The intent of therapy for anal cancer is cure with the least morbidity. Traditionally, the primary treatment for SCC of the anal canal was abdominoperineal resection (APR). Depending on tumor stage, five-year survival after APR was 48% to 71% (6-10). Locoregional recurrence was common and ranged from 18% to 27%.
Contemporary studies for patients receiving radiotherapy alone reported similar five-year survival of 42% to 94%, but with typical sphincter preservation and colostomy-free survival of between 56% and 74% (11-16). Proponents of brachytherapy (BRT), with or without external-beam radiation therapy (EBRT), reported five-year survival rates of 60% to 65% and locoregional control rates of 75% to 79% (17-19). Retrospective studies show excellent local control and survival of >85% at five years obtained by radiotherapy alone for early stage T1-2 anal cancer (20,21). For in situ (Tis) and T1 tumors <1 m, treated with sphincter preserving resection and radiation (EBRT +/- BRT), Ortholan et al. report five-year overall and disease-free survival of 94% and 89%, respectively (22). Toxicity was acceptable, with only grade 1-2 late toxicity occurred in 27% of patients, less in those receiving <60 Gy (14%) than >60 Gy (37%). As with surgery, patients with larger tumors (>5 cm) or nodal involvement had poorer outcome with five-year survival of <60% (20,23,24). The optimal dose, intensity, and duration of radiotherapy either alone, or for that matter in combination with chemotherapy, as discussed later, remain to be defined. Radiation therapy, was thus considered an acceptable alternative to surgery, particularly for patients who might otherwise not be suitable surgical candidates. There is no randomized trial comparing these two modalities of treatment.
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