Anal Cancer Signs & Symptoms While it is possible to have no symptoms of anal cancer, the first sign for many people is bleeding from the anus. There are other signs to watch for, but they may be caused by more common noncancerous conditions, such as anal fissures or hemorrhoids. If you notice something is wrong, it is important to go see your doctor as soon as possible. Anal Cancer Symptoms

1. Rectal Bleeding

• Bleeding is usually very light at first, which is why it can easily be confused as a symptom of something else.

2. Anal Itching

• Itching is often intense and consistent.

3. Abnormal Discharge

• Discharge can include pus, mucus, or blood.

4. Change in Bowel Habits

• This can include diarrhea, constipation, narrow stool, or blood in the stool. You should talk to your doctor if these changes last more than a few days.

5. Feeling of Fullness

• You may feel like you are sitting on something or may even feel a small lump.

If you have one or more of these symptoms, it does not mean you have anal cancer. However, you should still speak with your doctor to identify the cause of your problems.

The human papillomavirus (HPV) is the most common sexually transmitted infection. Many people have HPV but may not know it. In most people, the virus is dormant. That means HPV is not active in the body. For some people, HPV infection can lead to certain types of cancer. These include cervical cancer, vaginal cancer, head and neck cancer, and anal cancer. Most anal cancer — more than 90 percent — is caused by HPV. Your risk of developing HPV-positive anal cancer depends in part on the strain of HPV that you were exposed to. For instance, some strains cause warts on the skin, mouth, or genitals but rarely, if ever, lead to cancer. Other strains put you at a higher risk of anal cancer. There are more than 150 variations of HPV, but the strain most commonly linked to anal cancer is HPV 16. Sexual Activity Because it increases your chances of being exposed to HPV, having multiple sexual partners can lead to a higher risk of developing anal cancer. Having anal sex is one of the known predisposing factors of anal cancer for both men and women. The disease is more common in men who have sex with men. Smoking Smoking cigarettes increases your risk for many types of cancer, including anal cancer. If you are currently a smoker, it is never too late to quit. These factors increase your risk as well:

• lowered immunity due to HIV infection or immunosuppressant drugs
• past history of other cancers, including penile cancer, cervical cancer, vaginal cancer, or vulvar cancer
• age (people over 50 are more likely to develop anal cancer)
• gender (women have a higher risk of anal cancer)

How to Protect Yourself against Anal Cancer You can lower your chances of developing anal cancer if you:

• Practice safe sex.
• Get the HPV vaccine. The Centers for Disease Control and Prevention advises girls between ages 11 and 26 and boys between ages 11 and 21 to get vaccinated. The HPV vaccine is also approved for women and men age 27 through 45.
• Don’t smoke, or stop immediately if you currently smoke.

Anal Cancer Diagnosis Anal cancer is often found after symptoms appear. It can be detected in several ways. It may be discovered during a procedure for another condition, such as a hemorrhoid. For people who have a higher risk or who are experiencing symptoms, it may be found during a diagnostic test, such as an endoscopy. Anal cancer is not usually found during a regular screening colonoscopy for colorectal cancer. If anal cancer is suspected, your primary care doctor should refer you to a specialist for additional tests. How is anal cancer diagnosed? Medical History When you go to your primary care doctor with symptoms, the first thing they will do is assess your medical history. They will ask you questions to find out if you have any anal cancer risk factors. They may refer you to a specialist, such as a gastroenterologist. Digital Rectal Exam and Physical Exam Your doctor will use a finger to feel for any tumors or abnormalities in your anus and rectum. Other parts of your body may be checked for health problems that are causing your symptoms. Women might need a Pap test or pelvic exam. Anoscopy During an anoscopy, your doctor will use a small device with a light at the end to help see inside your anus and rectum more clearly. The doctor will look for any lumps or abnormal tissue. Flexible Sigmoidoscopy A sigmoidoscopy is used in the same way as an anoscopy. A sigmoidoscopy uses a small camera instead of a light. During this procedure, your doctor may also perform a biopsy, which involves removing a small piece of tissue. Biopsy Due to the location of anal cancer, an exam under anesthesia is often needed to obtain a biopsy. During the procedure, your doctor will remove small pieces of tissue. A pathologist will look at the tissue to see if it contains any cancer cells. It is important that an experienced pathologist performs this evaluation so that you get a precise diagnosis. If the pathologist sees cancer cells, advanced tests will be used to determine the type of cancer. Imaging Tests If cancer cells are found in your biopsy, your doctor will order imaging tests to see if the cancer has spread to other parts of your body. These may include CT, MRI, or PET scans, or some combination of the three. Stages of Anal Cancer If your care team diagnoses you with anal cancer, the next critical step is figuring out the stage of the cancer, or how advanced it is. To do this, we may recommend CT and MRI scans to see if the cancer has spread. Staging helps our experts design a plan that treats your anal cancer in the most effective way possible. Our doctors use the American Joint Committee on Cancer TNM system to determine how advanced a tumor is. We will tell you the stage of the disease by using a combination of the numbers and letters below. We will carefully explain exactly what they mean when we tell you the stage. Regardless of the stage of the cancer, TNM System Your doctor will use a combination of letters and numbers to help describe the stage of the cancer:

• T is the size of the tumor.
• N is whether the cancer has spread to the lymph nodes.
• M is whether the cancer has metastasized (spread) to other parts of the body.

Anal cancer is categorized into five stages:

• Stage 0 is very early cancer that is found only in the top layer of the lining of the anus.
• Stage I tumors are small (less than two centimeters, or smaller than the size of a peanut) and have grown deeper into the lining of the anus. The cancer has not spread outside the anus.
• Stage II cancer means the tumor is larger than two centimeters but has not spread.
• Stage III cancer has spread to nearby lymph nodes.
• Stage IV cancer has spread to nearby lymph nodes and other parts of the body.

Anal Cancer Treatment The type of treatment you receive for anal cancer depends on the size, location, and stage of the tumor. Our experts realize that one size does not fit all, and we will work with you to create a treatment plan specifically designed for your unique needs. Anal cancer experts includes radiation oncologists, colorectal surgeons, medical oncologists, pathologists, and radiologists. We work together to diagnose, stage, and treat each person we care for in a carefully coordinated way. Radiation Therapy for Anal Cancer If the cancer is found before it has spread, the best treatment option may be radiation therapy. Radiation is often combined with chemotherapy. This is called chemoradiation. The chemotherapy helps make the cancer more vulnerable to the radiation. Our radiation oncologists are experts at targeting radiation to a tumor while avoiding damage to healthy tissue. We are pioneers in using special techniques to help protect important bodily functions, like bowel and sexual functions. Surgery for Anal Cancer Surgery is usually not the main treatment option for anal cancer. Your doctor may discuss it with you in addition to chemotherapy or radiation depending on the stage of the tumor. If you do need surgery, you are in good hands at KIMS. Our anal cancer surgeons are highly experienced in removing tumors without damaging nearby organs. Our team members are experts in using minimally invasive, robot-assisted techniques. With these methods, you may have a quicker recovery time. Surgery may be an option if anal cancer comes back (recurs) after radiation or chemotherapy. Chemotherapy for Anal Cancer Chemotherapy is usually given in combination with surgery or radiation therapy. It may also be used if the cancer is advanced and has spread to other parts of your body. Your care team will customize your chemotherapy treatment based on genetic information about the tumor. With this information, we can refine your care plan to help minimize side effects.

Radiation therapy is often the main treatment for anal cancer. Your doctor may discuss surgery with you too depending on the size and location of the tumor. If you and your care team decide that surgery is the best approach, it’s important that your procedure is performed by an experienced surgeon. A surgeon has extensive experience in caring for people with all stages and types of anal cancer. We will offer you options that are tailored to your personal situation. We have particular expertise in treating anal cancer that has come back (recurred). We can also help if your disease has not responded to other treatments. There are two main types of surgery to treat anal cancer: local resection and abdominoperineal resection. Local Resection for Anal Cancer Your doctor may recommend a local resection if the tumor is small, located in the outermost layer of the anus (called the anal margin), and has not spread to other parts of the body. During a local resection, your surgeon removes the tumor as well as a small amount of tissue around the tumor to make sure no cancer cells are left behind. Most people can have normal bowel movements after a local resection. In rare cases, bowel function may be temporarily altered after a local resection. If needed, our expert team of colorectal surgeons, physician assistants, and nurses will help you adjust and adapt after surgery so that you can get back to normal bowel function as soon as possible. Abdominoperineal Resection for Anal Cancer In the past, abdominoperineal resection (APR) was the main treatment for anal cancer, but now chemoradiation is the primary therapy. If anal cancer does not respond to radiation or chemotherapy, or if it comes back after initial treatment, APR may be the right option for you. During an APR, your surgeon removes the anus, rectum, and bottom part of the colon. You may have the nearby lymph nodes removed too if the tumor has spread. Your surgeon creates an ostomy after the cancer has been removed so that your body has a new way to release stool. Minimally invasive, robot-assisted methods are often used for an APR. The surgeons at KIMS are leaders in this area. We perform the most robot-assisted rectal cancer and anal cancer procedures in the country. Whenever possible, we use these advanced techniques. People who have minimally invasive surgery have faster and less-painful recoveries and a reduced risk of complications. Before an APR, you will meet with a specialized nurse who is trained in ostomy care. At KIMS, we have some of the most experienced and knowledgeable stoma therapists in the world. We will help you adjust to living with a permanent colostomy. We can also connect you to a rich network of people who have had an APR so that you will better understand life after an APR

Your treatment for anal cancer may include chemotherapy. Chemotherapy uses powerful drugs to attack cancer cells. It is usually given in combination with radiation. This is called chemoradiation. If the cancer is advanced or has spread (metastasized) to other parts of your body, chemotherapy may stop the cancer from growing and help relieve your pain. Medical oncologists are doctors who treat cancer using drugs. you will receive chemotherapy from a highly experienced medical oncologist who specializes in your type of cancer. We will work with you to develop a treatment plan that fits your needs and leads to the best possible outcome. Depending on your personal situation, Medical oncologists may advise against chemotherapy if the benefits are not clear and there will be significant side effects. Immunotherapy for Anal Cancer Your medical oncologist may speak with you about immunotherapy as a treatment option. Immunotherapy uses your own immune system to fight cancer cells. In recent years, doctors have found that checkpoint inhibitors can be effective in treating anal cancer. These drugs release the immune system’s natural brakes, helping it attack cancer cells. Nivolumab (Opdivo®) and pembrolizumab (Keytruda®) are two checkpoint inhibitors approved to treat anal cancer. Researchers are continuing to study how immunotherapy can benefit people with the disease.

Radiation therapy is the most common treatment for anal cancer. If your doctor recommends radiation, you may be worried about what treatment will entail. You may also be concerned about the possible side effects. Radiation oncologists specialize in treating cancer with radiation. radiation oncologists are some of the most experienced in the country. Our unmatched level of expertise means that you will receive the best care possible. When you receive radiation for anal cancer, your care team will include dedicated radiation oncologists, nurses, therapists, and physicists, as well as a surgeon and other highly trained staff. We will work together to ensure you receive the safest, most effective treatment, and that all of your needs are met. We also use special techniques and provide support services to help you keep your quality of life. Types of Radiation for Anal Cancer There are several ways to treat anal cancer with radiation, including:

• as the main treatment, so you don’t need surgery
• in combination with chemotherapy
• after surgery, to get rid of any remaining cancer cells

Radiation therapy team has access to the most advanced forms of radiation available. We have extensive knowledge about which approach will provide you with the most benefit. Our goal is twofold. We want to eliminate the cancer cells and prevent the side effects of treatment by keeping the healthy cells around the tumor safe. Here you will find in-depth information about the types of radiation used to treat anal cancer. Intensity-Modulated Radiation Therapy for Anal Cancer Intensity-modulated radiation therapy (IMRT) is the most common type of radiation for anal cancer. It is a form of external-beam radiation. IMRT uses a highly advanced computer program so your care team can precisely shape the radiation beams to the dimensions of the treatment area. Before treatment begins, expert radiation oncologists and medical physicists will collect detailed information about the treatment area. You will have:

• a CT scan to map the tumor in 3-D
• PET, CT, and MRI scans to identify the outline of the tumor

Your care team uses this information along with sophisticated treatment-planning software. With this program, we can calculate the right number of radiation beams and the specific angle of those beams. You may also receive chemotherapy to weaken the cancer cells before the radiation treatment. This helps the radiation be more effective. This approach allows us to deliver more-precise doses of radiation to the tumor while protecting your nearby healthy tissue. Proton Therapy for Anal Cancer Proton therapy is a form of radiation that uses charged particles called protons. Conventional radiation uses X-rays. Proton therapy can reduce the likelihood of damage to healthy tissue because proton beams do not penetrate beyond the tumor. It also allows us to deliver higher doses of radiation, maximizing the chance of destroying the tumor Using proton therapy to treat anal cancer is a relatively new approach. Doctors are still studying its benefits. Proton therapy is most commonly used to treat head and neck cancer and pediatric cancers. KIMS is one of a limited number of centers nationwide to offer proton therapy. You and your doctor will discuss if you are a good candidate for this treatment. Currently, patients receive proton therapy in Somerset, New Jersey. Side Effects of Radiation Therapy for Anal Cancer Some immediate side effects of radiation may include:

• diarrhea and pain while going to the bathroom
• burns or rashes on the skin at the treatment site
• tiredness
• nausea
• vaginal irritation

Our radiation oncologists will talk with you in detail about what to expect from radiation. You will know when side effects are likely to appear. We can prescribe items to help keep you as comfortable as possible, like a topical cream or pain medication. Most of these side effects go away after treatment ends. Other long-term side effects are possible, but our experts have developed techniques and support programs to help you deal with them.

• Fertility: Radiation can affect fertility for both men and women. Our experts know that fertility is an important and very personal concern. We’ve developed ways to give you the best chance of preserving your fertility. Learn more about fertility preservation options.
• Vaginal health: Radiation for anal cancer can cause damage to the vagina. You may have discomfort and pain. KIMS has an entire program dedicated to helping you maintain your vaginal and sexual health before, during, and after treatment. Using special devices while you receive radiation can help protect your vaginal health. Learn more about sexual health services.
• Bowel function: Radiation to the anus can cause tissue damage. Eventually, this damage may lead to the formation of scar tissue. If this happens, it may impact how the muscles in the anus function. This may cause problems with bowel function and continence. Your care team may use special techniques or treatments to reduce or adapt to changes in bowel function.