NOTE

🌱 created from: anal cancer

management_nonmetastatic_disease_of_anal_cancer

• 1st line:
  • Nigro Protocol in 1970s established chemoRT as standard compared to APR; chemoRT is superior to RT (JCO 1997;15:2040)
  • Chemo:
    • Capecitabine + MMC or infusional 5-FU + MMC.
    • Infusional 5-FU w/ bolus MMC as above (JCO 1996;14:2527).
    • Capecitabine, Mon–Fri on days of RT, also widely used based on retrospective data (Br J Cancer 2014;111:1726) & other small studies. 5-FU + cis may be considered if MMC contraindicated
• Radiation:
  • Dosing of ≤59 Gy is sufficient,
  • w/ no additional benefit to high-dose RT or induction chemo (ACCORD-03, JCO 2009;27:4033);
  • Rx breaks should be minimized, but may be necessary due to
    • acute anoproctitis,
    • perineal dermatitis, or cytopenia.
  • Chronic adverse effects may include anal ulcers, stenosis, & necrosis
• IMRT:
  • ↓ Tox & effective (J Radiat Oncol 2012;1:165); IMRT is acceptable only at experienced centers (must avoid “marginal-miss” ↓ in local control)
• 3-fold ↑ pelvic fracture risk in women s/p RT
• Women should be considered for vaginal dilator to reduce vaginal stenosis
• Post-Rx follow-up:
  • DRE 8–12 weeks after Rx.
  • If regression w/o CR,
    • repeat DRE in 4 wks.
  • Pts w/ persistent dz may be followed for up to 6 mos, provided there is no progression.
  • If CR,
    • repeat DRE, inguinal exam q3–6mos for 5 y, anoscopy every 6–12 mos for 3 y, annual CT C/A/P for 3 y
• HIV pts w/ adequate T4 counts & undetectable viral load should be treated w/ same protocols.
  • Data suggests similar ORR & OS but ↑ skin tox & local relapse