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:
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. You can read the comprehensive guide for anal cancer patients and on this page we provide an overview of these guidelines.
The NCCN is a US-based organization, but the guidelines on this page reflect UK protocols as well. More information on UK treatment can be found on the National Health Service (NHS) website.
These treatment regimens are primarily for squamous cell carcinoma, which accounts for more than 90% of all anal cancers. These are tumors that arise because of abnormal growth of the 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 categorized as follows:
- 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).
It should be noted that estimates of the prevalence of each of these anal cancers vary based on different studies, which is why the numbers we have provided here do not add up. These types of anal cancer will be discussed in greater detail below.
The standard protocols for treating anal cancer are listed in the NCCN guidelines and on the NHS website (UK). For stages I – III, radiation and chemotherapy are the standard protocol and are usually used in conjunction with one another (often called 'chemoradiation'). 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 the creation of tools for scientists to create better therapies, the Anal Cancer Foundation is working to revive a once near-extinct 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.
Although anal cancer is primarily treated with chemotherapy and radiation protocols, there may be times when surgery is employed.
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 his/her 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.
Another type of surgery is used for an ostomy. An ostomy is a surgically created opening in the abdominal wall that is used for the removal of bodily waste, i.e. stool. The opening is called a stoma, and feces will thereafter pass through this opening into a special collection bag. You will need to learn to care for this area and 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 a much more invasive surgery called an abdominoperineal resection (APR), which may be recommended later in treatment. It may occur after chemoradiation is unsuccessful in treating the primary tumor, but the cancer has not metastisized to other locations in the body. In this procedure, 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 Side Effects of Surgery.
Cancer Research UK has put together a useful list of questions that you might want to ask your doctor about your anal cancer surgery.
Treatment 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.
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. This treatment regimen is called the Nigro Protocol. The combination of chemotherapy and radiation has been found to be more effective than surgery in treating these stages of anal cancer.
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 who is to receive chemotherapy. These tools allow for the chemotherapy to be infused for 96- to 120-hours at a time. Recently, 5-FU has become available to some individuals in pill form, which may be administered every day.
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 small studies and in other cancers, such as lung cancer and head and neck cancer. Several other single agent or combination treatments have been tested in clinical trials and case studies, with varying evidence of 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.
Currently, an international study is taking place to investigate the most effective chemotherapy regimen for recurrent or metastatic anal cancer using the drugs that are currently used to treat advanced disease. This 50-center study will compare the results of two treatment regimens for patients with locally recurrent or metastatic anal cancer. One arm consists of cisplatin and 5-FU, and the other consists of carboplatin and paclitaxel. You can read more about this study here.
The side effects of cisplatin, paclitaxel and carboplatin differ from one another and from person to person. The most common side effects of cisplatin include nausea, vomiting, appetite and hair loss, and diarrhea. The most common side effects of paclitaxel include nausea, weakness, darkening of skin or nails, temporary hair loss or irritation and swelling at the injection site. The most common side effects of carboplatin include pale skin, lightheadedness, easy bruising or unusual bleeding, and flu-like symptoms. Please be sure to discuss any severe and/or unusual side effects with your care team immediately.
For more information about preparing for chemotherapy, the side effects of chemotherapy and how to manage them, please see Side Effects of Chemotherapy.
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 for anal cancer involves using an external beam of radiation that is directed towards the location of the cancer 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.
Individuals receiving radiation may not experience side effects at the beginning of treatment, but should expect to feel them as the treatment progresses and for a period of time after treatment. This is because radiation therapy has cumulative effects, meaning they build up over time. Individuals receiving radiation can expect to feel the effects for a few weeks after completing the treatment. 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 bowl 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. Both men and women may experience narrowing of the anus, which may make bowel movements difficult.
Individuals undergoing pelvic radiation for anal cancer may have gastrointestinal and sexual dysfunction that lasts throughout their life. Due to the location of the cancer and the radiation, 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. Also 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 Side Effects of Radiation.
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.
TREATMENT FOR ANAL CANCER BY STAGE
- The standard of care to treat anal cancer stages I-III is combined chemoradiation therapy, otherwise known as the ‘Nigro Protocol’.
- The standard of care to treat stage IV anal cancer is chemotherapy.
- Surgery is less commonly used for the primary treatment of anal cancer.
More information from the Experts
To address the limited information that exists about anal cancer, the Foundation holds forums to educate anal cancer patients about treatment, side effects and life after treatment. These were the first forums to focus on these subjects for thrivers. Links to several of these forums are listed below.
Please see the slides that were presented by Dr. Karyn Goodman and Dr. Jeanne Carter at our anal cancer forum at Memorial Sloan Kettering Cancer Center.
Dr. Karyn A. Goodman, Associate Attending in the Radiation Oncology Department: Addressing Long-Term Side Effects after Treatment for Anal Cancer.
Dr. Jeanne Carter, Head of Female Sexual Medicine and Women’s Health programs: Long-Term Side Effects After Treatment for Anal Cancer.
This video from is our anal cancer forum at UCSF, which gave an overview of anal cancer, its treatment, and side effects:
View the specific section on long-term follow-up after treatment for anal cancer, by Dr. Berry-Lawhorn:
The Foundation also offers online educational forums. Check the blog for updates on upcoming events tailored for individuals living with anal cancer.
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.
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.
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 dosing 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.
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.
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.
What happens 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.
Support During and After Treatment
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.
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.