Abramson Cancer Center

Risk factors can increase the chance of getting cancer. There are different kinds of risk factors. Some risk factors for cancer, like age and family history, cannot be prevented.

Patients who feel they are at risk may benefit from consulting with a risk assessment specialist within Penn Medicine's GI genetics program at the Abramson Cancer Center.

Anal Cancer Risk Factors

Risk factors affect the chance of getting anal cancer. Having a risk factor, or even several, does not always mean that someone will get cancer.

• Being infected with HPV. Anal cancer is also associated with the human papilloma virus (HPV). This virus causes warts also called condyloma in and around the anus, and on the cervix in women. HPV is also associated with an increased risk for cervical cancer.
• Age. Anal cancer is most often diagnosed in people over 50 years old, but young people with HIV are a large affected group.
• Anal intercourse. People who participate in unprotected anal sex are at an increased risk.
• Having many sexual partners. People who have many sexual partners who engage in anal intercourse are at an increased risk for anal cancer.
• Immunosuppression. People with weakened immune systems, such as those who take certain drugs or have HIV, are at an increased risk.
• Chronic local inflammation. People with long-standing fistulas, open wounds, redness, swelling or soreness around the anus may be at an increased risk.
• Smoking. Smoking has been linked to an increased risk of developing anal cancer.

Anal Cancer Prevention

While cancer cannot be totally prevented, a person's risk for anal cancer may decrease significantly with preventative measures.

• Quit smoking. Quitting smoking or chewing tobacco can decrease the risk of developing cancer. Patients can get help to stop smoking through Penn Medicine's Lung Center or through a smoking cessation research program at the Abramson Cancer Center.
• Avoid unprotected anal intercourse.
• Use condoms to prevent HIV or HPV infection.

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• Anal margin
• Anal canal

Anal Margin Cancer

Cancer of the anal margin is cancer that is found just outside of the anus – on the skin. This type of cancer is usually treated in the same way skin cancer is treated – with surgery, excising the lesion, but not the anus itself.

Cancer of the anal margin should not be confused with melanoma of the anus.

Anal Canal Cancer

Cancer in the anal canal cannot be detected by sight. Anal canal cancer is usually detected with a digital rectal exam or a proctoscopy.

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Many cases of anal cancer can be found early because the cancer forms in an area that physicians can see and reach easily. This is why it is important to have regular check-ups.

Anal cancer can be mistaken for hemorrhoids because some symptoms are similar.

Some symptoms of anal cancer include:

• Bleeding from the rectum or anus
• A lump or mass at the anal opening
• Pain or pressure in the area of the anus
• Itching in the anus or discharge
• Change in bowel movements, or straining during a bowel movement
• Narrowing of the stools
• Mucous or pus discharge from the anus
• Swollen lymph nodes in the groin or anus

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Staging systems provide doctors with a common language for describing tumors. After cancer is first diagnosed, a series of tests are used to investigate the extent of the cancer and to see whether it has spread to other parts of the body from where it started. Staging is a way of recording the size and growth of a cancer, and determining the plan for treatment. By understanding the stage of their cancer, patients can make informed decisions about their treatment.

Staging anal cancer attempts to discover the following:

• The size of the tumor
• Whether the cancer has spread to nearby tissues
• Whether the cancer has spread to other parts of the body

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After being diagnosed with anal cancer, patients at the Abramson Cancer Center may be evaluated through the Gastrointestinal Cancer Evaluation Center (GICEC). The center provides patients with expert support and evaluation to discuss treatment options and individualized treatment plans.

Patients with anal cancer are treated by a multidisciplinary team of cancer specialists who see more patients with gastrointestinal (GI) cancers in one year than many doctors see in their careers.

The physicians of Penn Medicine's GI cancer program are nationally recognized for their expertise in the diagnosis and treatment of cancer. Patients with anal cancer are treated by Penn surgeons in the Division of Colon and Rectal Surgery.

Penn's GI cancer treatment team includes:

• Nationally recognized medical experts with years of experience in diagnosing and treating GI cancer.
• Nurses with advanced training and experience in caring for patients with GI cancer.
• Oncology Navigation Specialists to help patients navigate the health system.
• Registered dietitians to provide nutrition counseling.
• Cancer counselors to provide individual or family counseling for issues many cancer patients face.
• Rehabilitation therapists who specialize in the diagnosis and treatment of physical effects from cancer and its treatment.

Penn's GI cancer program is also supported by a robust research program with immediate translation from bench to bedside.

Patients at Penn Medicine can benefit from participating in clinical trials. Patients interested in learning more about clinical trials should speak with a member of their treatment team.

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Currently, there are no recommendations for screening the general public for anal cancer, such as mammograms for breast cancer or colonoscopies for colon cancer. However, people who are at increased risk for anal cancer should talk to their physicians about anal cancer screening

Those at increased risk include HIV-positive men, men who have sex with men, individuals with multiple sexual partners and women with a history of cervical warts or precancerous changes identified in the cervix.

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Anal cancer can either be seen if it is on the anal skin or if it is within the anal canal. If a physician suspects anal cancer, he may perform or order one or more of these tests to diagnose and stage anal cancer.

• Medical history and physical exam. An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments is also taken.
• Lymph node exam. Physicians may examine lymph nodes in the groin to check for swelling. Samples of lymph tissue may also be removed through a needle biopsy.
• Digital rectal exam. The anus and rectum are examined by the physician or nurse who inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else unusual.
• Proctoscopy. An exam of the rectum using a short, lighted tube called a proctoscope.
• Imaging tests. Pictures of the inside of the body can help find out whether a suspicious area might be cancerous, to learn how far cancer may have spread, and to help determine if treatment is working.
  • Endoscopic ultrasound (EUS). Ultrasound uses sound waves to create a picture of the internal organs. This procedure is often done at the same time as the upper endoscopy.
  • Computed tomography (CT) scan. A three-dimensional X-ray of the inside of the body in which a series of images are combined by a computer into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan is used to see if the tumor has spread. Sometimes, a contrast medium (dye) is used to provide better detail.
  • Chest X-ray. An energy beam passes through the body to create a picture of areas inside the body. If anal cancer is found, a chest X-ray may be done to determine if the cancer has spread to the chest.
• Biopsy. If other tests find a changed that may be cancer, a sample of the suspicious area is removed and viewed under a microscope. A biopsy is the only way to tell if cancer is really present.
• Needle biopsy. A thin needle is inserted into the lymph node to remove a small sample of lymph fluid. This is usually done in the groin or anus area if cancer is suspected.

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Staging anal cancer attempts to discover the following:

• The size of the tumor
• Whether the cancer has spread to nearby tissues
• Whether the cancer has spread to other parts of the body

Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if 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 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 chance of recovery.

• Stage 0. Abnormal cells are found only in the innermost layer of the anus. Also called carcinoma in situ.
• Stage I. Cancer has formed and the tumor is 2 cm or smaller. 
• Stage II. Tumor is larger than 2 cm.
• Stage III. One of the following:
  • IIIA. Tumor is any size and
    • Has spread to either the lymph nodes near the rectum.
    • Has spread to nearby organs such as the vagina, urethra and bladder.
  • IIIB. Tumor is any size and
    • Has spread to nearby organs and lymph nodes near the rectum.
    • Has spread to lymph nodes on one side of the pelvis and/or groin and may have spread to nearby organs.
    • Has spread to lymph nodes near the rectum and in the groin and/or lymph nodes on both sides of the pelvis and/or groin and may have spread to nearby organs.
• Stage IV. The cancer has spread (metastasized) from where it started to lymph nodes, nearby organs and distant parts of the body.

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Penn medicine offers patients one of the most advanced colorectal surgery programs in the United States with a nationally recognized record for high-quality patient care and survivorship.

Local resection surgery for anal margin cancer, or cancer that can be seen on the outside of the anus, is generally the first treatment if the cancer is located on the skin surrounding the anus and can be completely removed with surgery. Typically, if the tumor is removed completely, no further treatment is required. Close surveillance and follow-up with the surgeon and medical oncologist are needed to ensure that rare recurrences are detected early.

Local Resection

Local resection is a surgical procedure in which the tumor is cut from the skin around the anus along with some of the surrounding healthy tissue. Local resection may be used if the cancer is small and has not spread. This procedure saves the sphincter muscles and anus so the patient can still control bowel movements. This surgery is used for anal margin cancers.

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Radiation oncologists at Penn Medicine are recognized for techniques that target radiation precisely to the disease site while sparing nearby tissue.

Proton therapy at Penn Medicine is now being used to treat upper gastrointestinal cancers and recurrent tumors in the digestive tract. Penn Medicine is one of the only facilities in the country treating gastrointestinal cancers in this way.

Radiation therapy uses high-energy radiation to kill cancer cells. A radiation therapy schedule usually consists of a specific number of treatments given over an extended period of time. In many cases, radiation therapy is capable of killing all of the cancer cells.

Radiation therapy for anal cancer is commonly used first in combination with chemotherapy for anal canal cancer, or cancer that is inside the anal canal and cannot be seen. Anal canal cancer is very sensitive to chemotherapy and radiation treatments.

3-D Conformal Radiation Therapy

The imaging technology used by radiation oncologists at Penn Medicine helps shape the radiation treatment beam to the shape of the tumor. Known as conformal radiation therapy, this technology gives doctors more control when treating tumors.

In conformal radiation, a special computer uses CT imaging scans to create 3-D maps of the cancer’s location in the body. The system permits the delivery of radiation from several directions and the beams can then be shaped, or conformed, to match the shape of the cancer. Conformal radiation therapy limits radiation exposure to nearby healthy tissue as well as the tissue in the beam's path.

Intensity-Modulated Radiation Therapy (IMRT)

This advanced type of radiation therapy uses a computer-controlled device, called a linear accelerator, to deliver precise doses of radiation to tumors or specific areas within the tumors. Radiation therapy, including IMRT, stops cancer cells from dividing and growing, thus slowing or stopping tumor growth.

In many cases, radiation therapy is capable of killing all of the cancer cells. Using 3-D computed tomography (CT) images along with computerized dose calculations, IMRT allows for the radiation dose to conform more precisely to the shape of the tumor by controlling — or modulating — the intensity of the radiation beam. The therapy allows higher radiation doses to be delivered to areas within the tumor while minimizing the dose to the surrounding area.

Volumetric-Modulated Arc Therapy (VMAT)

Volumetric modulated arc therapy (VMAT) is a type of specialized intensity-modulated radiation therapy, or IMRT. VMAT delivers radiation by rotating the radiation machine, through one or more arcs while radiation is continuously delivered.

VMAT allows Penn radiation oncologists to treat complex cancers while minimizing exposure to surrounding healthy tissue. VMAT shortens radiation delivery time, and offers patients more comfort because it does not require them to lie completely still for long periods of time.

Penn radiation oncologists use RapidArc™ radiotherapy technology to treat hard to reach tumors.

Proton Therapy

Penn Medicine is the only health care facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials.

Penn Medicine's Roberts Proton Therapy Center is the largest and most advanced facility in the world for this precise form of cancer radiation. Patients have access to one of the most sophisticated weapons against cancer, seamlessly integrated with the full range of oncology services available at Penn Medicine. Proton therapy is external beam radiotherapy in which protons are directed at a tumor.

The radiation dose that is given through protons is very precise, and limits the exposure of normal tissues. This allows the radiation dose delivered to the tumor to be increased beyond conventional radiation. The result is a better chance for curing cancer with fewer harmful side effects.

Proton therapy, like all forms of radiation therapy, works by aiming the energized particles, in this case protons, onto the target tumor. The particles damage the DNA of cells, ultimately causing their death. Unlike X-rays, protons can be manipulated to release most of their energy only when they reach their target. With more energy reaching the cancerous cells, more damage is administered by each burst of radiation.

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Penn Medicine specializes in a team approach to cancer treatment with interdisciplinary care and innovative approaches that use chemotherapy to target tumors prior to and after surgery.

Chemotherapy

Chemotherapy uses drugs to kill cancer cells. It is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is usually delivered intravenously through a catheter or orally by pill.

Chemoradiotherapy

Chemoradiotherapy is the practice in which chemotherapy and radiation therapy are used simultaneously. 

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Local resection surgery for anal canal cancer is very rare. If surgery for anal canal cancer is needed, Penn Medicine offers patients one of the most advanced colorectal surgery programs in the United States with a nationally recognized record for high-quality patient care and survivorship.

Local resection surgery removes cancer and surrounding tissues from the anal canal.

Close surveillance and follow-up with the surgeon and medical oncologist is needed to ensure that rare recurrences are detected early. 

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Today, more and more people are surviving cancer. Clinical trials benefit patients by providing access to breakthrough therapies and treatments. These new advances in cancer treatment are occurring every day at Penn Medicine, giving patients hope that even greater discoveries lie ahead. Through clinical trials:

• Diagnosing cancer has become more precise.
• Radiation and surgical techniques have advanced.
• Medications are more successful.
• Combinations of medical, surgical and radiation therapy are improving treatment effectiveness and enhancing outcomes.
• Strategies to address the late effects of cancer and its treatment are improving quality of life.

Penn Medicine is the only health care facility in the country that is using proton therapy to treat recurrent gastrointestinal tumors in clinical trials. Also, radiation oncologists at Penn Medicine will soon use proton therapy to treat gastrointestinal cancers in the upper digestive tract.

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In addition to standard treatments and clinical trials, patients at Penn Medicine may wish to add additional therapies and treatments such as massage therapy, acupuncture and art therapy. These therapies do not have curative intent, and are designed to complement standard treatments – not take their place.

Integrative Medicine and Wellness Programs

At Penn Medicine, integrative medicine and wellness services can supplement traditional cancer treatments such as chemotherapy, surgery and radiation therapy. While conventional medicine plays a critical role in eradicating cancer, integrative medicine and wellness programs offer patients and their families ways to enhance the quality of their lives, minimize or reduce the side effects of cancer and cancer treatment, and promote healing and recovery.

The physicians at Penn Medicine are knowledgeable and supportive of complementary cancer treatments. The cancer team works with patients and families to integrate these supportive programs into the overall care plan, while ensuring the safety and health of patients.

The Abramson Cancer Center's range of integrative supportive services is designed to help patients cope with the cancer experience and improve their overall sense of well-being. Services include:

• Acupuncture
• Diet and nutrition
• Mindfulness-based stress reduction therapy
• Reiki therapy
• Yoga
• Exercise and rehabilitation

The Joan Karnell Cancer Center at Pennsylvania Hospital offers a variety of supportive care programs for patients and families, from diagnosis through survivorship. These programs are available at no cost to the patients treated at Pennsylvania Hospital, and some are open to patients treated elsewhere. These services include social work counseling, nutrition counseling, psychological counseling and spiritual counseling.

The Cancer Appetite and Rehabilitation Clinic focuses on patients with loss of appetite and weight as well as deconditioning.

The Supportive Care Clinic helps to manage cancer-related symptoms. Integrative support programs include:

• Music therapy
• Art therapy
• Shiatsu massage
• Mindfulness meditation

Support groups and educational programs are available at Pennsylvania Hospital throughout the year.

Palliative Care

Palliative care provides medical and non-medical interventions to ease the symptoms of cancer and its treatment. Palliative care includes physical, emotional and spiritual care that can enhance the quality of life for cancer patients.

Palliative care can be used to complement traditional cancer therapies, or can be used to improve quality of life when curative therapies are no longer an option to treat symptoms.

Palliative care is an approach to patient care that can be integrated with curative therapies at any point from diagnosis to survivorship or end of life care.

Palliative care services include palliative chemotherapy, radiation therapy and surgery as well as psychological counseling, art therapy and support groups for patients and families. The goals of palliative care are to enhance the quality of life for cancer patients and their families, and provide emotional and spiritual support to enhance personal growth.

Palliative care services are offered at Pennsylvania Hospital, and at the Hospital of the University of Pennsylvania.

Penn Home Care and Hospice Services

Penn Home Care and Hospice Services offers a full range of home health care needs by partnering three top-level home health care services under one roof:

• Penn Wissahickon Hospice
• Penn Care at Home
• Penn Home Infusion Therapy

Penn Home Care and Hospice Services provides an array of specialized therapies and medications for patients with cancer and cancer-related conditions

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Anal cancer has the highest rate of recurrence in the first one to two years after completing cancer treatment. It is important for patients to schedule follow-up visits with their physician as soon as their cancer treatment is completed.

At the end of treatment, anal cancer patients should schedule a survivorship visit with their oncologist and nurse practitioner. At this time, patients are provided with a summary of the treatment received as well as a plan for follow-up care.

Patients who have completed treatment for anal cancer can expect follow-up visits with their physician every three to four months for the first two years. A check of the anal area at the time of the office visit is routine.

Penn cancer providers work one-on-one with patients to develop survivorship care plans. Since every cancer is unique, the plans are tailored to the patients. 

The survivorship care plan includes information on:

• Potential long-term or late side effects of cancer treatment, the symptoms and treatment.
• Recommendations for cancer screening for disease recurrence or a new cancer.
• Psychosocial effects, including relationships and sexuality.
• Planning follow-up visits.

A survivorship care plan encourages patients to review the information with their health care team and become active participants in their follow-up care.

Penn also offers anal cancer patients a number of support programs and groups to enhance their survivorship care plans.

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Penn Medicine’s Living Well After Cancer™ Program is a nationally recognized program that focuses on issues facing cancer survivors. The Abramson Cancer Center is a member of the LIVESTRONG™ Survivorship Center of Excellence Network. The program focuses on survivorship, a distinct phase of care.

Prescription for Living: The Cancer Survivorship Program at the Joan Karnell Cancer Center at Pennsylvania Hospital provides patients with a summary of important information about specific cancer diagnoses and treatments, as well as follow-up information and steps to take towards recovery, supportive care and education to help patients adjust to their lives as cancer survivors.

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Penn offers cancer patients support programs and groups to enhance their survivorship care plans.

The Abramson Cancer Center hosts a wide range of materials and activities that provide education and support to address key areas of concern including survivorship for cancer patients and their loved ones.

Focus On: Gastrointestinal Cancers is a day-long conference that addresses issues for patients with anal cancer, as well as their loved ones.

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