About anal cancer. Incorporating hospital and community health services, teaching and research

Transcription

1 About anal cancer Incorporating hospital and community health services, teaching and research

2 The Homerton Anal Neoplasia Service is a referral centre that provides a screening and treatment service for people at risk of anal cancer and people who have developed precancerous lesions in the genital area. This includes the anal canal, and the skin surrounding the anus, penis, vagina and vulva. We have a team of experts to give you information and look after you. About anal cancer In the United Kingdom, about 1300 people are diagnosed with anal cancer each year. Anal cancer is increasing in its incidence and is affecting more people across the world every year. The HPV connection 90% of anal cancers are caused by the human papillomavirus (HPV). There are many types of HPV. Some HPV types cause benign warts, but some cause lesions (also called dysplasia) that can progress to invasive cancer. HPV-16 and HPV-18 are the high-risk strains responsible for the majority of HPV-associated cancers. HPV causes cervical, anal, vulvar, vaginal, penile and head and neck cancers, as well as recurrent respiratory papillomatosis. Most people who acquire HPV infection however fight it off with the body s natural defences and do not go on to develop cancer. HPV is common and cancer due to it is rare. Intercourse is not necessary to transmit the HPVs that ultimately can cause anal cancer or cervical, vulvar, oral or penile cancers, although it is a common route of transmission. HPV can also be transmitted from person to person by deep kissing, manual stimulation of the genitals, rubbing, sex toys or shared use of any object used for genital contact, that has the potential of being contaminated with an agent such as HPV. A person can also spread 2

3 an HPV infection from one site on his/her own body to another site (e.g. hand-to-genitals). Risk factors for anal cancer Women with a history of high-grade (advanced) cervical or vulvar pre-cancerous lesions (dysplasia) are at an increased risk for anal cancer. After treatment for cervical precancer, women often return to having normal smear tests. While many women eliminate the virus through treatment or naturally through the body s immune system, for others this same HPV infection may remain undetected for years while it slowly develops into cancer in another site. Women with a history of cervical or vulvar pre-cancer or cancer therefore have an increased risk of anal cancer. HIV-positive women and men are at a higher risk of developing anal cancer, as HIV weakens the body s immune system and prevents the healthy resolution of HPV infection. Organ transplant recipients, and people taking medications for autoimmune disorders, often are immunocompromised and also are at a slightly higher risk for developing anal cancer. HIV-positive men with a history of anal intercourse are at the greatest risk for developing anal cancer, although HIV-negative men with a history of receptive anal intercourse are also at a higher risk compared with the general population. Men who have sex with men (MSM) who do not have HIV, are 5 times more likely to develop anal cancer than the general population. The incidence rate doubles for HIV-positive MSM compared with HIV-negative MSM. 3

4 Whether male or female, having multiple sexual partners increases the chances of contracting HPV, although having just one sex partner who is infected with HPV can result in an infection that can lead to cancer. While anal intercourse is a well-recognised risk factor for anal HPV infections and anal precancerous dysplasia, other forms of contact (such as touching or vaginal intercourse) can be responsible for the transmission of the virus to the anus. In short, anal intercourse is not a pre-requisite for getting anal cancer. Every year however, people who do not have any of the above risk factors are also diagnosed with anal precancer and cancer. This is a simple consequence of the fact that the HPVs that cause this cancer are so common in the human population. Treatment for anal cancer When detected early, anal cancer is usually curable and may be effectively treated by surgical removal alone. The standard of care to treat more advanced anal cancer is combined chemo-radiation therapy. Doctors reserve radical surgery (salvage abdomino-perineal resection) for use only if the chemo-radiation is not completed or if it is ineffective and unable to eliminate all of the disease. Even in early diagnoses, treatment can often have serious and difficult side effects. There are both short term and long term effects associated with treatment despite the benefits of cure. Patients who receive local radiation to their pelvis and anus, for example, may suffer from long-term fatigue and bowel dysfunction. For women, this may result in vaginal stenosis, which means narrowing of the vagina due to scar tissue formation, and may affect sexual activity. There are strategies to prevent this which will be 4

5 explained to you at the time. For men, it can lead to erectile dysfunction. Anal intercourse after radiotherapy may be affected by sensitivity and sometimes by stenosis (narrowing of the anal canal). Anal bowel function can be affected also by radiotherapy, leading to a feeling of needing to open the bowels urgently and frequent bowel movements. Many of these issues improve with time after radiotherapy and patients with long term sequelae are supported by the nurse-led clinic follow up. Chemotherapy may cause nausea, appetite loss, thinning of the hair, diarrhea, mouth sores, and low blood counts. Sometimes patients require a colostomy (where the large bowel is diverted and brought out through an opening in the abdominal wall). This can be a temporary measure during chemoradiation or, occasionally it is required if salvage surgery is needed to remove the tumour if chemoradiation does not work. Like many other cancers, mortality rates increase once the disease has spread beyond the origin to other organs (called metastasis). The smaller the cancer or tumour (T stage) and the less it has spread (N stage) the better the outcome of the treatment. Overall anal cancer survival is 65% at 5 years in HIV positive men. The key to anal cancer is early detection and treatment, the reason why the Homerton Anal Neoplasia Service has been brought into being. 5

6 For additional support/advice please call the HANS Clinical Nurse Specialist References A meta-analysis suggest that 74.9% prevalence of HPV in anal cancer in men (De Vuyst, Clifford, Nascimento, Madeleine, & Franceschi, 2009; Hoots, Palefsky, Pimenta, & Smith, 2009) Parkin DM. Cancers attributable to infection in the UK in 2010 (link is external). Br J Cancer 2011;105(S2):S49-S56. : De Vuyst, H., Clifford, G. M., Nascimento, M. C., Madeleine, M. M., & Franceschi, S. (2009). Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: a meta-analysis. International Journal of Cancer. Journal International Du Cancer, 124(7), Grulich AE, van Leeuwen MT, Falster MO, et al. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis (link is external). Lancet 2007;370(9581): Machalek, D. A., Poynten, M., Jin, F., Fairley, C. K., & et al. (2012). Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis. Lancet Onco, 13(5),

7 Alfa-Wali, M., Allen-Mersh, T., Antoniou, A., Tait, D., Newsom- Davis, T., Gazzard, B., Bower, M. (2012). Chemoradiotherapy for anal cancer in HIV patients causes prolonged CD4 cell count suppression. Annals of Oncology: Official Journal of the European Society for Medical Oncology / ESMO, 23(1), Oehler-Jänne, C., Huguet, F., Provencher, S., Seifert, B., Negretti, L., Riener, M.-O., Ciernik, I. F. (2008). HIV-specific differences in outcome of squamous cell carcinoma of the anal canal: a multicentric cohort study of HIV-positive patients receiving highly active antiretroviral therapy. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 26(15),

8 Where can I get more information? HANS Clinical Nurse Specialist NHS Choices Cancer Research UK Patient Advice and Liaison Service (PALS) PALS can provide information and support to patients and carers and will listen to your concerns, suggestion or queries. The service is available between 9am and 5pm PALS@homerton.nhs.uk For information on the references used to produce this leaflet, please ring , text: or patientinformation@homerton.nhs.uk If your require this information in other languages, large print, audio or Braille please telephone the Patient Information Team on Text: or patientinformation@homerton.nhs.uk Produced by: Homerton Anal Neoplasia Service, SWSH Homerton University Hospital NHS Foundation Trust Homerton Row, London E9 6SR enquiries@homerton.nhs.uk Date produced March 2017 Review date: March