The interdisciplinary management of anal epidermoid carcinoma

Background: The treatment of primary epidermoid anal carcinoma has changed substantially the latest 2 decades. Radical radiotherapy with or without chemotherapy has been widely accepted. However, the optimal treatment is not yet settled. Methods: Since 1978, patients from the Uppsala region, Sweden, were primarily treated with radiotherapy plus bleomycin with surgery only in those with residual disease after a dose of 40 Gy. The total radiation dose in patients not having surgery was approximately 60 Gy. This policy was not introduced in most other Swedish regions until 1984. Population-based materials between 1978 and 1984 from the Uppsala (n=50) and the Stockholm (n=91) Health Care Regions were compared. Results: Comparisons of these entirely unselected materials indicate that a primarily nonsurgical approach improves 5-year survival in the order of 25 to 30% units. Results are favourable also after long-term follow-up. Bleomycin does not seem to add therapeutic benefit. Conclusions: A primarily non-surgical approach is to be preferred, first because it more often results in preserved anal function than surgery, and second because it also improves survival. The place for surgery is still unknown. Should it be used early in patients where the likelihood of tumor control with radio-chemotherapy is not sufficiently high as adapted in Sweden, or should it be reserved for patients in whom the cancer recurs? The latter approach may seem more attractive since it maximizes anal preservation, but healing after surgery in an area where a high tumoricidal radiation dose has been given is impaired. This is not the case after a lower, preoperative dose where the aim is to kill microscopic disease only. Therefore, an interdisciplinary management of this group of patients is essential, where surgeons, radiotherapists and medical oncologists work close to each other. Since anal carcinoma is a rare condition, it is also necessary to centralize the treatment.