We all know when you turn to Dr. Google for medical advice, the answer that always comes up is cancer. Given that hemorrhoids are a very common problem that can have similar symptoms, anal cancer is not an uncommon concern for patients presenting to my office. So how do you know when to see a doctor? A good recommendation is to schedule an evaluation with your primary care physician (PCP), gastroenterologist (GI) or colorectal surgeon for rectal bleeding that doesn’t resolve within a month after trying the following: a high fiber diet, stool softeners, avoidance of time and straining on the toilet, and the use of hemorrhoid suppositories. Anal pain that lasts more than two weeks, is constant or increasing and doesn’t respond to the above treatments is worth a visit. Symptomatic hemorrhoids are a common problem that can happen to anyone, since everyone has hemorrhoids. Anal pain and bleeding should be self-limiting and respond to diet and lifestyle changes, if not, then further evaluation is warranted.
Let’s talk a little about anal cancer, since it seems to be a common theme in my office this month. Anal cancer is a relatively rare cancer, occurring <1% of the general population with about 5,000 new cases a year. For comparison, there are about 140,000 new cases of colorectal cancer per year. Anal cancers are typically a squamous cell carcinoma, or a skin cancer, occurring in the skin or mucosa of the anus (the last 3 cm of the digestive tract) or skin near the anus. Colorectal cancer, on the other hand, is typically an adenocarcinoma arising from the colon mucosa.
Anal cancer is similar to cervical and vulvar cancers, in the fact that it is associated with human papilloma virus (HPV). HPV is a sexually transmitted virus, which is very common, but often has no symptoms. Once people have had more than four sexual partners, the exposure rate can be upwards of 85%. Condoms are not protective. There are numerous strains of HPV, but the most common associated with cervical, vulvar and anal cancer are HPV 16 and 18. Other strains of HPV cause anal warts, but these do not increase risk of cancer. There is a vaccine for HPV, which protects against the higher risk and anal wart causing strains. We hope that with vaccination anal, vulvar and cervical cancers can be prevented, or even eradicated.
Other risk factor for anal cancer include: HIV, solid organ transplant (due to immunosuppression), age over 50 years, prior pelvic radiation, smoking, prior cervical or vulvar pre-cancerous lesions (also associated with HPV) and anal receptive sex. There is no routine screening for anal cancer given its low incidence. It can be easily missed on colonoscopy, as the anal canal is not well visualized during this exam. Anal pap smears and high-resolution anoscopy (similar to colposcopy for cervical cancer screening) are offered to higher risk patients in some practices. This procedure evaluates and destroys pre-cancerous lesions, in hopes of preventing anal cancer. Right now, there is no standard recommendations of exactly which patients should be screened or how often to screen.
If an anal cancer is suspected, work up includes, tissue biopsy, a staging CT or PET scan, to look for disease outside the local area, GYN exam for women and HIV testing. Anal cancers are generally treated with a combination of chemotherapy and radiation over 5-6 weeks. If detected early, anal cancers have an excellent response to treatment. The overwhelming majority of patients respond to this treatment and surgery with a colostomy (bag) is rarely required. Once treated, patients are evaluated with office exams every 3-6 month for 5 years.
Anal cancers are rare, but treatable. Patients with HIV, solid organ transplant, anal receptive sex and HPV related cancers are at higher risk and should be watched more closely. There is no routine screening for anal cancer, but an anorectal exam in the office is often sufficient. If rectal bleeding or anal pain persists, visit with a PCP, colorectal surgeon or GI for further evaluation.
Visit fairfaxcolorectal.com or call 703-280-2841 for more information or to schedule a consult.