and the rectum. The surgeon may also take out some of the lymph nodes in both of the groins during this operation, although this step (called a lymph node dissection) can also be done later.

The anus (and the anal sphincter) is removed, so a new opening needs to be made to let stool leave the body. This opening is called a colostomy, or an ostomy. It is a permanent opening in the abdomen where the end of the colon is attached so that feces can exit the body. A bag to collect the feces is attached to the body over the opening. For more information on colostomies, refer to our document, Colostomy: A Guide.

An APR was commonly done in the past for cancers of the anal canal, but it can almost always be avoided by treating the patient with combined radiation therapy and chemotherapy instead. It is now more often used as an option if other treatments don't get rid of the cancer or if the cancer comes back after treatment.

For more information about surgery for cancer treatment, see Understanding Cancer Surgery: A Guide for Patients and Families.

Radiation therapy for anal cancer

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. There are 2 major forms of radiation therapy: external beam and brachytherapy.

External-beam radiation therapy (EBRT)

The most common way to deliver radiation for anal cancer is to use a focused beam of radiation from a machine outside the body. This is known as external-beam radiation therapy. Treatments are usually given 5 days a week for a period of 5 weeks or so.

Radiation can harm nearby healthy tissue along with the cancer cells. 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. Sometimes, doctors use some newer techniques that let doctors give higher doses of radiation to the cancer while reducing the radiation exposure to nearby healthy tissues.

Three-dimensional conformal radiation therapy (3D-CRT) uses special computers to precisely map the location of your cancer. Radiation beams are then shaped and aimed at the tumor from several directions, which makes it less likely to damage normal tissues. You will most likely be fitted with a plastic mold resembling a body cast to keep you in the same position each day so that the radiation can be aimed more accurately. This method seems to be at least as effective as standard radiation therapy for anal cancer and may have lower side effects.

Intensity modulated radiation therapy (IMRT) is an advanced form of 3D therapy. It uses a computer-driven machine that actually moves around the patient as it delivers radiation. In addition to shaping the beams and aiming them at the cancer from several angles, the intensity (strength) of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. This lets doctors deliver an even higher dose to the cancer areas. It is available at many major hospitals and cancer centers.

Side effects of radiation therapy vary based on the area of the body treated and the dose of radiation given. Some common short-term side effects include:

§  Skin changes (like a sunburn)

§  Temporary anal irritation and pain

§  Discomfort during bowel movements

§  Fatigue

§  Nausea

§  Diarrhea

In women, radiation may irritate the vagina. This can lead to discomfort and drainage (a discharge).

These side effects often improve after radiation stops.

Long-term side effects can also occur. Damage to anal tissue by radiation may cause scar tissue to form. This scar tissue can sometimes keep the anal sphincter from working as it should. Radiation to the pelvis can weaken the bones, increasing the risk of fractures of the pelvis or hip. Radiation can also damage blood vessels that nourish the lining of the rectum and lead to chronic radiation proctitis (inflammation of the lining of the rectum). This can cause rectal bleeding and pain.

Radiation can also cause infertility in both women and men. In women, it can also lead to vaginal dryness and even cause scar tissue to form in the vagina The scar tissue can make the vagina shorter or more narrow (called vaginal stenosis), which can make sex (vaginal intercourse) painful. A woman can help prevent this problem by stretching the walls of her vagina several times a week. This can be done by using a vaginal dilator (a plastic or rubber tube used to stretch out the vagina).

The radiation field may include some of the pelvis in order to treat lymph nodes in the groin, because the cancer will often spread to these lymph nodes. This can lead to problems with abnormal swelling in the legs, called lymphedema. Radiation to groin lymph nodes isn’t always needed. People with small tumors may not need radiation therapy to the groin lymph nodes because the cancer is less likely to spread. If the doctors think the cancer has spread to the lymph nodes, because they are enlarged, then they will either treat them with radiation therapy or surgery.

Internal radiation (brachytherapy)

Another method of delivering radiation is to place small sources of radioactive materials in or near the tumor. This method, internal radiation, concentrates the radiation in the area of the cancer. It is also called brachytherapy,interstitial radiation, and intracavitary radiation. This may involve implanting permanent radioactive pellets, or "seeds," which release their dose slowly over time, or other techniques where the radioactive substance is in the body for only a brief period. Internal radiation can be more convenient because it usually requires only one or a few sessions, but it may require some type of surgery.

Brachytherapy is used much less often than external-beam radiation therapy to treat anal cancer. When it is used, it is usually given along with external radiation. The possible side effects are often similar to those seen with external radiation.

For more information about radiation, see Understanding Radiation Therapy: A Guide for Patients and Families.

Chemotherapy for anal cancer

Chemotherapy (chemo) uses drugs to treat cancer. Some drugs can be swallowed in pill form, while others need to be injected into a vein or muscle. The drugs enter the bloodstream to reach and destroy the cancer cells throughout the body. This makes chemo a systemic or "whole body" treatment.

Some drugs kill the cancer cells directly. Chemo can also make it easier for radiation to kill the cells. In anal cancer, chemo combined with radiation therapy can often cure the cancer without the need for surgery. Often, chemo is given alone at first, followed by chemo with radiation (chemoradiation). Chemo may also be given after chemoradiation, to help shrink the tumor further. Chemotherapy often uses 2 or more drugs because one drug can boost the effect of the other. The main combination used to treat anal cancer is 5-fluorouracil (5-FU) and mitomycin. The combination of 5-FU and cisplatin is also used fairly often.

Chemotherapy drugs can reach just about any place inside the body. Doctors sometimes give chemo after surgery has removed the cancer. The chemo is meant to destroy any cancer cells that were left behind because they were too small to see. This is called adjuvant therapy. It is meant to lower the chance of the cancer coming back. Chemo may also be used to treat anal cancer that has spread to distant sites, such as the liver or lungs.

Chemotherapy drugs can also damage some normal cells, which can cause side effects. This can depend on the specific drugs, the amount taken, and the length of treatment. Common temporary side effects might include:

§  Nausea and vomiting

§  Loss of appetite

§  Hair loss

§  Diarrhea

§  Mouth sores

§  Low blood counts

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)

If you get chemo, it is important to tell your doctor or nurse about any side effects as soon as you notice them. Your cancer care team can help you deal with them. For example, anti-nausea drugs can help control nausea and vomiting. Sometimes changing the treatment dosage or how you take your medicines can reduce side effects. Most side effects will stop when your course of treatment ends.

For more information about chemotherapy, see Understanding Chemotherapy: A Guide for Patients and Families.

Clinical trials for anal cancer

You may have had to make a lot of decisions since you've been told you have cancer. One of the most important decisions you will make is choosing which treatment is best for you. You may have heard about clinical trials being done for your type of cancer. Or maybe someone on your health care team has mentioned a clinical trial to you.

Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures.

If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or on our Web site at www.cancer.org/clinicaltrials. 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 (1-800-422-6237) or by visiting the NCI clinical trials Web site at http://www.cancer.gov.

There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.

Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.

You can get a lot more information on clinical trials in our document called Clinical Trials: What You Need to Know.You can read it on our Web site or call our toll-free number (1-800-227-2345) and have it sent to you.

Complementary and alternative therapies for anal cancer

When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.

What exactly are complementary and alternative therapies?

Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care.Alternative treatments are used instead of a doctor's medical treatment.

Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not to be helpful, and a few have even been found harmful.

Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.

Finding out more

It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.

As you consider your options, here are 3 important steps you can take:

§  Look for "red flags" that suggest fraud. Does the method promise to cure all or most cancers? Are you told not to have regular medical treatments? Is the treatment a "secret" that requires you to visit certain providers or travel to another country?

§  Talk to your doctor or nurse about any method you are thinking about using.

§  Contact us at 1-800-227-2345 to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at.

The choice is yours

Decisions about how to treat or manage your cancer are always yours to make. If you want to use a non-standard treatment, learn all you can about the method and talk to your doctor about it. With good information and the support of your health care team, you may be able to safely use the methods that can help you while avoiding those that could be harmful.

Treatment of anal cancer 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 sums up the options for anal cancer treatment according to the stage of disease. Anal tumors affecting the anal margin or the perianal skin (and not the anal canal) are considered to be skin cancers. Information about their treatment can be found in our document, Skin Cancer: Basal and Squamous Cell. These cancers are not treated in the same way as anal canal cancers.

Stage 0

Stage 0 tumors can often be completely removed by surgery (local resection). Radiation therapy and chemotherapy (chemo) are rarely needed.

Stages I and II

Local resection can be used to remove small tumors (usually less than 1 centimeter or ½ inch) that do not involve the sphincter. In some cases, resection may be followed with chemo and radiation therapy.

The standard treatment for anal cancers that can't be removed without harming the anal sphincter is radiation therapy combined with chemo (chemoradiation). Chemoradiation is as good as (or even better than) removing the cancer as part of a radical surgery called abdominoperineal resection (APR). APR involves removing the anus and rectum and requires a colostomy to be formed. Chemoradiation can work just as well and avoid the need for a colostomy.

Using radiation therapy combined with chemo has been shown to be better than using radiation alone in the treatment of anal cancer. The 2 treatments are given over the same time period. The chemo usually consists of 5-FU with mitomycin C. The mitomycin is given as a short intravenous (IV) injection, usually at the start of radiation treatment and then again near the end, at around 4 to 6 weeks. The 5-FU is often given by a long IV infusion over 4 to 5 days and repeated in 4 to 6 weeks. In some cases, your doctor may suggest internal radiation along with the external beam radiation.

If the cancer has not completely gone away after radiation and chemo have been completed, more treatment may be needed. But it is important to know that it may take several weeks or even months after completing radiation therapy to see the full effects of treatment on the cancer. Doctors may observe any possible remaining cancer for up to 6 months as it may continue to shrink and even go away without further treatment. Sometimes additional chemo (with or without extra radiation) may be given to try to shrink any cancer remaining. Any cancer that is left will then be removed with surgery.

Stages IIIA and IIIB

In most cases, the first treatment will be combined radiation therapy and chemo (as is used in stage I and II disease).

If the tumor shrinks but some cancer remains after the chemoradiation, it may be watched closely for up to 6 months to see if it gets larger. If it does, more treatment is needed. Some patients are given more chemo. The drugs most often used are 5-FU plus cisplatin. Sometimes more radiation is given as well (this is called a radiation boost). Another option is to remove the cancer with surgery. This is most often an APR, but sometimes only a local resection is needed. If the cancer has spread to local lymph nodes, these may be removed with surgery or treated with radiation therapy.

Some doctors treat patients with larger tumors with chemo prior to starting chemoradiation. The chemo often consists of the drugs 5-FU and cisplatin, which may be given for a few cycles to shrink the cancer before starting chemoradiation.

Stage IIIB anal cancer can be hard to treat, so patients with this stage might be helped by taking part in a clinical trial.

Stage IV

In this stage, the cancer has spread to distant organs or tissues. Most often, anal cancer first spreads to the lungs, but it can spread anywhere, including the liver, brain, and bones.

Stage IV anal cancer is not thought to be curable. Treatment is aimed at controlling the disease and relieving symptoms. To do this, doctors may recommend surgery, radiation therapy, chemo, or some combination of these methods. People with this stage of anal cancer might also want to think about taking part in a clinical trial.

Anal melanoma

Melanoma doesn't respond well to chemotherapy or radiation, so surgery to remove the cancer is the main treatment when possible. Early stage anal melanomas are treated with surgery to remove the tumor and a rim of surrounding normal tissue (local excision). If the tumor is large or has grown into deeper tissues (such as the sphincter muscle) a bigger operation, such as an abdominoperineal resection may be needed. If the melanoma has spread to other organs, it is treated like skin melanoma that has spread. For more information about the treatment of advanced melanoma, see our document, Melanoma Skin Cancer.

Recurrent anal cancer

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs or bone). If your cancer returns in the anus or nearby lymph nodes after treatment, your treatment depends on what treatment you had the first time. For example, if you had surgery alone, you may receive radiation therapy and chemo. If you first had chemoradiation, then you can be treated with surgery and/or chemo. Treating recurrent anal cancer often requires an abdominoperineal resection (APR). Again, clinical trials may prove to be valuable for people with recurrent anal cancer.

In some people, the cancer will come back in distant sites or organs in the body. The most common sites are the liver and lungs. Another common site is the lung. The main treatment for this is chemo, but in rare cases surgery to remove the cancer might be an option. The typical chemo drugs used are 5-FU and cisplatin. Chemo might not be curative, but it can help to reduce any symptoms from the disease.

HIV-infected patients

Most people with HIV infection can be given the same treatment as others with anal cancer, and they can have a good outcome. Patients who have advanced HIV disease and weakened immune systems may need to have less intensive chemotherapy.