2019 Standard 4.6 Monitoring Compliance with Evidence-Based Guidelines Prepared by: Kelvin Raybon, MD, FACP, Medical Director, Center for Cancer & Blood Disorders important features. Along with cervical and oropharyngeal carcinomas, it is one of the malignancies associated with infection with the Human Papilloma Virus (HPV), and is expected be amenable to eradiation by means of vaccination of young unexposed people to HPV. Another important feature is its curability; anal carcinomas can be successfully cured in a majority of patients by a combination of radiation and cytotoxic chemotherapy, making appropriate evaluation and therapy imperative. Introduction Anal carcinoma is an uncommon disease. In 2019 there will be an estimated 8300 new cases in the United States, with an estimated 1280 deaths (American Cancer Society website, October 2019). Despite its relative rarity, it has several 2018 Analytic Cancer Case Distribution (N=727) MALE GENITAL 12% RESPIRATORY SYSTEM 18% Anal carcinomas are squamous cell cancers, and typically present with pain or bleeding with defecation; they are often initially mistaken for hemorrhoids. Risk factors for anal cancer include genital warts, increased number of sexual partners, infection with HIV, and smoking. Incidence is twice as common in women than men. Diagnosis is made by examination and biopsy; staging includes imaging with CT scans, supplemented with MRI or PET/CT if needed. Prognosis depends on clinical staging, and worsens with local nodal spread and increasing size of tumor. DIGESTIVE SYSTEM 20% Treatment historically was surgical, with the morbidity of a permanent colostomy and an overall cure rate of about 50%. However, neoadjuvant treatments with radiation and chemotherapy during the 1980’s led to the realization that anal cancer can be cured with radiation and chemotherapy only, reserving surgery only for salvage (J Natl Cancer Inst 1989; 81:850-56). Attempts to improve on a combination of mitomycin and 5-flourouracil given with radiation (Cancer 1983; 51:1826-29) have largely been unsuccessful (J Clin Oncol 2012; 30:4344-51), and this combination remains standard of care (Curr Opin Oncol 2007; 19:396-400). The expected cure rate with combined modality therapy is 70-80%, with an overall 5 year survival of greater than 65%. BREAST 20% BLOOD & BONE MARROW 6% Monitoring Compliance with Evidence-Based Guidelines BRAIN 3% Other/Ill-defined 0% ORAL CAVITY 1% SKIN 1% ENDOCRINE 1% CONNECTIVE/SOFT TISSUE 1% 8 AUGUSTA HEALTH • CANCER PROGRAM ANNUAL REPORT 2019 FEMALE GENITAL 2% UNK PRIMARY 1% LYMPHATIC SYSTEM 3% URINARY BLADDER 11% Current standard of care guideline used for this review is National Comprehensive Cancer Network (NCCN) Guidelines Version 1.2019, most recently updated 04/25/2019. Methods All cases of anal cancer diagnosed at Augusta Health in 2018 were identified through tumor registry and chart review. Data was individually extracted and reviewed for compliance with standards per NCCN guidelines as noted. continued on page 9
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