May 2009 Squamous Cell Carcinoma of Anal Canal Treatment Guidelines Presented at Cancer Committee: August 6, 2009 By Shelly Smits, RHIT, CCS, CTR Conclusions by Ian Thompson, MD Data Source: Cancer registry information on squamous cell cancers of anus, anal canal and anorectum (ICD-O-3 codes C21.0-C21.8) diagnosed in 2000 through 2008. Reason for Report: To determine if providers at St. Joseph Hospital (SJH) treat anal canal cancers according to NCCN guidelines. Findings: During this time period, there were 23 cases of invasive squamous cell carcinoma of anus, anal canal or anorectum and 4 cases of in situ squamous cell carcinoma. For purposes of this study, the in situ cases were excluded. These 23 cases were the compared to a study done by Dr. Karl Bilimoia using the National Cancer Data Base (NCDB). This study was presented at the 2008 annual meeting of the Society of Surgical Oncology in March 2008. The national treatment guidelines state that T1N0 well differentiated anal margin cancer can be treated with chemo/radiation or local excision alone. For all others stages, chemo/radiation is recommended as primary treatment for these cancers. The chart below shows the noncompliance percentages. The operative and pathology reports from the 9 patients who were treated with excision alone, or excision followed by Chemo/radiation were reviewed. After reviewing the pathology and operative reports, 4 patients were T1 treated with excision, 3 patients who were coded as excision were actually biopsies and 2 were T2 lesions who had excisions as an attempt at definitive treatment. Hence, 2/9 (22.2%) of the patients who had excisions fell out of recommended care. Overall, there were 4/23 patients who did not receive recommended care (17.4%). Two T2 patients were treated with excision. The other 2 patients did not receive chemotherapy, one of the patients refused chemotherapy and another patient had too many comorbidities to tolerate chemotherapy. While HIV status was mentioned in the study only 5 of the SJH patients had HIV status mentioned in their records. Only 3 (13%) were noted to be HIV positive. All of the HIV stated patients were given the recommend chemoradiation therapy treatment.
Nonguideline care (vs recommended chemoradiation) 2000-2008 SJH cases; 2003-2005 study cases SJH Study All Patients n=23 n=6696 17.4% 22.7% T2 w/excision refused 2/4(50%) 1/4(25%) comorbidity 1/4(25%) Gender Female 13.0% 20.2% Male* 12.5% 28.0% Age <75 yrs 6.3% 20.8% 75 or older 42.9% 27.3% HIV/AIDS Status** Negative 20.0% 22.9% Positive 0.0% 31.3% Overall AJCC I 33.3% 36.6% II 16.7% 20.5% III 10.0% 13.5% *only one patient & too many comorbidities **only 5 patients had HIV status mentioned, others assumed neg. According to the NCCN guidelines for anal cancer, the recommended chemotherapy agents are 5FU and mitomycin. Of the 19 cases that did receive chemotherapy, 16 (84.2%) received this regimen, while 2 (10.5%) received 5FU alone (one due to age and medical problems; other not stated). Only one patient (5.3%) received cisplatin instead of mitomycin due to the advanced stage and per an RTOG trial (as noted by oncologist).
Squamous cell CA of Anus Diagnosed at SJH 2000-2008 Treatment choices Patients Surg 1 Surg + Rad/chemo 6 Rad alone 1 Rad/chemo 1 agent Rad/chemo 2 13 agents Surg/Rad* 2 TOTAL 23 *refused chemo or too sick Survival: The following chart and graphs show the survival rates for anal cancer. 4-Year Anal Cancer Survival SJH (2000-2008)compared to NCDB* (1998-2001) I II III NCDB 82% 68% 49% SJH 100% 67% 78% *National Cancer Data Base
Conclusions: The national standard of care for Anal Cancer is excision or chemo/radiation for T1 Cancers. For all other patients, the preferred treatment is radiation/chemotherapy with surgery reserved for salvage only. In the review by Bilimoia, 22% of patients from the NCDB (a comprehensive and hence reliable picture of national care) did not receive recommended care. At SJH, only 17% of patients did not receive standard of care. HIV positive patients and patients younger than 75 received appropriate care far more commonly at SJH than the national numbers. The only group which received care far less than the national numbers was those SJH patients over age 75. One could argue that the excellent care provided by our Infectious Disease Specialists allow SJH patients to tolerate aggressive radiochemotherapy better than most national patients. It is clear SJH providers must be careful to avoid age bias, but with the small numbers of SJH patients, the differences in care by age may be totally due solely to chance. Overall, it is reassuring to know that SJH provides a high level of recommended standard of care for even rare and unusual cancer like Anal Cancer. Although there is always room for improvement, we meet or exceed the national performance in compliance to the NCCN guidelines.
References: 1. Bilimoria, Karl Y, MD, MS,P lunkett, Sheila A, BA, Bentrem, David J, MD, Halverson, Amy L. Underutilization of recommended treatment for squamous cell carcinoma of the anal canal. The American Journal of Hematology/Oncology April 2009: Vol 8 No 4:177-183. 2. Pappou, Manny, MD, Eckhauser, Frederic, MD. Treatment guidelines and quality of care for patients with squamous carcinoma of the anal canal. The American Journal of Hematology/Oncology April 2009: Vol 8 No 4:185-186. 3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Anal cancers V.1.2009. Available at www.nccn.org. Accessed May 2009