Fluorouracil, mitomycin, and radiotherapy vs fluorouracil, cisplatin, and radiotherapy for carcinoma of the anal canal: a randomized controlled trial

Colon, rectal, and anal cancers

OBJECTIVES

To review the incidence, risk factors, staging, diagnosis, and treatment of colon, rectal, and anal cancers, as well as nursing care associated with managing patients diagnosed with these malignancies.

DATA SOURCES

Published research reports, epidemiologic data, published patient management guidelines, and institution-based clinical tools.

CONCLUSIONS

Significant advances in the management of colon, rectal, and anal cancers in the past decade have extended patient survival. Further clinical research will refine current therapeutic strategies and treatment decision-making aids while minimizing symptoms of disease and treatment.

IMPLICATIONS FOR NURSING PRACTICE

Nurses need to be familiar with risk factors, disease course, and current and emerging therapies to assist patients with treatment decision-making, and to anticipate and intervene in managing disease and treatment-induced problems. Early identification and management of distressing symptoms can help to avoid life-threatening effects and promote patient adherence to prescribed therapies; timely patient/family education may minimize anxiety and promote self-management.

[Curative salvage treatment of mediastinal and pleuropulmonar metastatis from anal canal cancer]

This case report presents a 57 years-old woman treated for a squamous cell carcinoma of the anal canal by radiochemotherapy and brachytherapy. The particularity of this case lays on the fact that she presented a mediastinal and pleural metastatic evolution three years later, which was also treated by radiochemotherapy, leading to a complete remission of 50 months. This observation is interesting for its curative treatment in metastatic cancer of the anal canal. It also illustrates the radiosensibility of anal canal cancers, including metastatic situations, and raises the contribution of PET-scanner to evaluate the response to treatment and detect a recurrence.

HIV and anal cancer outcomes: a single institution's experience

PURPOSE

The purpose of this study is to identify the effect of HIV status on outcome of treatment for squamous-cell carcinoma of the anal canal.

METHODS

A retrospective review was performed on all patients with squamous-cell carcinoma of the anal canal treated at a single academic institution between January 1996 and December 2006.

RESULTS

Our search identified 87 (21 HIV-positive) patients who had invasive squamous-cell cancer. The median follow-up was 38 months. Eighty-five percent of HIV-negative patients and 81 percent of HIV-positive were identified as complete responders at 6 weeks after completion of combined modality therapy. Eight percent of HIV-negative and 29 percent of HIV-positive patients developed recurrent disease after 6 months (P = 0.0009). Overall survival for HIV-negative and HIV-positive patients was 71 percent and 73 percent, respectively.

CONCLUSIONS

HIV-positive patients respond equally to combined modality therapy but have recurrences more frequently than patients who are HIV negative. Overall survival in these two groups is equivalent.

Outcomes of chemoradiotherapy with 5-Fluorouracil and mitomycin C for anal cancer in immunocompetent versus immunodeficient patients

PURPOSE

Information is limited as to how we should treat invasive anal squamous cell carcinoma (SCC) in patients with chronic immunosuppression, since the majority of clinical studies to date have excluded such patients. The objective of this study is to compare treatment outcomes in immunocompetent (IC) versus immunodeficient (ID) patients with invasive anal SCC treated similarly with combined modality therapy.

METHODS AND MATERIALS

Between January 1999 and March 2007, a total of 36 consecutive IC and ID patients received concurrent chemoradiotherapy using three-dimensional conformal radiotherapy with infusional 5-fluorouracil and mitomycin C. The IC and ID groups consisted of 19 and 17 patients, respectively, with 14 human immunodeficiency virus-positive (HIV+) and 3 post-solid organ transplant ID patients. There were no significant differences in tumor size, T stage, N stage, chemotherapy doses, or radiation doses between the two groups.

RESULTS

With a median follow-up of 3.1 years, no differences were found in overall survival, disease-specific survival, and colostomy-free survival. Three-year overall survival was 83.6% (95% CI = 68.2-100) and 91.7% (95% CI = 77.3-100) in the IC and ID groups, respectively. In addition, there were no differences in acute and late toxicity profiles between the two groups. In the human immunodeficiency virus-positive patients, Cox modeling showed no difference in overall survival by pretreatment CD4 counts (hazard ratio = 0.994, 95% CI = 0.98-1.01). No correlation was found between CD4 counts and the degree of acute toxicities.

CONCLUSION

Our data suggest that standard combined modality therapy with three-dimensional conformal radiotherapy and 5-fluorouracil plus mitomycin C is as safe and effective for ID patients as for IC patients.

Is Survival Reduced for Patients with Anal Cancer Requiring Surgery after Failure of Radiation? Analysis from a Population Study over Two Decades

Chemoradiotherapy is the standard treatment for anal cancer. Surgery is reserved for failure of therapy, but there are limited data examining outcomes after surgery. From a prospective population-based database on radiation and surgical therapy, we compare outcomes for patients with anal cancer undergoing rectal resection after radiation with patients undergoing radiation alone. Patients undergoing surgical resection of the rectum after initial radiation (SRT) for squamous cell carcinoma of the anus, anal canal, cloacogenic zone, and overlapping lesions of the rectum and anal canal from 1983 to 2002 were identified from the Surveillance, Epidemiology and End Results database. Patient and tumor characteristics of SRT were compared with those of patients who underwent radiation alone (RT). Survival was calculated by the Kaplan-Meier test. There were 1202 patients undergoing RT and 48 patients undergoing SRT. RT and SRT had similar median age, gender, and grade of tumor. SRT had more patients with regional stage of disease (66.7 vs 42.4%, P = 0.001). Mean survival for SRT was, however, similar to RT (103 vs 96 months, P = 0.8). For patients with localized stage, survival for SRT and RT was similar (105 vs 98 months, P = 0.7). For patients with regional stage, survival for SRT and RT was similar (95 vs 83 months, P = 0.6). The presence of regional disease appears to be associated with surgical resection after radiotherapy. Mean survival for such patients is comparable to that of patients undergoing radiation alone. Because radiation is combined with chemotherapy, this suggests that salvage surgery after failure of therapy results in outcomes comparable to combination therapy alone.

US intergroup anal carcinoma trial: tumor diameter predicts for colostomy

PURPOSE

The US Gastrointestinal Intergroup Radiation Therapy Oncology Group 98-11 anal carcinoma trial showed that cisplatin-based concurrent chemoradiotherapy resulted in a significantly higher rate of colostomy compared with mitomycin-based therapy. Established prognostic variables for patients with anal carcinoma include tumor diameter, clinical nodal status, and sex, but pretreatment variables that would predict the likelihood of colostomy are unknown.

METHODS

A secondary analysis was performed by combining patients in the two treatment arms to evaluate whether new predictive and prognostic variables would emerge. Univariate and multivariate analyses were carried out to correlate overall survival (OS), disease-free survival, and time to colostomy (TTC) with pretreatment and treatment variables.

RESULTS

Of 682 patients enrolled, 644 patients were assessable and analyzed. In the multivariate analysis, tumor-related prognosticators for poorer OS included node-positive cancer (P < or = .0001), large (> 5 cm) tumor diameter (P = .01), and male sex (P = .016). In the treatment-related categories, cisplatin-based therapy was statistically significantly associated with a higher rate of colostomy (P = .03) than was mitomycin-based therapy. In the pretreatment variables category, only large tumor diameter independently predicted for TTC (P = .008). Similarly, the cumulative 5-year colostomy rate was statistically significantly higher for large tumor diameter than for small tumor diameter (Gray's test; P = .0074). Clinical nodal status and sex were not predictive of TTC.

CONCLUSION

The combined analysis of the two arms of RTOG 98-11, representing the largest prospective database, reveals that tumor diameter (irrespective of the nodal status) is the only independent pretreatment variable that predicts TTC and 5-year colostomy rate in patients with anal carcinoma.

Anal cancer: is neoadjuvant cisplatin chemotherapy or chemoradiotherapy friend or foe?

This Practice Point commentary discusses the findings of the Intergroup RTOG 98-11 trial, which aimed to investigate both the potential role of cisplatin as neoadjuvant chemotherapy, and also its role concurrently in combination with radiotherapy, for anal-canal carcinoma. Although chemoradiotherapy has had an important effect on the treatment of anal cancer, and allows preservation of anorectal function with survival rates similar to or better than those of surgical treatment, overall survival rates for advanced tumors are still in the region of 50-60% at 5 years. A strong theoretical rationale for cisplatin-based treatment in anal cancer exists; several phase II trials have demonstrated a high response rate with reduced colostomy rates. The Intergroup results are disappointing in that neoadjuvant chemotherapy with cisplatin and 5-fluorouracil, followed by cisplatin-based chemoradiotherapy did not improve overall survival, disease-free survival and locoregional control when compared with the standard treatment of combined 5-fluorouracil and mitomycin chemoradiotherapy.

Diagnosis and management of anal cancer

During the past three decades, anal cancer has served as a paradigm for the successful application of chemoradiation to solid tumors. Since the early 1990s, the increasing incidence of anal cancer in homosexual men has highlighted the causative role of oncogenic human papilloma-virus infection. This review focuses on significant trends and developments in the management of patients with squamous cell carcinoma of the anal canal, emphasizing three major aspects of diagnosis and treatment: routine screening and eradication of premalignant lesions in high-risk individuals; outcome of chemoradiation therapy in HIV-positive individuals in the era of highly active antiretroviral therapy; and potential improvements in chemoradiation protocols through improved radiation delivery technique and the combination of mitomycin with cisplatin in current prospective randomized trials.

Multimodality therapy in penile cancer: when and which treatments?

OBJECTIVES

Metastatic penile cancer typically comes to attention while the clinical extent of disease is limited to the inguinal or pelvic lymph nodes. Primary surgical management of lymph node metastases achieves tumor control and long-term survival for only a small percentage of these patients. To determine the optimal use of multimodality treatment in locally advanced penile cancer, we conducted a literature review.

METHODS

Relevant English-language literature was identified with the use of Medline; additional cited works not detected on the initial search were also reviewed.

RESULTS

There is an emerging strategy of preoperative (neoadjuvant) combination chemotherapy to improve the progression-free survival of penile cancer patients with bulky regional lymph node metastases. Radiotherapy for inguinal metastases and postoperative (adjuvant) radiation for selected patients has also been effective in this setting.

CONCLUSIONS

In patients with lymph node metastases, the benefit of ilioinguinal lymphadenectomy may be extended by the addition of neoadjuvant chemotherapy. Postoperative radiotherapy can be offered depending on the amount of residual disease after chemotherapy. Chemo-radiotherapy has been successful in squamous cell cancers from other sites (vulva and anal canal) and may be considered for unresectable penile cancer.