Anal Squamous Cell Cancers
Publication Date: July 1, 2018
Last Updated: March 14, 2022
Recommendations
Premalignant Neoplasms of the Anal Canal and Perianal Region
Patients at increased risk for anal squamous neoplasms should be identified by history, physical examination, and laboratory testing, noting that the risk is higher in HIV-positive individuals, men who have sex with men (MSM), and women with a history of cervical dysplasia. (1B)
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Standardized nomenclature with a 2-tiered system should be used. Biomarkers, including p16, should be used selectively to clarify equivocal high-grade lesions. (1C)
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Individuals with anal dysplasia should be followed at regular intervals with a history, physical examination, and a discussion of screening options. (2B)
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Screening with anal cytology (or anal Papanicolaou (Pap) tests) may be considered in high-risk populations as part of a comprehensive screening program, but the sensitivity and specificity of the test do not support its use for universal screening. (2B)
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HPV testing may be used as an adjunct to screening for anal cancer. (2B)
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HRA may be considered as a screening option for patients at high risk for cancer when performed by clinicians with appropriate training in the procedure. (2B)
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Topical imiquimod, fluorouracil, trichloroacetic acid and cidofovir with close long-term follow-up are each options for the treatment of LSIL or HSIL. (2B)
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Ablative treatments with conventional anoscopy or HRA are appropriate therapies for HSILs. (2B)
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- Vaccination against HPV in men and women under age 26 years for primary prevention is typically recommended.
- Vaccination of individuals with anal dysplasia for secondary prevention of dysplasia and cancer is not recommended.
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Patients who have been treated for anal dysplasia may be observed without regular cytology, HPV testing, or HRA; however, treatment of visible or palpable disease should be offered. (2C)
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MALIGNANT NEOPLASMS OF THE ANAL CANAL AND PERIANAL REGION
A disease-specific history and physical examination should be performed, emphasizing symptoms, risk factors, and signs of advanced disease. (1C)
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Endoscopic and radiologic evaluation should be performed to help determine tumor extension and assess for metastatic disease. (1C)
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2-[18F] Fluoro-2-deoxy-d-glucose positron emission tomography (PET)/CT may be considered as an adjunct radiologic study in the staging of anal SCC, although it does not replace CT scanning for clinical staging. (1C)
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The primary treatment for all squamous cell cancers of the anal canal, and for most perianal squamous cell cancers, is CRT. (1A)
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Multimodal therapy involving chemotherapy combined with radiotherapy provides superior locoregional control compared with treatment with radiotherapy alone. (1A)
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The combination of 5-FU and MMC in conjunction with radiotherapy remains as first-line multimodal therapy for the treatment of squamous cancers of the anus. (1A)
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No oncologic benefit exists for providing radiation doses >59 Gy. (1B)
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Missed treatments should be avoided, because they are strongly associated with inferior disease control. (1B)
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Surveillance
Disease surveillance should typically start 8 to 12 weeks from the completion of CRT. (1B)
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Surveillance involving digital rectal examination, anoscopy, and imaging should be continued for 5 years after completion of CRT. (1B)
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Treatment of Recurrent or Persistent Disease
APR is effective salvage therapy for persistent or recurrent disease. (1B)
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Patients with HIV or AIDS who present with anal cancer as the first manifestation of their immunosuppression, and who are not medically deconditioned, can be safely treated according to the same regimens as immunocompetent patients. (1C)
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Perianal squamous cancers, which are well-differentiated, node-negative, T1 lesions, can be adequately treated with wide-local excision with 1-cm margins of resection. All other anal margin cancers are preferentially treated with CRT. (1C)
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Treatment of Distant Disease
Systemic chemotherapy should be considered for patients with distant metastatic disease. Metastasectomy, radiation, and radiofrequency ablation can be considered in selected cases. (2C)
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CRT, chemoradiotherapy; HPV, human papillomavirus; HRA, high-resolution anoscopy; HSIL, high-grade squamous intraepithelial lesions; LSIL, low-grade squamous intraepithelial lesions; PET/CT, 2-[18F] Fluoro-2-deoxy-d-glucose positron emission tomography; SCC, squamous cell cancer
Recommendation Grading
Overview
Title
Anal Squamous Cell Cancers
Authoring Organization
American Society of Colon and Rectal Surgeons
Publication Month/Year
July 1, 2018
Last Updated Month/Year
January 22, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D002294 - Carcinoma, Squamous Cell
Keywords
anal cancer, anal squamous cancer, anal intraepithelial neoplasia
Source Citation
Stewart, David B. M.D.1; Gaertner, Wolfgang B. M.D., M.Sc.2; Glasgow, Sean C. M.D.3; Herzig, Daniel O. M.D.4; Feingold, Daniel M.D.5; Steele, Scott R. M.D.5; Prepared on Behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Anal Squamous Cell Cancers (Revised 2018), Diseases of the Colon & Rectum: July 2018 - Volume 61 - Issue 7 - p 755-774 doi: 10.1097/DCR.0000000000001114
Supplemental Methodology Resources
Methodology
Number of Source Documents
167
Literature Search Start Date
June 1, 2015
Literature Search End Date
January 1, 2018