What Is Anal Cancer?

The anus

The anus is the opening at the lower end of the intestines. It’s where the end of the intestines connect to the outside of the body.

As food is digested, it passes from the stomach to the small intestine. It then moves from the small intestine into the main part of the large intestine (called the colon). The colon absorbs water and salt from the digested food. The waste matter that’s left after going through the colon is known as feces or stool. Stool is stored in the last part of the large intestine, called the rectum. From there, stool is passed out of the body through the anus as a bowel movement.

The anal opening is connected to the rectum by the anal canal. The anal canal is about 1-1/2 inches long. It goes from the rectum to the anal verge. This is where the canal connects to the outside skin at the anus.

The inner lining of the anal canal is the mucosa. Most anal cancers start from cells in the mucosa. Glands and ducts (tubes leading from the glands) are found under the mucosa. The glands make mucus, which acts as a lubricating fluid. Anal cancers that start from cells in the glands are called adenocarcinomas.

The anal canal changes as it goes from the rectum to the anal verge:

• Cells above the anal canal (in the rectum) and in the part of the anal canal close to the rectum are shaped like tiny columns.
• Most cells near the middle of the anal canal are shaped like cubes and are called transitional cells. This area is called the transitional zone.
• About midway down the anal canal is the dentate line, which is where most of the anal glands empty into the anus.
• Below the dentate line are flat (squamous) cells.
• At the anal verge, the squamous cells of the lower anal canal merge with the skin just outside the anus. This skin around the anal verge (called the perianal skin or the anal margin) is also made up of squamous cells, but it also contains sweat glands and hair follicles, which are not found in the lining of the lower anal canal.

Anal cancers are often divided into 2 groups, which are sometimes treated differently:

• Cancers of the anal canal (above the anal verge)
• Cancers of the anal margin (below the anal verge)

Sometimes anal cancers extend from one area into the other, so it’s hard to know exactly where they started.

The anal canal is surrounded by a sphincter, which is a circular muscle that keeps stool from coming out until it relaxes during a bowel movement.

Anal tumors

Many types of tumors can develop in the anus. Not all of these tumors are cancers – some are benign (not cancer)

• Inflammatory polyps start because of irritation from injury or infection.
• Lymphoid polyps are caused by an overgrowth of lymph tissue (which is part of the immune system). Lymph tissue under the anal inner lining (mucosa) is normal, but these overgrowths are not.
• Hypertrophied anal papillae are benign growths of connective tissue that are covered by squamous cells. They are simply enlarged normal papillae, which are small folds of mucosa found at the dentate line. Hypertrophied anal papillae are also called fibroepithelial polyps.

Skin tags are benign growths of connective tissue that are covered by squamous cells. Skin tags are often mistaken for hemorrhoids (swollen veins inside the anus or rectum), but they’re not the same.

Anal warts (also called condylomas) are growths that form just outside the anus and in the lower anal canal below the dentate line. Sometimes they can be found just above the dentate line. They’re caused by infection with human papilloma virus (HPV). People who have or had anal warts are more likely to get anal cancer. (See “Potentially pre-cancerous anal conditions” below and Risk Factors for Anal cancer).

• Adnexal tumors: Usually benign growths that start in hair follicles or sweat glands of the skin just outside of the anus. These tumors stay in the perianal skin area and do not grow into the anal region.
• Leiomyomas: Benign tumors that develop from smooth muscle cells
• Granular cell tumors: Tumors that develop from nerve cells and are composed of cells that contain lots of tiny spots (granules)
• Hemangiomas: Tumors that start in the cells lining blood vessels
• Lipomas: Benign tumors that start from fat cells
• Schwannomas: Tumors that develop from cells that cover nerves

Potentially pre-cancerous anal conditions

Some changes in the anal mucosa are harmless at first, but might later develop into a cancer. These are called pre-cancerous conditions. A common term for these potentially pre-cancerous conditions is dysplasia. Some warts, for example, contain areas of dysplasia that can develop into cancer.

Dysplasia in cells of the anus is also called anal intraepithelial neoplasia (AIN) or anal squamous intraepithelial lesions (SILs). Depending on how the cells look, AIN or anal SIL can be divided into 2 groups:

Low-grade AIN (sometimes called AIN1 or low-grade anal SIL)

The cells in low-grade AIN look like normal cells in many ways.

Low-grade AIN often goes away without treatment. It has a low chance of turning into cancer.

High-grade AIN is less likely to go away without treatment and, with time, could become cancer. It needs to be watched closely. Some cases of high-grade AIN need to be treated.

Types of anal cancer

Some doctors see this as the earliest form of anal cancer. Others consider it the most advanced type of AIN, which is a pre-cancer (see above), but not a true cancer.

Invasive anal cancers

These are the different types of cancer that can start in the anal region:

Squamous cell carcinomas

Most anal cancers in the United States are squamous cell carcinomas. (Nearly 9 out of 10 cases.) These tumors start in the squamous cells that line most of the anal canal and the anal margin.

Squamous cell carcinomas in the anal canal have grown beyond the surface and into the deeper layers of the lining (as opposed to carcinoma in situ which is only in the surface cells).

Cloacogenic carcinomas

(also called basaloid or transitional cell carcinomas) are a type of squamous cell cancer. They develop in the transitional zone, also called the cloaca. These cancers look slightly different under a microscope, but they behave and are treated like other squamous cell carcinomas of the anal canal.

Squamous cell carcinomas of the anal margin (perianal skin) are treated much like squamous cell carcinomas of the skin elsewhere. For more on this, see Skin Cancer: Basal and Squamous Cell.

Adenocarcinomas

A small number of anal cancers are known as adenocarcinomas. These start in cells that line the upper part of the anus near the rectum. They can also start in the glands under the anal mucosa that release secretions into the anal canal. Most anal adenocarcinomas are treated the same as rectal carcinomas. For more information, see Colorectal Cancer.

Adenocarcinomas can also start in apocrine glands (a type of sweat gland of the perianal skin). Paget’s disease is a type of apocrine gland carcinoma that spreads through the surface layer of the skin. Paget’s disease can affect skin anywhere in the body but most often affects skin of the perianal area, vulva, or breast. This should not be confused with Paget’s disease of the bone , which is not cancer and a different disease.

Basal cell carcinomas

Basal cell carcinomas are a type of skin cancer that can develop in the perianal skin. These tumors are much more common in areas of skin exposed to the sun, such as the face and hands, and account for very few anal cancers. They are often treated with surgery to remove the cancer. For more information, see Skin Cancer: Basal and Squamous Cell.

Melanomas

These cancers start in cells in the skin or anal lining that make the brown pigment called melanin. Only a very small portion of anal cancers are melanomas. Melanomas are far more common on the skin in other parts of the body. If melanomas are found at an early stage (before they have grown deeply into the skin or spread to lymph nodes) they can be removed with surgery, and the outlook for long-term survival is very good. But because anal melanomas are hard to see, most are found at a later stage. If possible, the entire tumor is removed with surgery. If all of the tumor can be removed, a cure is possible. If the melanoma has spread too far to be removed completely, other treatments may be given. For more on this, see Melanoma Skin Cancer.

Gastrointestinal stromal tumors (GISTs)

These cancers are much more common in the stomach or small intestine, but rarely they can start in the anal region. When these tumors are found at an early stage, they are removed with surgery. If they have spread beyond the anus, they can be treated with drug therapy. For more information, see Gastrointestinal Stromal Tumor (GIST).

The anal cancer information on our web site focuses mainly on anal squamous cell carcinoma, which is, by far, the most common type of anal cancer.

Symptoms and signs

  Common symptoms of anal cancer may include

• rectal bleeding noticeable if there is blood on feces or toilet paper
• pain in the anal area
• lumps around the anus, which may be mistaken for piles, or hemorrhoids
• mucus or jelly-like discharge from the anus
• anal itching
• changes in bowel movements, including diarrhea, constipation, or thinning of stools
• fecal incontinence, or problems controlling bowel movements
• bloating
• women may experience lower back pain as the tumor presses on the vagina
• women may experience vaginal dryness

Causes

In anal cancer, a tumor is created by the abnormal and uncontrolled growth of cells in the anus.

The anus is the area at the very end of the gastrointestinal tract. The anal canal connects the rectum to the outside of the body. It is surrounded by a muscle known as the sphincter. The sphincter controls bowel movements by contracting and relaxing. The anus is the part where the anal canal opens to the outside.

The anal canal is lined with squamous cells. These flat cells look like fish scales under the microscope. Most anal cancers develop from these squamous cells. Such cancers are known as squamous cell carcinomas.

The point at which the anal canal meets the rectum is called the transitional zone. The transitional zone has squamous cells and glandular cells. These produce mucus which helps the stool, or feces, pass through the anus smoothly.

Most anal cancers are squamous cell carcinomas, but adenocarcinoma can also develop from the glandular cells in the anus.

Risk factors

Multiple risk factors have been studied that are linked to anal cancer. They include any or a combination of the following:

• Human papilloma virus (HPV): Some types of HPV are closely linked to anal cancer. Around 79 percent of people with anal cancer have HPV 16 or 18, and 8 percent have other types of HPV.
• Multiple sexual partners: This activity increases the risk of contracting HPV, which, in turn, increases the risk of anal cancer, which is a known risk factor.
• Receptive anal intercourse: Men and women who receive anal intercourse have a higher risk of developing anal cancer. Men who are HIV-positive and who have sex with men are up to 90 times more likely to develop anal cancer, compared with the general population.
• Other cancers: Women who have had vaginal or cervical cancer, and men who have had penile cancer are at higher risk of developing anal cancer. This is also linked to HPV infection.
• Age: Anal cancer, like most cancers, are more likely to be detected at an older age.
• A weakened immune system: People with HIV or AIDS and those who are taking immunosuppressant medications after a transplant are at greater risk.
• Smoking: Smokers have a significantly higher risk of anal and other cancers than non-smokers.
• Benign anal lesions: Irritable bowel disease (IBD), hemorrhoids, fistulae, or cicatrices have been linked to anal cancer. Inflammation resulting from benign anal lesions may increase the risk.

Treatment

Treatment for anal cancer will depend on various factors, including how big the tumor is, whether or not it has spread, where it is, and the general health of the patient. Surgery, chemotherapy, and radiation therapy are the main options.

Surgery

The type of surgery depends on the size and position of the tumor.

Resection

The surgeon removes a small tumor and some surrounding tissue. This can only be done if the anal sphincter is not affected. After this procedure, the person will still be able to pass a bowel movement.

Abdominoperineal resection

The anus, rectum and a section of the bowel are surgically removed, and a colostomy will be established. In a colostomy, the end of the bowel is brought out to the surface of the abdomen. A bag is placed over the stoma, or the opening. The bag collects the stools outside the body. A person with a colostomy can lead a normal life, play sports, and be sexually active.

Chemotherapy and radiotherapy

Most patients will probably need chemotherapy, radiation therapy, or both.

Radiation therapy may be combined with chemotherapy to destroy anal cancer cells. Treatments may be given together or one after the other. This approach increases the chance of retaining an intact anal sphincter. Survival and remission rates are good.

Chemotherapy uses cytotoxic drugs that prevent the cancer cells from dividing. They are given orally or by injection.

Radiotherapy uses high-energy rays that destroy the cancer cells. Radiation can be delivered internally or externally.

Radiotherapy and chemotherapy have adverse effects, and combining them may make the side effects more acute.

Side effects may include:

• diarrhea or constipation
• soreness and blistering around the target area, which is the anus
• a higher susceptibility to infections during treatment
• fatigue
• loss of appetite
• nausea or vomiting
• mouth ulcers or sore mouth
• loss of hair
• narrowing and dryness of the vagina
• a low white blood cell count, increasing the risk of infection
• anemia, due to a low red blood cell count
• a low platelet count, raising the risk of bruising or bleeding
• dry skin
• rashes
• muscle and nerve problems
• excessive coughing and sometimes breathing difficulties
• fertility problems

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