What you need to know about anal carcinoma
When most people think of carcinoma, they may think of more common forms of the disease, whether it might be the announcement from Rush Limbaugh, who recently made news with his diagnosis of advanced lung cancer, or the beloved Alex Trebek, struggling through a second round of chemotherapy for Stage IV pancreatic cancer. Additionally, they may relate to a more personal struggle, such as a relative with breast cancer. They may empathize with recent news from Shannen Doherty of 90210 fame. She is battling with insurance providers, who she has alleged want to quibble over a remote smoking history as opposed to her current fight with metastatic breast cancer. These are the cancer battles we are used to hearing in everyday lives.
But anal carcinoma? This topic is barely discussed among professionals, let alone communities where the words need to be heard.
Unfortunately, the rising incidence (and mortality) associated with this form of cancer dictates that professionals need to become comfortable with the topic very soon.
Background Information
In 2009, the world lost a great actress, one of the original Charlie’s Angels. Farrah Fawcett was known for an iconic poster, world famous hair, and an unbelievable smile. She was also a true warrior in fighting anal cancer and bringing her battle to national television, hoping to lessen the stigma associated with an “ugly” disease that would prove to be terminal for her, despite innovative treatment in Switzerland4. Since that time, Marcia Cross (of Desperate Housewives fame) has been diagnosed. She has also become a celebrity spokesperson for the disease, assisting to bring this disease to the forefront. As we will find, timely recognition of symptoms as well as prompt treatment is pivotal to survival from anal carcinoma.
Incidence and Prevalence
Anal carcinoma could be considered one of the fastest growing types of cancers in the United States, but most people don’t know the statistics. Within the last 15 years, the incidence of squamous cell carcinoma of the anus (the most common type) rose 2.7% each calendar year, while anal cancer mortality rates increased 3.1% per year during that same time. Since public perception of the disease is that this type of cancer is very rare, knowledge and awareness of the disease is neglected. However, rates are increasing very rapidly, particularly among two population groups: young black men and elderly white females.4
HPV (human papillomavirus) is the most frequent cause of anal cancers, but people don’t realize that HPV is the most common sexually transmitted infection in the United States. Although generally healthy people who have HPV don’t get anal cancer, those with weakened immune systems, such as those at risk for HIV or the elderly may be more likely to get anal cancers. HPV can also cause other carcinomas, such as cancers of the vagina, vulva, and penis.2
Human papillomavirus is a group of more than 200 viruses, the majority of which do not cause carcinoma. Two types, HPV16 and HPV18 are related to most HPV-related carcinomas. However, even if a person is infected with one of these two types, their system may be able to override the virus if the body is healthy. Only those in a weakened or elderly state may be unable to fight off the infection, which could lead to chronic HPV-infected status, and eventually carcinomatosis. In particular, patients such as those living longer lives with HIV, patients with compromised immune systems (post-transplant, post-chemo or radiation treatment for other HPV-related carcinomas, or weakened immune systems through the aging process) may be more likely to become infected if exposed to the human papillomaviruses known to cause cancer.2
Vaccines
If you watch television, you would be aware that vaccinations for human papillomavirus are now available. These vaccines, however, have a very narrow window of indication. The “CDC recommends two doses of the vaccine one year apart for children ages 11 to 12 in the US.” Young adults up to age 26 can also be vaccinated, but for those over the age of 15, three doses are recommended. The CDC does states that adults age 27 to 45 may discuss risks/benefits with their primary provider regarding the vaccine, but the vaccine is currently not licensed for individuals over the age of 45.1
Causation
It has been speculated that the shocking rise in anal carcinoma may be due to multiple factors: rise in HIV numbers (same-sex partners, IV drug use), increase in number of sex partners per individual, willingness for more sexual experimentation, including anal sex, lack of public awareness related to widespread HPV infection, etc3. Risk may also rise among those who have had cervical or vulvar cancer, or who have been smokers. At this time, young black males and elderly white females are the two population groups that have been diagnosed with the disease most frequently, although no standards for screening exist.
If you are an Advanced Practiced nurse working with patients, this information may be important to keep in mind when screening for GI symptoms, concerns while interviewing patients.
Symptoms
From the years 2001 to 2015 the National Cancer Institute analyzed data in the U.S cancer registries and found 68,809 cases of anal cancer with 12,111 deaths from the disease. Approximately 91% of these cases were caused by the HPV virus, but the patients and the public would be shocked to learn of this detail. Unfortunately for most of the patients, symptoms of the disease begin insidiously in the tissue of the anus, and most patients chalk their symptoms up to those of a similar complaint: hemorrhoids.4
The symptoms of anal carcinoma may be uncomfortable and may be difficult to discuss with a provider, but any one of the following symptoms should be cause for concern if they occur:
- Bleeding, either from the anus or rectum, particularly if hemorrhoids are not present.
- Any symptoms of pain or pressure in the anal area.
- Discharge or persistent itching in the anal area.
- Lumps or bumps near the anus.
- Narrowing of the stools.4
Detection and Treatment
Marcia Cross was diagnosed by discussing symptoms with her physician. A digital exam can quickly find abnormalities within the anal area, such as small lumps that need to be biopsied. Treatment is determined by where the malignancy is located and whether it has metastasized. Standard treatment would include local removal of the tumor(s), radiation, and chemotherapy.
More radical treatment, called an abdominoperineal resection, which includes removal of the anus, rectum, and part of the colon, can be performed if other treatments prove unsuccessful, or if there is a recurrence of the carcinoma. Survival statistics are ~ 80% for patients whose cancer was localized at the time of detection but drops to 30% if the cancer has spread to the liver or lungs.4
Conclusion
With the rising incidence of anal carcinoma, nurses can join celebrity spokespeople to assist in educating the public to gain comfort with this “uncomfortable” topic. We can begin to teach patients that symptoms merit immediate attention and screening. We cannot afford to feel awkward discussing the anus when lives depend upon early detection of this deadly disease. If we feel the need for a great opening salvo, we can talk about one of our favorite Charlie’s Angels; she left a beautiful legacy fighting this terrible disease.
Websites:
- Amp.cnn.com “Anal cancer rates and deaths are climbing in the united states, study says.” Rogers, K., November 19, 2019.
- Cancer.gov “Anal cancer incidence and deaths are rising in the United States.”, NCI Staff, December 19, 2019.
- Medscape.com “’Dramatic’ rise in anal cancer incidence and mortality.”, Davenport, L., November 29, 2019.
- Nbcnews.com “What are the symptoms of anal cancer? Disease is on the rise in the U.S.”, Pawlowski, A., November 19, 2019.
