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anal-cancer

Anal Cancer

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What is Anal Cancer?

The anus is part of the gastrointestinal tract. It is the opening at the end of the large intestine, below the rectum, where bowel movements leave the body. Anal cancer begins when normal cells in or on the anus change and grow uncontrollably, forming a mass called a tumor. A tumor of the anus can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other areas of the body).

At first, the changes in a cell are abnormal, not cancerous. Researchers believe, however, that some of these abnormal changes are the first step in a series of slow changes that can lead to cancer. Some of the abnormal cells go away without treatment, but others can become cancerous. This phase of the disease is called dysplasia (an abnormal growth of cells). Dysplasia in the anus is called anal intraepithelial neoplasia (AIN) or anal squamous intraepithelial lesions (SILs). Growths—such as polyps or warts—that are not cancerous can also occur in or around the anus; some may become cancerous over time. In some cases, the precancerous tissue needs to be removed to keep cancer from developing.

The anus is made up of different types of cells, and each type can become cancerous. There are several different types of anal cancer based on the type of cell where the cancer began:

Squamous cell carcinoma is the most common type of anal cancer. This cancer begins in the outer lining of the anal canal.

Cloacogenic carcinoma accounts for about one-quarter of all anal cancers. This type of cancer arises between the outer part of the anus and the lower part of the rectum. Cloacogenic cell cancer likely starts from cells that are similar to squamous cell cancer, and it is treated similarly.

Adenocarcinoma arises from the glands that make mucous located under the anal lining.

Basal cell carcinoma is a type of skin cancer that can appear in the perianal (around the anus) skin.

Melanoma begins in cells that produce pigment (color), found in the skin or anal lining.

Symptoms & Signs

People with anal cancer may experience the following symptoms or signs. Sometimes, people with anal cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom or sign on this list, please talk with your doctor.

Bleeding from the anal area

Pain or pressure in the anal area

Itching or discharge from the anus

A lump or swelling near the anus

A change in bowel habits or change in the diameter of the stool

Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you've been experiencing the symptom(s) and how often.

If cancer is diagnosed, relieving symptoms and side effects remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

Risk Factors and Prevention

A risk factor is anything that increases a person's chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a person's risk of developing anal cancer:

Human papillomavirus (HPV) infection. Research indicates that infection with this virus is a risk factor for anal cancer. HPV is most commonly passed from person to person during sexual activity. There are different types, or strains, of HPV, and some strains are more strongly associated with certain types of cancer. HPV vaccines protect against certain strains of the virus.

Age. Most people diagnosed with anal cancer are between age 50 and 80.

Frequent anal irritation. Frequent anal redness, swelling, and soreness may increase the risk of developing anal cancer.

Anal fistula. An anal fistula is an abnormal tunnel between the anal canal and the outer skin of the anus that often drains pus or liquid, which can soil or stain clothing. An anal fistula may irritate the outer tissues or cause discomfort. An anal fistula may increase the risk of developing anal cancer.

Cigarette smoking. Cigarettes can cause harm throughout the body, because chemicals from cigarettes can enter the bloodstream and affect nearly every organ and tissue in the body. Smokers are about eight times more likely to develop anal cancer than nonsmokers.

Lowered immunity. People with diseases or conditions affecting the immune system—such as HIV or organ transplantation—and people who take immunosuppressive drugs that make the immune system less able to fight disease are more likely to develop anal cancer.

Prevention

Even though some people who have no risk factors develop anal cancer, there are ways to prevent or reduce your risk of developing anal cancer.

Talk with your doctor about HPV vaccination. In 2010, the U.S. Food and Drug Administration (FDA) approved the HPV vaccine Gardasil for prevention of anal cancer in females and males ages nine to 26. 

Avoid anal sexual intercourse, which carries an increased risk of HPV and HIV infection.

Limit the number of sex partners, because having many partners increases the risk of HPV and HIV infection.

Use a condom. However, even though condoms can protect against HIV, they cannot fully protect against HPV.

Stop smoking. 

Anal cancer screening. Cancer screening is done to find cancer as early as possible in people who don't yet have any signs of the disease. Anal cytology is a test being developed that doctors can use for people who don't have symptoms of anal cancer but do have a high risk of contracting a sexually transmitted disease (STD), such as HPV and HIV. The test is similar to a Pap test, which looks for cervical cancer. The doctor can swab the anal lining and look at the cells on the swab under a microscope to find early cellular changes that might lead to cancer or may diagnose cancer from this swab. Some doctors are advocating the routine use of this test for men who have HIV and who have sex with men and for other people who are at high risk for developing anal cancer.

Diagnosis

Doctors use many tests to diagnose cancer and find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:

Age and medical condition

Type of cancer suspected

Severity of symptoms

Previous test results

In addition to a physical examination, the following tests may be used to diagnose anal cancer:

Digital rectal examination (DRE). During this test, the doctor inserts a gloved finger into the anus to feel for lumps or abnormalities. General cancer guidelines suggest men have a DRE annually after the age of 50 and women have one during routine pelvic examinations. If you are at higher risk for developing anal cancer, your doctor may perform a DRE more often.

Anoscopy. If the doctor feels a suspicious area during a DRE, this endoscopic test may be performed to see the abnormality. An anoscopy allows the doctor to see inside the body with a thin, lighted, flexible tube called an anoscope. Similarly, a proctoscope can be used to view the rectum in a procedure called a proctoscopy. The person may be sedated as the tube is inserted into the anus and/or rectum.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed during the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). The type of biopsy performed will depend on the location of the cancer. For instance, an excisional biopsy can remove the entire lump if the lump is small and does not extend into other tissues. Lymph nodes may also be removed and examined in a biopsy.

Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. In an anal ultrasound, an ultrasound wand is inserted into the anus to obtain the pictures.

X-ray. An x-ray is way to create a picture of the structures inside of the body using a small amount of radiation.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient's vein to provide better detail.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient's vein to create a clearer picture.

Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient's body. This substance is absorbed mainly by organs and tissues that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

Stages

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancers.

                                  

One tool that doctors use to describe the stage is the TNM system. This system judges three factors: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

How large is the primary tumor, and where is it located? (Tumor, T)

Has the tumor spread to the lymph nodes? (Node, N)

Has the cancer metastasized to other parts of the body? (Metastasis, M)

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below:

TX: The primary tumor cannot be evaluated.

T0: There is no tumor.

Tis: Carcinoma in situ (early cancer that has not spread to other tissue) is present.

T1: The tumor is no larger than 2 centimeters (cm).

T2: The tumor is larger than 2 cm but not larger than 5 cm.

T3: The tumor is larger than 5 cm.

T4: The tumor has invaded other organs, such as the urethra, bladder, or a woman's vagina.

Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the anus are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: Regional lymph nodes cannot be evaluated.

N0 (N plus zero): There is no regional lymph node metastasis.

N1: Cancer had spread to the perirectal (around the rectum) lymph nodes.

N2: Cancer has spread to the internal iliac (pelvic) and/or the inguinal (groin) lymph nodes on the same side of the body.

N3: Cancer had spread to the perirectal and inguinal lymph nodes and/or the internal iliac and/or inguinal lymph nodes on both sides of the body.

Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: Distant metastasis cannot be evaluated.

M0 (M plus zero): There is no distant metastasis.

M1: There is metastasis to other parts of the body.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications.

Stage 0: Abnormal cells are in the first layer of the lining of the anus only. The abnormal cells may become cancer. This stage is also called carcinoma in situ (Tis, N0, M0).

Stage I: The tumor is no larger than 2 cm and has not spread to the lymph nodes or other parts of the body (T1, N0, M0).

Stage II: The tumor is larger than 2 cm and has not spread to the lymph nodes or other parts of the body (T2 or T3, N0, M0).

Stage IIIA: The tumor may be any size and has spread to either the nearby lymph nodes or to organs, such as the urethra, bladder, or a woman's vagina (T1 or T2 or T3, N1, M0; or T4, N0, M0).

Stage IIIB: The tumor has invaded other nearby organs, but lymph node spread is limited to the area around the rectum; there is no distant spread. Or, the tumor may be of any size; lymph node spread can be local or distant, but there is no disease spread to distant organs (T4, N1, M0; or any T, N2 or N3, M0).

Stage IV: The tumor may be any size and has spread to the lymph nodes and to distant parts of the body (any T, any N, M1).

Recurrent: Recurrent cancer is cancer that comes back after treatment. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

Grading

Histologic grade (G). In addition to the TNM system, doctors may also assign a histologic grade to the cancer. Histologic grade indicates how closely the cancer cells resemble normal tissue under a microscope. In general, the more differentiated the anal cancer tissue, the better the prognosis. A tumor's grade is described using the letter “G” and a number.

GX: The tumor grade cannot be identified.

G1: The cells look more like normal tissue cells (well differentiated).

G2: The cells are somewhat different from normal cells (moderately differentiated). G3: The cells do not look like normal cells (poorly differentiated).

G4: The cells barely resemble normal cells (undifferentiated).

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