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Anal Cancer and Kerry’s Story: Beware of HPV
THE STORY OF KERRY
Kerry was a 42-year-old female executive who was in good health. She was married but had no children and had never been pregnant. She was a non-smoker with no past medical history and no family history of cancer. Specifically, Kerry had no history of sexually transmitted diseases and was HIV negative. When she noticed blood on the toilet paper after her bowel movements, she initially thought the problem was hemorrhoids. However, after two weeks, the bleeding increased and was accompanied by pain and itching around the anus. She went to her primary care physician, whose examination revealed a 2 x 2-inch mass at the sphincter of the anus. Her doctor did not feel any abnormal lymph nodes in her groin. He referred her to a colon surgeon who performed a colonoscopy. This test confirmed the mass her primary doctor had seen, but no other lesions. The biopsy revealed a squamous cell carcinoma, cancer of the anus.
After her diagnosis, Kerry’s surgeon sent her for a PET/CT scan which revealed an abnormality only in the rectal mass. There was no distant activity to indicate metastatic (distant, incurable) spread of her cancer. Her surgeon referred her to a radiation oncologist and a medical oncologist. They recommended radiation therapy (RT) and chemotherapy given together (concurrent chemotherapy) which she underwent over 6 weeks. Kerry was treated with modulated radiation therapy (IMRT) to minimize the RT dose to critical organs, including her small bowel and bladder, while treating possible tiny cancer cells in the lymph nodes in her pelvis and groin and the rectal tumor . He received concurrent mitomycin and intravenous fluorourea chemotherapy as an outpatient. Kerry had expected side effects of the treatment, including severe irritation and redness of the skin in the groin and anus, but did not need a break during IMRT. She had significant fatigue that kept her off work during most of her chemotherapy. She had some loose bowels which were well controlled after adjusting her diet. Near the end of her treatment, there was no evidence of a tumor. He recovered from the side effects of the treatment for about six weeks. Kerry has been seeing one of her cancer doctors every three to six months for the past five years and remains cancer free!
Although it is one of the less common cancers of the gastrointestinal tract, there are still about 5000 cases of rectal cancer diagnosed in the US each year. There are more women than men who are diagnosed. The average age at diagnosis is about 60 years, but it can occur in patients in their 30s and 40s. If the disease is localized, as it is in 50% of patients, then the cure rate is about 80%.
RISKS & CAUSES
The majority of patients diagnosed with rectal cancer do not have a clearly defined risk factor. However, factors that increase the risk of developing anal cancer are related to the risk of human papillomavirus (HPV) infection. This virus is the same type that causes genital warts. Certain strains of HPV are associated with a high risk of developing anal cancer, as well as cervical cancer and some types of throat cancer. Activities that put people at risk for HPV, such as receptive anal intercourse, also put them at risk for later developing anal cancer.
SIGNS & SYMPTOMS
Patients often present to their doctors with complaints of rectal pain or bleeding. Many patients ignore or downplay the symptoms, often initially attributing them to hemorrhoids. While most people who have these symptoms do not have anal cancer, persistent pain or bleeding should always seek medical attention. Less often, patients complain of itching or a painless mass in the groin. A lump may develop in the groin as a result of rectal cancer spreading to the lymph nodes and causing them to enlarge.
Rectal cancer is usually diagnosed with a biopsy of the rectal mass or area of the ulcer. Generally, this procedure is performed by a specialist gastroenterologist or surgeon. These doctors can directly examine the anus and rectum with a proctoscopy (or the entire colon with a colonoscopy) with special instruments after administering medications to minimize discomfort. Biopsies are performed during these procedures, after sedation and/or a numbing drug injection. Most rectal cancers (80%) are squamous cell carcinomas. A thorough evaluation of a person suspected of rectal cancer should also include an examination of the pelvis, particularly both groins. If the lymph nodes are enlarged, then a biopsy may also be done. Many enlarged lymph nodes are only inflamed, with no evidence of cancer. Blood tests that may be ordered include a complete blood count, kidney function tests, and possibly an HIV test, depending on the patients’ risk factors for the virus.
The American Joint Committee on Cancer (AJCC) TNM staging system is used to determine whether rectal cancer is localized (early stage) or has spread to other sites (advanced or late stage). Early-stage disease is limited to the anus, while advanced disease refers to cancers that have invaded nearby organs or lymph nodes in the pelvis or groin. Imaging studies should include abdominal and pelvic CT and chest X-ray at a minimum. Staging may also include a PET/CT scan. This imaging test allows the radiologist as well as the treating cancer specialists to see if rectal cancer has spread to lymph nodes in the groin or pelvis, or if it has metastasized to other parts of the body, such as the liver or lungs.
Standard treatment for rectal cancer does not involve surgery, which comes as a surprise and a relief to many patients. Since most rectal cancers invade the sphincter that controls bowel movement, surgery to remove such a cancer would require removing the sphincter and creating a colostomy. Therefore, surgery is generally avoided in favor of a treatment that will keep the anal sphincter intact. An exception would be very early cancers of the anal margin, in the skin outside the anus.
Concomitant chemotherapy is the standard treatment for the majority of rectal cancer patients in order to achieve the best chance of cure with sphincter preservation. RT given over approximately 6 weeks with concomitant intravenous fluorouracil (5FU) and mitomycin-C chemotherapy (MMC) gives patients the best chance for cure. RT is delivered in daily fractions using either 3D conformal RT or IMRT. The latter technique can be used to minimize the amount of normal gut and/or genitalia receiving a full dose of RT (and thus minimize side effects).
The main side effects that are possible during RT to the anus and pelvis include a skin reaction that can be severe around the anus and skin folds in the groin, as well as bowel irritation and diarrhea. Most patients will resolve these acute symptoms within 1-2 months after completing treatment. Extremely rare (<1%) but serious side effects include bowel obstruction or fistula (a hole between the anus and the bladder or urethra). 5FU can also cause intestinal irritation, diarrhea, mouth or lip irritation, poor appetite, and fatigue. Rarely, discoloration of the skin or nails or severe peeling of the hands and feet (hand-foot syndrome) or other significant side effects may occur. In rare cases, heart problems, including a heart attack, may occur. MMC can cause low blood counts, mouth sores, poor appetite, and fatigue. Nausea, vomiting and urinary irritation may also occur. Rarely, life-threatening lung or kidney damage can occur.
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