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Anal Cancer and Kerry's Story: Beware of HPV

KERRY's STORY
Kerry is a 42-year-old female executive in excellent health. He was married but had no children and was never pregnant. He is not a smoker with no past medical history and no family cancer history. In particular, Kerry has no history of sexually transmitted diseases and she is HIV negative. When he saw blood on the toilet paper after the bowel movement, he initially thought the problem was due to hemorrhoids. However, after two weeks, the bleeding increased and was accompanied by pain and itching around the anus. She went to her primary doctor, whose test showed a mass of 2 x 2 inches on the anal sphincter. The doctor did not feel abnormal lymph nodes in the groin. He referred her to a colorectal surgeon who did colonoscopy. The examination confirmed the mass seen by his primary physician but no other injuries. Biopsy reveals squamous cell carcinoma, anal cancer.

After her diagnosis, Kerry's surgeon sent her for a PET / CT scan which revealed an abnormality only in the anal mass. There is no long-term activity to recommend the dissemination of metastatic cancer (far, far beyond cure). Her surgeons refer her to radiation oncologists and medical oncologists. They recommend radiation therapy (RT) and concurrent chemoRT together for 6 weeks. Kerry was treated with intensity modulated radiation therapy (IMRT) to reduce the dose of RT to critical organs including the small intestine and bladder, while treating potential microscopic cancer cells in the lymph nodes of the pelvis and thighs and anal tumors. She received mitomycin and fluorouracial chemotherapy concurrently with IV infusion as an outpatient. Kerry had expected side effects including severe irritation and redness in the thighs and anus, but he did not need rest during IMRT. He has a lot of fatigue that makes him unable to work all the time. She has some loose coats that are well controlled after adjusting to her diet. When it comes to treatment, there is no evidence of a tumor. She recovered from the side effects of the treatment for about six weeks. Kerry has seen one of her cancer doctors every three to six months for the last five years and she is cancer free!

POLICY
Although it is one of the rare cancers of the GI tract, there are still about 5000 cases of anal cancer diagnosed in the U.S. annually. There are more women than men diagnosed. The average age at diagnosis is around 60, but it can occur in patients in their 30s and 40s. If the disease is localized, of which 50% are patients, then the cure rate is approximately 80%.

RISK & TREATMENT
The majority of patients diagnosed with anal cancer do not have a clear risk factor. However, factors that increase the risk of anal cancer are associated with increased risk of human papillomavirus (HPV) infection. This virus is the same type that causes genital warts. Some types of HPV virus are associated with a high risk of developing colon and 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 developing colon cancer.

MARKET & GRAVE
Patients often present to their doctors with complaints of anal pain or bleeding. Many patients ignore or reduce these symptoms, often associating them with hemorrhoids. Although most people who have these symptoms do not have anal cancer, constant pain or bleeding should always receive medical attention. Less commonly, the patient will complain of anorexia or non-painful mass in the thigh. Bumps can develop in the thighs due to anal cancer that spreads to the lymph nodes and causes them to grow.

DIAGNOSIS
The diagnosis of anal cancer is usually made by biopsy of the anal mass or area of ​​the ulcer. Generally, this procedure is performed by a GI physician or surgeon. These doctors can see the rectal and rectal canals directly by proctoscopy (or whole intestine by colonoscopy) with special tools after they deliver the medication to reduce discomfort. Biopsy is performed during this procedure, after sedation and / or injection of numbing drugs. Most anal cancers (80%) are squamous cell carcinoma. A comprehensive assessment of someone suspected to have anal cancer should also include a pelvic examination, especially both the thighs. If the lymph nodes are enlarged, they can also be biopsied. Many enlarged lymph nodes are simply inflamed, with no evidence of cancer. Pre-ordered blood tests include complete blood count, kidney function tests, and possible HIV tests, depending on the patient's risk factors for the virus.

STAGING
The United States TNM staging system (AJCC) is used to determine if anesthesia is localized (early stage) or has spread to other sites (advanced or late). Early stage disease is limited to the anus, while advanced disease refers to cancer that invades nearby organs or lymph nodes in the hip or thigh. Imaging studies should include at least a CT scan of the abdomen and pelvis and chest X-ray. Staging may also include PET / CT scans. This imaging test allows radiologists and veterinarians to see whether an invasive cancer has spread to involve lymph nodes in the thighs or pelvis, or metastasized to other sites in the body such as the liver or lungs.

TREATMENT
Standard treatment for anal cancer does not involve surgery, which comes as a shock and a relief to many patients. Because most anal cancers invade the sphincter that controls removal, surgery to remove such a cancer will require removal of the spleen and colostomy. Therefore, surgery is generally avoided in favor of treatment that will keep the rectal sphincter intact. The exception will be the cancer of the anterior margin, on the skin beyond the anus.

Concurrent ChemoRT is a standard treatment for the majority of patients with anal cancer, to get the best chance of healing with sphincter care. RT is given for approximately 6 weeks with fluorouracil IV (5FU) and mitomycin-C (MMC) chemotherapy giving patients the best chance of healing. RTs are delivered in daily fractions using 3D conformal RT or IMRT. This latter technique can be used to reduce the number of normal intestines and / or genitals receiving full-dose RT (and thus minimize side effects).

Major side effects that may occur during RT to the anus and pelvis include possible skin reactions around the anus and skin folds in the hip, as well as intestinal and diarrhea irritation. Most patients will experience these acute symptoms within 1-2 months after treatment. Very rare (<1%) but serious side effects include intestinal obstruction or fistula (holes between the anus and the urinary tract or urethra). 5FU can also cause bowel irritation, diarrhea, irritation in the mouth or lips, poor appetite, and fatigue. Unusually, skin or nail color changes or severe hand and foot pain (elbow syndrome) or other major side effects may occur. In rare cases, heart problems including heart attacks can occur. MMC can lead to decreased blood volume, mouth injury, poor appetite, and fatigue. Nausea, vomiting, and urinary irritation may also occur. Rarely, lung damage or life-threatening kidney damage can occur.



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