Anal cancer treatment can include surgery, chemotherapy, and radiation as well as emerging therapies. There are treatments for squamous and non-squamous forms of anal cancer. The three treatment options for anal cancer include:
- Chemotherapy
- Radiation
- Surgery
The treatment descriptions here are for general information and are based on general guidelines. However, the information on this site does not reflect medical advice. You should talk to your medical provider about the best treatment options for you.
ANAL CANCER TREATMENT OPTIONS
Treatment options for anal cancer depend on stage and type. The US National Comprehensive Cancer Network (NCCN) produces an in-depth anal cancer treatment guidelines document that is updated yearly. The document has a detailed and technical overview of treatment pathways and regimens.
NCCN is a not-for-profit alliance of 26 of the world’s leading cancer centers. Experts from these institutions regularly review and update the standard of care for many cancers. We also created a comprehensive guide for anal cancer patients to put this guidance in more accessible terms that are easier for patients and their loved ones to understand.
An overview of the medical guidelines:
These treatment regimens are primarily for squamous cell carcinoma, which accounts for more than 90% of all anal cancers. These are tumors that are caused by abnormal growth of squamous cells that line most of the anal canal and anal margin (where the anal canal meets the outside skin).
The remaining anal cancers are:
- Basal cell carcinomas of the perianal region: these are considered a subset of squamous cell carcinoma and are extremely rare – they comprise less than 1% of all abnormal growths of the anal region.
- Adenocarcinomas (around 5-19% of all anal cancers).
- Malignant melanomas (2-4% of all anal cancers).
Estimates of the prevalence of each of these anal cancers vary based on different studies. We discuss these anal cancer types in more detail below.
The Nigro Protocol
The standard protocols for treating anal cancer are listed in the NCCN guidelines and on the NHS website (UK).
For stages I – III, the standard protocol is radiation and chemotherapy, used in conjunction with one another (often called 'chemoradiation'). The combination of chemotherapy and radiation has been found to be more effective than surgery in treating these stages of anal cancer.
The chemotherapy and radiation protocols that have been used for decades are known collectively as the Nigro Protocol. The Nigro Protocol typically includes several weeks of radiation with two different types of chemotherapy given at the beginning and end of treatment.
Stage IV cancers are usually addressed with chemotherapy alone first.
Treatment for anal cancer has remained overwhelmingly the same since the 1970s. The Nigro Protocol was established in 1974 and, unbelievably, there is no FDA-approved chemotherapy drug specific to anal cancer – a fact we are working to change. By working with scientists on novel research projects and investing in new tools for scientists to create better therapies, the Anal Cancer Foundation is reviving a once near-closed pipeline. Our goal is to increase the options for patients and accelerate new treatments that are less toxic and just as effective.
Read more below about the current protocol for surgery, chemotherapy, and radiation. For a helpful list of questions to have with you at your medical appointments, please see our list of Questions to Ask Your Doctor.
Chemotherapy
Chemotherapies are a class of drugs that kill cancer cells and prevent them from multiplying.
Anal cancers between stages I-III are often treated with the chemotherapy drugs mitomycin-C and 5-fluorouracil (5-FU) in addition to radiation.
For these individuals, chemotherapy is typically administered twice, once at the beginning of radiation and then again at 5 weeks of radiation. Before treatment, a temporary central venous catheter (“CVC”) or peripherally inserted central catheter (“PICC”) may be placed on an individual. These allow for chemo infusions from 96 to 120 hours at a time. Recently, 5-FU has become available in pill form, which may be administered every day to patients who could benefit from taking it this way.
Common side effects of these drugs include, but are not limited to, decreased white blood cells, decreased red blood cells and/or platelets, nausea, vomiting, mouth sores, hair loss, neuropathy, and fatigue. Individuals taking these drugs should talk to their doctors about possible side effects and tell their doctors if they experience these or other side effects.
For stage IV cancers, the NCCN recommends a combination of 5-FU and cisplatin, which is a platinum-based therapy. There are encouraging results from studies that have employed either a combination of paclitaxel, carboplatin, and 5-FU; a combination of carboplatin and paclitaxel; or single-agent paclitaxel. These treatment regimens are being tried in part because they have shown efficacy in other cancers, such as lung and head and neck cancer.
Several other single-agent or combination treatments have been tested in clinical trials and case studies, with varying success. We believe a better standard of care for all stages of anal cancer needs to be established and support research to better understand and treat it.
An international study recently took place to investigate the most effective chemotherapy regimen for recurrent or metastatic anal cancer. This 60-center study compared the results of two treatment regimens for patients with locally recurrent or metastatic anal cancer. One arm consisted of cisplatin and 5-FU, and the other consisted of carboplatin and paclitaxel. Although overall response rates were the same between arms, reduced side effects and potentially longer survival rates suggested that carboplatin plus paclitaxel should be considered as a new standard of care.
For more information about preparing for chemotherapy, the side effects of chemotherapy, and how to manage them, please see our Chemotherapy page.
Cancer Research UK has put together a useful list of questions that you might want to ask your doctor specifically about chemotherapy for anal cancer.
Radiation
Radiation for anal cancer involves using an external beam of radiation that is directed towards the cancer location to shrink tumors and kill cancer cells. You are likely to have radiotherapy in combination with chemotherapy as your main form of treatment. For individuals with anal cancer stages I-III, radiation is typically 5 days a week for 5 to 6 weeks. Individuals with stage IV or recurrent cancer may receive radiation in locations where the cancer has spread.
You may not experience side effects at the beginning of treatment but should expect them as treatment progresses. You may feel the effects for a few weeks after completing treatment, too. This is because radiation has cumulative effects, meaning they build up over time. During radiation, it is important to take care of your skin and drink lots of liquids.
Side effects for radiation targeted at an anal tumor may include: skin irritation, gastrointestinal and anal discomfort, pain during bowel movements and while urinating, fatigue, diarrhea, and nausea. Women may experience side effects unique to their anatomy, including: vaginal pain, irregular vaginal discharge, and closure of the vagina through the accumulation of scar tissue called stenosis. Side effects unique to the male anatomy may include erectile dysfunction and impotence. Everyone may experience narrowing of the anus, making bowel movements difficult.
Individuals undergoing pelvic radiation for anal cancer may have gastrointestinal and sexual dysfunction that can last throughout their life. Due to the cancer’s location, individuals may experience a weakened pelvis and an inability to use their sphincter.
Please talk to your radiation oncologist about your specific treatment and side effects, as they vary from person to person. Ask your doctors about mitigating radiation side effects. Management aides may include moisturizers, lubricants, dilators, pelvic rehabilitation, and a referral to a sex therapist who is familiar with pelvic radiation side effects.
For more information about the side effects of radiation and how to manage them, please see our Radiation page.
Four weeks after my diagnosis, I was off to the radiation oncologist. I met the radiation team, received my tattoos (four very small dots used to line up the radiation machine) and they built a form to hold my legs during treatment. My legs were put together like a frog and the mold material was put around them. Within minutes they had a mold. Lying on my back on the table of the radiation machine, the ceiling had a wonderful backlit scene of clouds and blue sky. At least there was something to focus on during those 20 minutes lying still like a frog on that cold table! Talk about embarrassment! But that quickly subsides and it doesn’t matter who sees what anymore.
Sue B.
Stage IIIB
Surgery
Although anal cancer is primarily treated with chemotherapy and radiation protocols, there may be times when surgery is used.
Although uncommon, surgery can be used for early-stage anal cancer when the tumor is extremely small and localized. Your provider may refer to this type of cancer as “superficially invasive”. During surgery, the area in which cancer is present is excised (removed). This operation is called a local resection. If tests after the surgery show that there is no evidence of disease, the individual will be observed by their doctors. If the tests after surgery show that anal cancer is still present, the patient will undergo further treatment, which may include another excision or chemotherapy and radiation.
Ostomy and Abdominoperineal Resection
Another type of surgery is used for an ostomy. An ostomy is a surgically created opening in the abdominal wall used for the removal of bodily waste, i.e. stool or poop. The opening is called a stoma, and feces will pass through it into a special collection bag. You will need to learn to care for this area. A specialized stoma nurse will be able to help you with this.
There are different types of ostomies. For anal cancer, the most common ostomy is colostomy.
Some thrivers may need a temporary ostomy when they are going through chemoradiation treatment to help them avoid the pain of going to the bathroom, but this can be reversed after treatment.
There is a much more invasive surgery called an abdominoperineal resection (APR), which may be recommended later in treatment. This is especially in cases where chemoradiation has unsuccessfully treated the primary tumor, but cancer has not metastasized to other areas. In an APR the surgeon will remove the anus, rectum, part of the colon, and the lymph nodes.
Due to the nature of this surgery, you will need to have a permanent colostomy.
Please see our Ostomy Section in Side Effects of Surgery for more information about how to adjust to living with an ostomy, and be sure to speak with your care team about any questions or concerns you may have.
For more information about the side effects of surgery and how to manage them, please see our Surgery page.
Cancer Research UK has put together a useful list of questions that you might want to ask your doctor about your anal cancer surgery.
Trea
tment for stage IIIB cancer isn’t any fun, but then I suppose no cancer treatment is a walk in the park. In January of 2010, I had a colostomy and then began simultaneous radiation and chemotherapy the day I got out of the hospital with my new ‘appliance’ (colostomy bag). It was my good fortune, or so my oncologist told me, that I was in perfect health except for the 7cm tumor hanging off…well…you know where. They treated the cancer very aggressively. I had radiation daily for 33 days along with 2 rounds of chemo where I had a bottle attached to my arm for a week during each round.
Karen, US
Stage IIIB
Treatments by Stage of Anal Cancer
Stages 0
Stage 0 anal cancer means that the abnormal cells are only at the very top layer of the anal lining. It is also called carcinoma in situ or AIN3 (AIN means anal intraepithelial neoplasia).
AIN is treated using topical (i.e., applied directly) therapies such as imiquimod, 5-flurouracil, and trichloroacetic acid. Ablative therapy can also be used—this is a minimally invasive treatment used to remove the top layer of skin, often with a laser.
If you have been diagnosed with AIN be sure to screen regularly to prevent abnormalities from developing into cancer. Learn more on our anal precancer + screening page.
Stages 1, 2 & 3
The standard of care to treat anal cancer stages I-III is combined chemoradiation therapy, otherwise known as the ‘Nigro Protocol’. See our sections above for more details.
Learn more about the side effects of chemotherapy and radiation.
Stage 4
The standard of care to treat stage IV anal cancer is chemotherapy. Read more about treatment for stage IV anal cancer
Treatment for Recurrent Anal Cancer
Cancer is called ‘recurrent’ when it comes back after being treated. It can come back in or near the same place as before, or it can spread to other organs such as the lungs, liver or bones.
Once you have been diagnosed with recurrent anal cancer your doctor will restart the cycle of testing to learn as much as possible about the recurrence, including staging. This will help determine treatment which often depends on where the cancer has recurred, and what type of treatment you had last time.
For more information please see our section on Recurrent and Advanced Cancer.
Emerging Treatment Options
Immunotherapy
Immunotherapies are a developing classification of interventions for cancer that seek to harness the power of an individual’s immune system. The theory behind immunotherapies is that one’s immune system can be 'taught' to defend the body against cancer.
Immunotherapies would enable one’s immune system to find and destroy cancerous cells without damaging healthy cells, something other cancer therapies are unable to accomplish. Current immunotherapies under research include cancer-fighting vaccines, checkpoint inhibitors and creams that can be applied topically. The Foundation supports research in this field, which you can read more about here. Please remember, however, that the role of immunotherapy remains in clinical trials, and as of yet, no drugs are FDA-approved for anal cancer and only a very select few are FDA approved for other cancers.
Radiosensitizers
Radiosensitizing agents are drugs that increase the sensitivity of tumors to radiation by disrupting their DNA, making radiotherapy more effective. The hope is that lower doses of radiation and chemotherapy will be needed.
Clinical Trials
Clinical trials look at new ways to prevent, detect, or treat disease.
We list current anal cancer clinical trials from ClinicalTrials.gov on our Clinical Trials page. The registry is searchable and each listing provides info about the purpose of the trials, eligibility, the study location, and more. You can sort by cancer type, stage, and geography.
We recommend discussing everything you find with your medical team. They are often the ones who can hopefully connect you to the right enrollment process if you fit the profile.
Genomic Research
Genomic research is also a fast-growing and relatively new area of study in the cancer research world. Cancer genome research compares genes in tumors to genes in healthy, noncancerous tissues in order to understand important differences between the two.
The research goal is to provide insight into what drives cancer development. Ultimately, if we understand how a healthy cell’s DNA has changed to become cancerous, it may indicate areas of the genome that can be targeted by specific drugs. In the future this may mean that each individual has 'personalized' medicine where people are no longer treated by the anatomical site but by the genetic mutations in their tumor.
For more information on genomic research, please see our section on Recurrent and Advanced Cancer.
See our Research Roadmap for our vision to advance development of effective treatments for anal and all HPV-related cancers.
Treating Non-Squamous Forms of Anal Cancer
Other forms of anal cancer are adenocarcinoma, basal cell carcinoma, and malignant melanoma. Adenocarcinoma accounts for 5-19% of anal cancer, malignant melanoma for 2-4% and basal cell carcinoma for less than 1% of all abnormal anal growths.
ADENOCARCINOMA
This is a rare type of anal cancer that affects the glandular cells used in mucus production in the anal canal. On occasion, adenocarcinoma is treated with the Nigro Protocol, as described above, but for the most part it is treated in the same way as rectal cancer. Because of this, the treatment for rectal cancer is outlined below. As with squamous cell carcinomas, treatment varies by stage.
There is an ongoing discussion in the scientific community about whether these types of cancers should be classified as anal or rectal cancer. We consider all cancers that affect the anus as under the umbrella of anal cancer, and our resources are available to all.
Surgery is a common treatment for adenocarcinomas that are stage 0 or 1. Surgery can be minimally invasive in stage 0 cancers, which usually only require a local excision or transanal resection. In stage I cancers, the type of surgery required, and how invasive it is, usually depends on the location of the cancer. Additional therapy is not always needed after surgery but if the cancer turns out to be more advanced than previously thought, a combination of chemotherapy and radiation is usually advised.
In more advanced adenocarcinomas, such as stages II and III, chemotherapy and radiation therapy tends to be given prior to surgery. After surgery, more chemotherapy is given. This chemotherapy may be what is called the FOLFOX regimen (oxaliplatin, 5-FU and leucovorin), or it may be 5-FU and leucovorin, CapeOx (capecitabine plus oxaliplatin) or capecitabine alone. Please note that this is not an exhaustive list of treatment options and that you should discuss your individual treatment with your medical team. The regimen and dosage depend on your health status and needs.
Treatment options for stage IV are similar, but depend on where the cancer has spread. Your health status and ability to tolerate treatment are also taken into account when determining a course of action. Chemotherapy, radiation and surgery are usually prescribed in various combinations depending on your needs.
The American Cancer Society and the National Comprehensive Cancer Network (requires a free registration) both have in-depth information pages on the treatment of rectal cancer.
For more information about the side effects and how to manage them, please see our Radiation, Chemotherapy and Surgery pages.
BASAL CELL CARCINOMA
Basal cells make up part of the lowest layer of the epidermis, or skin. These cancers usually develop in areas exposed to sunlight, and in fact are the most common type of cancer in humans.
Anal basal cell carcinomas are rare, however. For the purposes of categorization for anal cancer, the NCCN considered basal cell carcinomas a subtype of squamous cell carcinomas.
Please see the National Comprehensive Cancer Network’s (requires a free registration) page for more in-depth information.
MALIGNANT MELANOMA
Melanoma develops from cells known as melanocytes, which produce melanin. This is the pigment responsible for the color of our skin. Melanocytes are found in our skin and hair, and in other internal organs, including the anus and rectum. Anal melanoma is quite rare, and is mostly found in older adults, aged 60-80. Anal melanoma follows the treatment protocols for melanoma.
As with other types of anal cancer, treatment will depend on the staging and position of the cancer, and your overall health and wellness. Surgery is usually the main option in these cases, as melanomas do not typically respond as well to chemotherapy and radiation as other types of anal cancer.
Early-stage melanomas are usually removed via local excision, while larger tumors or those that have grown into the deeper tissue are removed using abdominoperineal resection.
If the melanoma has spread to other organs, treatment usually involves chemotherapy and radiation, and may also include immunotherapy or targeted therapy drugs.
Please see the American Cancer Society and National Comprehensive Cancer Network’s treatment and patient guidelines pages (requires a free registration) for more in-depth information about melanoma treatment.
For more information about the side effects and how to manage them, please see our Radiation, Chemotherapy and Surgery pages.
Anal Cancer and HIV
Immunocompromised people, such as those living with HIV are at greater risk of having high-grade AIN and/or anal cancer than other people.
Being consistent with HIV treatment and maintaining a high CD4 count can help protect against both of these. Being vigilent with screening for AIN too, can help catch Anal cancer does still occur at a higher rate in HIV-positive people taking effective HIV treatment than in non-HIV+ people. Additionally, because people with HIV are, luckily, living longer due to effective treatment, these and other cancers have more time to develop.
The treatment regimen for people with is the same as for those without HIV, and treatment outcomes have generally been found to be similar.
It’s important to note that if you are diagnosed with anal cancer but haven’t been tested for HIV, your medical team may discuss testing with you. People who have anal cancer sometimes have undiagnosed HIV, and getting on effective treatment is definitely to the thriver’s benefit.
Treatment Side Effects
As we’ve discussed throughout, anal cancer treatments can cause side effects that may be quite uncomfortable. Side effects vary from person to person, and each individual thriver may not experience all of the side effects described, and in different intensities.
Learn more on our side effects of treatment page or jump to our Radiation, Chemotherapy and Surgery pages.
Palliative Care
Palliative care is specialized medical care that focuses on providing pain relief. Treatments vary widely and can involve medication, nutrition, mindfulness and relaxation practices, spiritual support, and more. Palliative care specialists work with you to provide that additional support that's meant to complement your direct cancer care. Make sure to speak with your medical team early in your treatment planning about what palliative care options are available to you. Receiving this type of care alongside traditional, more aggressive cancer therapies often has the impact of improving quality of life and treatment satisfaction.
Support During & After Treatment
Once treatment has concluded, individuals should expect to see their provider regularly for follow-up visits. These visits may include physical exams as well as tests to determine the presence or absence of anal cancer. At first, these visits typically occur every three months and gradually change to every six months after a two-year period. Generally, if a recurrence happens, it is in the first two years after treatment. If you are concerned about anything in between follow-up appointments, be sure to see your provider as soon as possible.
Anal cancer is considered uncommon, with an incidence rate in the US of 1.8 in 100,000 people. In 2020, around 8,600 people were predicted to be diagnosed with anal cancer in the US and 1,600 people in the UK. Due to its rarity and the stigma associated with it, it is extremely important for those with anal cancer to reach out to others in the community for information and support. Anal cancer does not need to be isolating. If you are interested in finding a peer to speak with, the Anal Cancer Foundation has a Peer to Peer Support Program specifically for individuals diagnosed with anal cancer and their caregivers. For more information on this and other support services, please visit Find Support.
Peer-to-Peer Support
Anal cancer can often be an isolating experience, and even if you have a supportive circle of family and friends, unless they have been through anal cancer treatment themselves there is often a limit on their understanding. Our peer-to-peer support program aims to address this gap, matching anal cancer thrivers seeking support from trained peer mentors who have been through treatment. Mentors provide 1:1 connection from the framework of those who have shared within this incredibly difficult experience.
We also provide caregiver matching as well.
The cancer thrivers who participate in the program, whether offering or receiving mentorship, build deep friendships and express relief at having found a knowledgeable and empathetic community. After recovery, many support-seekers come back to serve as mentors in the program themselves.
Learn more and sign up on our Peer-to-Peer Support page.
SUPPORT DURING AND AFTER TREATMENT
For a glossary of terms, please see our Common Anal Cancer Terms.
Please feel free to Contact Us if you have any further questions or concerns about the treatment for anal cancer.
