Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Anal Cancer

The value of routine histopathological examination after haemorrhoidectomy in patients at low and high risk of anal squamous intraepithelial lesions and cancer

AIM

Routine histopathological evaluation of haemorrhoidectomy specimens is not ubiquitous amongst surgeons as its utility is debatable. This is the first study to assess the detection rate of anal squamous intraepithelial lesions (aSIL) and anal squamous cell carcinoma (aSCC) in low- and high-risk patients.

METHOD

This 9-year retrospective study assessed electronic medical records of all patients who underwent excisional haemorrhoidectomy within an Australian tertiary referral hospital. Patients with sinister clinical examination findings were excluded from the study. Data collected included patient demographics, pertinent history, relevant risk factors, histopathology reports and digital rectal examination findings. Cost-benefit analysis of routine pathology submission and a city-wide survey of surgeons to ascertain current practices were also undertaken.

RESULTS

The overall prevalence of incidental aSIL and aSCC was 27 (8.1%); 19 patients (5.7%) had low-grade squamous intraepithelial lesions (LSILs), seven (2.1%) had high-grade squamous intraepithelial lesions (HSILs) and one patient (0.3%) had aSCC. More than three out of four were detected in low-risk patients, with most cases being LSIL. Comparing low-risk and high-risk patients, the observed incidental detection rate of aSIL and aSCC was 6.8% (95% CI 4.49-10.17) and 23.1% (95% CI 11.03-52.05), respectively. Multivariate logistic regression showed a large, significant association between high-risk risk factors and detecting aSIL and aSCC (OR 3.76, 95% CI 1.32-10.68, P = 0.013). A city-wide survey of surgeons demonstrated that 28.6% do not request routine histopathological evaluation and 64.3% thought that the prevalence of sinister incidental pathology in haemorrhoids was 1% or less. The total cost of conducting routine histopathological evaluation per patient was $96.80 AUD ($59.20 EUR, $65.30 USD).

CONCLUSION

Given the non-negligible incidental detection rate of aSIL and aSCC in both low-risk and high-risk patients, coupled with the cost-effectiveness of histopathological examination, this study suggests that routine histopathological examination should not be restricted solely to high-risk patients. Further study of the benefit of surveillance following clinical detection in low- and high-risk patients is needed.

Metformin modulates FJX1 via upregulation of Hsa-miR-1306-3p to suppress colon adenocarcinoma viability

Metformin, widely used for the treatment of type 2 diabetes, has recently gained attention for its potential anticancer properties. Several studies have shown that metformin treatment inhibits cell viability in colon adenocarcinoma (COAD); however, the research related to the tumor-node-metastasis (TNM) stage is limited. As COAD is frequently diagnosed at an advanced stage, understanding the genetic factors that regulate the pathogenesis of COAD at each TNM stage and the effects of metformin for potential treatment. Therefore, we identified differentially expressed factors at the TNM stage in metformin-treated COAD cells and investigated their regulatory mechanisms using microRNAs (miRNAs). Through bioinformatics analyses, four-jointed box kinase 1 (FJX1) and hsa-miR-1306-3p were identified as differentially expressed in COAD upon metformin treatment. Metformin treatment significantly reduced cell viability, with an observed decrease of approximately 50%. Analysis using quantitative real-time PCR showed an increase in hsa-miR-1306-3p and a decrease in FJX1 expression upon metformin treatment compared to untreated cells. Luciferase assay confirmed the sequence-specific binding of hsa-miR-1306-3p to FJX1. These findings highlight the potential of metformin as a therapeutic agent for COAD by modulating FJX1 expression via upregulation of hsa-miR-1306-3p, revealing novel avenues for COAD treatment.

Systematic review of survival following liver or lung metastasectomy for metastatic anal squamous cell carcinoma

INTRODUCTION

Metastatic anal squamous cell carcinoma (SCC) carries a poor prognosis and the evidence base for surgical resection of metastases remains limited. The aim of this study was to establish the survival outcomes for patients undergoing metastasectomy for anal SCC.

METHODS

A systematic review was performed using the MEDLINE®, Embase®, Cochrane and PubMed® databases. Studies were considered for inclusion in the review if they involved patients aged >18 years with a diagnosis of stage IV anal SCC who underwent metastasectomy for liver and/or lung metastases. The primary outcome measure was overall survival. Secondary outcome measures were disease free survival, early morbidity according to the Clavien-Dindo classification and quality of life, measured using a validated scoring tool. Risk of bias was assessed with the ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tool.

RESULTS

There were 10 studies with a total of 98 patients. There was heterogeneity in results reporting, with recurrence free survival the most reported outcome. For all studies reporting on liver metastasectomy, the one-year overall survival rate was 87%. In studies with adequate follow-up reported, the three and five-year overall survival rates were 53% and 38% respectively. Only one study reported on lung metastasectomy patients; the overall median survival was 24 months. None of the studies reported on quality of life measures. The ROBINS-I tool identified a critical risk of bias in six studies, a serious risk in one study and a moderate risk in three studies.

CONCLUSIONS

The evidence base for metastasectomy in metastatic anal SCC is limited. Further information is required to inform future treatment methods and use of a standardised outcomes reporting method is needed to support this.

Accuracy and Clinical Impact of Persistent Disease Diagnosed on Diffusion-Weighted Imaging and Accuracy of Pelvic Nodal Assessment on Magnetic Resonance Imaging for Squamous Cell Carcinoma of the Anus in the 6-Month Interval Post Chemoradiotherapy

PURPOSE

To evaluate the diagnostic performance of diffusion-weighted imaging (DWI) in the 6-month interval post chemoradiation therapy (CRT) in determining persistent disease and whether persistent diffusion restriction on DWI at 6 months is associated with overall survival; and secondarily, to investigate the accuracy of pelvic lymph node assessment on T2-weighted imaging and DWI in the 6-month interval post CRT, in patients with squamous cell carcinoma of the anus.

METHODS AND MATERIALS

This retrospective study included patients with squamous cell carcinoma of the anus who underwent CRT followed by restaging rectal MRI from January 2010 to April 2020, with ≥1 year of follow-up after CRT. DW images were qualitatively evaluated by 2 junior and 2 senior abdominal radiologists to determine anal persistent disease. The reference standard for anal persistent disease was digital rectal examination/endoscopy and histopathology. Diagnostic performance was estimated using sensitivity, specificity, negative predictive value, and positive predictive value. Survival outcomes were evaluated via Kaplan-Meier analysis, and associations between survival outcomes and DWI status were tested for significance using the log-rank test. Additionally, DW and T2-weighted images were evaluated to determine lymph node status.

RESULTS

Among 84 patients (mean age, 63 ± 10.2 years; 64/84 [76%] female), 14 of 84 (17%) had confirmed persistent disease. Interreader agreement on DWI between all 4 radiologists was moderate (Light's κ = 0.553). Overall, DWI had a sensitivity of 71.4%, specificity of 72.1%, positive predictive value of 34.5%, and negative predictive value of 92.5%. Patients with a negative DWI showed better survival than patients with a positive DWI (3-year overall survival of 92% vs 79% and 5-year overall survival of 87% vs 74%), although the difference did not reach statistical significance (P = .063). All patients with suspicious lymph nodes (14/14, 100%) showed negative pathology or decreased size during follow-up.

CONCLUSIONS

At 6 months post CRT, DWI showed value in excluding anal persistent disease. Persistent diffusion restriction on DWI was not significantly associated with overall survival. Pelvic nodal assessment on DWI and T2-weighted imaging was limited in predicting persistent nodal metastases.

Comparison between pelvic MRI, CT, and PET/CT in baseline staging and radiation planning of anal squamous cell carcinoma

PURPOSE

To investigate the differences in baseline staging of anal squamous cell carcinoma based on CT, MRI, and PET/CT, and the resultant impact on the radiation plan.

METHODS

This retrospective study included consecutive patients with anal squamous cell carcinoma who underwent baseline pelvic MRI, CT, and PET/CT (all examinations within 3 weeks of each other) from January 2010 to April 2020. CTs, MRIs, and PET/CTs were re-interpreted by three separate radiologists. Several imaging features were assessed; tumor stage was determined based on the eight edition of the American Joint Committee on Cancer (AJCC) staging manual; and T (tumor), N (node), and M (metastasis) categories were determined based on National Comprehensive Cancer Network (NCCN) guidelines. Radiologist assessments were then randomly presented to a radiation oncologist who formulated the radiation plan in a blinded fashion.

RESULTS

Across 28 patients (median age, 62 years [range, 31-78], T-category classification was significantly different on PET/CT compared to MRI and CT (p = 0.037 and 0.031, respectively). PET/CT staged a higher proportion of patients with T1/T2 disease (16/28, 57%) compared to MRI (11/28, 39%) and CT (10/28, 36%). MRI staged a higher proportion of patients with T3/T4 disease (14/28, 50%) compared to CT (12/28, 43%) and PET/CT (11/28, 39%). However, there was no significant difference between the three imaging modalities in terms of either N-category, AJCC staging, or NCCN TNM group classification, or in treatment planning.

CONCLUSION

Our exploratory study showed that MRI demonstrated a higher proportion of T3/T4 tumors, while PET/CT demonstrated more T1/T2 tumors; however, MRI, CT, and PET/CT did not show any significant differences in AJCC and TNM group categories, nor was there any significant difference in treatment doses between them when assessed independently by an experienced radiation oncologist.

Personalized medicine for locally advanced rectal cancer: five years of complete clinical response after neoadjuvant radiochemotherapy-a case report with a literature review

We present a case report of a 73-year-old male patient with a complete clinical response following neoadjuvant radiochemotherapy of mid-rectal adenocarcinoma. The patient was initially diagnosed with stage IIIB microsatellite stable mid-rectal adenocarcinoma in February 2017. During restaging in June 2017, which included rectoscopy, endosonography, computed tomography and magnetic resonance imaging, a complete clinical response was observed. After appropriate consultation, a watch-and-wait strategy was chosen. During stringent follow-up every 3 months for the first 3 years and thereafter every 6 months, no recurrence or regrowth was observed. After the fifth year of complete clinical response, we recommended an annual follow-up. As of November 2023, the patient has no signs of recurrence or late toxicity after radiochemotherapy. The omission of resection in patients with locally advanced rectal cancer and the establishment of a watch-and-wait strategy are currently under discussion as possible treatment courses in patients with complete clinical response. Long-term data on watch-and-wait strategies for patients with a complete clinical response in locally advanced rectal cancer are rare. A clear national and international accepted standardization of follow-up programs for patients managed by a watch-and-wait strategy in the long-term is missing. Here, we report the case of a patient who had undergone a follow-up program for more than five years and discuss the current literature. Our case report and literature review highlights that a watch-and-wait strategy does not seem to increase the risk of systemic disease or compromise survival outcomes in selected locally advanced rectal cancer patients. Thus, our case contributes to the growing body of knowledge on personalized and precision medicine for rectal cancer.

Transanal minimally invasive surgery (TAMIS) for local excision of benign and malignant rectal neoplasia: a 7-year experience

PURPOSE

Transanal minimally invasive surgery (TAMIS) is an advanced transanal platform that can be utilised to perform high-quality local excision (LE) of rectal neoplasia. This study describes clinical and midterm oncological outcomes from a single unit's 7-year experience with TAMIS.

METHODS

Consecutive patients who underwent TAMIS LE at our institution between January 1st, 2016, and December 31st, 2022, were identified from a prospectively maintained database. Indication for TAMIS LE was benign lesions not amenable to endoscopic excision or histologically favourable early rectal cancers. The primary endpoints were resection quality, disease recurrence and peri-operative outcomes. The Kaplan-Meier survival analyses were used to describe disease-free survival (DFS) for patients with rectal adenocarcinoma that did not receive immediate salvage proctectomy.

RESULTS

There were 168 elective TAMIS LE procedures performed for 102 benign and 66 malignant lesions. Overall, a 95.2% negative margin rate was observed, and 96.4% of lesions were submitted without fragmentation. Post-operative morbidity was recorded in 8.3% of patients, with post-operative haemorrhage, being the most common complication encountered. The mean follow-up was 17 months (SD 15). Local recurrence occurred in 1.6%, and distant organ metastasis was noted in 1.6% of patients.

CONCLUSIONS

For carefully selected patients, TAMIS for local excision of early rectal neoplasia is a valid option with low morbidity that maintains the advantages of organ preservation.

Predictors of recurrence following local excision for early-stage anal squamous cell carcinoma

INTRODUCTION

There is increasing use of local excision (LE) for definitive treatment of early-stage anal squamous cell carcinoma (ASCC) to avoid the morbidity associated with chemoradiotherapy (CRT). However, the importance of different histological variables on risk of recurrence is poorly understood.

METHODS

A detailed analysis of patient characteristics, histology results, recurrence patterns and salvage treatment was conducted in consecutive T1/T2N0 ASCC patients treated by LE 2010-2021 across a UK regional cancer network multi-disciplinary team (MDT). Associations between potential predictors of disease recurrence were explored using chi-squared and Kruskal-Wallis tests for categorical and continuous variables respectively.

RESULTS

Of 621 ASCC patients discussed in the network MDT, 164 had early-stage disease (T1/T2 N0). Of these, 36 (22%) were deemed suitable for LE (median age 61 years, female to male ratio 2:1). Twenty-two LE tumours were T1; 14 were T2. There were 12 well-differentiated tumours, 21 moderate and 3 poorly-differentiated. Seven out of 36 LE patients (19.4%) developed recurrence, all of whom went on to have salvage treatment with CRT (n = 4), re-excision (n = 2) or radiotherapy (n = 1). Predictors of disease recurrence following LE were: tumour differentiation (p = 0.024), tumour depth (p = 0.033) and R1 resection margin (p = 0.034). Tumour stage and site (margin/canal) were non-significant.

CONCLUSION

LE for T1/T2 N0 ASCC of the margin or canal is a viable treatment strategy to avoid the morbidity associated with CRT and salvage treatments are still available for patients that develop recurrence. Tumour differentiation, depth and margin status are all important factors to consider when discussing management of early-stage ASCC.

Colorectal cancer treatment guidelines and shared decision making quality and reporting assessment: Systematic review

INTRODUCTION

Physicians must share decisions and choose personalised treatments regarding patients´ beliefs and values.

OBJECTIVE

To analyse the quality of the recommendations about shared decision making (SDM) in colorectal (CRC) and anal cancer treatment clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Guidelines were systematically reviewed following prospective registration (Prospero: CRD42021286146) without language restrictions searching 15 databases and 59 professional society websites from January 2010 to November 2021. A validated 31-item SDM quality assessment tool was employed to extract data in duplicate.

RESULTS

We identified 134 guidelines. Only 46/134 (34.3 %) mentioned SDM. Fifteen (11.1 %) made clear, precise and actionable recommendations, while 9/134 (6.7 %) indicated the strength of the SDM-related recommendations. CPGs underpinned by systematic reviews reported SDM more often than those based on consensus or reviews (35.9 % vs 32.0 %; p = 0.031). Guidelines that reported following quality tools (i.e., AGREE II) more commonly commented about SDM than when it was not reported (75.0 % vs 32.0 %; p = 0.003).

CONCLUSION AND PRACTICE IMPLICATIONS

Most of the CRC and anal treatment guidelines did not mention SDM and it was superficial. Guidelines based on systematic reviews and those using quality tools demonstrated better reporting of SDM. Recommendations about SDM in these guidelines merit urgent improvement.

Imaging of Anal Squamous Cell Carcinoma: Survey Results and Expert Opinion from the Rectal and Anal Cancer Disease-Focused Panel of the Society of Abdominal Radiology

The role and method of image-based staging of anal cancer has evolved with the rapid development of newer imaging modalities and the need to address the rising incidence of this rare cancer. In 2014, the European Society of Medical Oncology mandated pelvic magnetic resonance imaging (MRI) for anal cancer and subsequently other societies such as the National Comprehensive Cancer Network followed suit with similar recommendations. Nevertheless, great variability exists from center to center and even within individual centers. Notably, this is in stark contrast to the imaging of the anatomically nearby rectal cancer. As participating team members for this malignancy, we embarked on a comprehensive literature review of anal cancer imaging to understand the relative merits of these new technologies which developed after computed tomography (CT), e.g., MRI and positron emission tomography/computed tomography (PET/CT). The results of this literature review helped to inform our next stage: questionnaire development regarding the imaging of anal cancer. Next, we distributed the questionnaire to members of the Society of Abdominal Radiology (SAR) Rectal and Anal Disease-Focused Panel, a group of abdominal radiologists with special interest, experience, and expertise in rectal and anal cancer, to provide expert radiologist opinion on the appropriate anal cancer imaging strategy. In our expert opinion survey, experts advocated the use of MRI in general (65% overall and 91-100% for primary staging clinical scenarios) and acknowledged the superiority of PET/CT for nodal assessment (52-56% agreement for using PET/CT in primary staging clinical scenarios compared to 30% for using MRI). We therefore support the use of MRI and PET and suggest further exploration of PET/MRI as an optimal combined evaluation. Our questionnaire responses emphasized the heterogeneity in imaging practice as performed at numerous academic cancer centers across the United States and underscore the need for further reconciliation and establishment of best imaging practice guidelines for optimized patient care in anal cancer.

Management of small (T1-T2) anal margin squamous cell carcinoma: clinical outcomes following local excision alone

AIM

Squamous cell carcinomas of the anus are normally treated with synchronous chemoradiotherapy (CRT). Small, localized anal margin tumours may be adequately treated by local excision (LE) alone. This study aims to investigate the outcomes of patients with anal margin tumours treated with LE alone, reserving the use of CRT for salvage on local recurrence (LR).

METHODS

Patients with small, localized (stage I/IIA) anal margin tumours treated by LE from October 1999 to September 2018 were identified. The effect of tumour size and resection margin on LR risk was analysed. Outcomes of overall survival and disease-free survival were measured.

RESULTS

Fifty-five patients with anal margin tumours were identified. Overall 5-year LR, overall survival and disease-free survival rates were 8%, 86% and 82% respectively. Of the seven LRs, five were successfully salvaged with CRT with no further recurrence and two were not fit for CRT. Resection margins in non-fragmented tumours and tumour size did not significantly influence LR risk.

CONCLUSIONS

Most small, localized anal margin tumours can be adequately treated by LE alone with low LR rates. Most patients who developed LR were salvaged using CRT, with no cancer-related deaths reported.

Anal Cancer in High-Risk Women: The Lost Tribe

In developed countries the incidence of anal squamous cell carcinoma (SCC) has been rising; especially in women over the age of 60 years who present with more advanced disease stage than men. Historically, anal SCC screening has focused on people living with Human Immunodeficiency Virus (HIV) (PLWH) who are considered to be at the highest risk of anal SCC, and its precancerous lesion, anal squamous intraepithelial lesion (SIL). Despite this, women with vulval high-grade squamous epithelial lesions (HSIL) and SCCs have been shown to be as affected by anal HSIL and SCC as some PLWH. Nevertheless, there are no guidelines for the management of anal HSIL in this patient group. The ANCHOR trial demonstrated that treating anal HSIL significantly reduces the risk of anal SCC in PLWH, there is therefore an unmet requirement to clarify whether the screening and treatment of HSIL in women with a prior genital HSIL is also beneficial. This review presents the current evidence supporting the screening, treatment, and surveillance of anal HSIL in high-risk women with a previous history of genital HSIL and/or SCC.

Anal Cancer: Emerging Standards in a Rare Rare Disease

The social stigma surrounding an anal cancer diagnosis has traditionally prevented open discussions about this disease. However, as recent treatment options and an increasing rate of diagnoses are made worldwide, awareness is growing. In the United States alone, 9,090 individuals were expected to be diagnosed with anal cancer in 2021. The US annual incidence of squamous cell carcinoma of the anus continues to increase by 2.7% yearly, whereas the mortality rate increases by 3.1%. The main risk factor for anal cancer is a human papillomavirus infection; those with chronic immunosuppression are also at risk. Patients with HIV are 19 times more likely to develop anal cancer compared with the general population. In this review, we have provided an overview of the carcinoma of the anal canal, the role of screening, advancements in radiation therapy, and current trials investigating acute and chronic treatment-related toxicities. This article is a comprehensive approach to presenting the existing data in an effort to encourage continuous international interest in anal cancer.

Pretreatment colostomy in patients with anal squamous cell carcinoma: Risk factors for a permanent stoma

BACKGROUND

The current standard of care for anal squamous cell carcinoma (SCC) is concurrent chemoradiation (CRT), which enables tumor eradication while preserving the anal sphincter. Patients with locally advanced tumors, however, may experience complications that preclude treatment before stoma creation.

OBJECTIVE

To evaluate the reversal rate of pretreatment stomas and the risk factors associated with nonreversal.

METHODS

This single-institution retrospective cohort study using a prospective database included patients diagnosed with anal SCC from January 2008 to December 2020 who required a stoma before curative CRT.

RESULTS

In total, 651 patients were identified; 65 required a stoma before chemoradiation due to obstruction (43.1%), rectovaginal fistula (20%), and perianal sepsis (36.9%). The stoma was reversed in nine patients after a mean follow-up of 35.8 months. Risk factors associated with a permanent stoma were perianal sepsis (p = 0.010), interruptions during radiotherapy for more than 7 days (p = 0.010), male sex (p = 0.013), poor performance status (Eastern Cooperative Oncology Group [ECOG] ≥ 2) (p = 0.023), large tumors (p = 0.045), and cisplatin-based chemotherapy (p = 0.047).

CONCLUSIONS

Pretreatment stomas are unlikely to be reversed, and risk factors for a permanent stoma are perianal sepsis, interruptions during radiotherapy for more than 7 days, male sex, poor performance status (ECOG ≥ 2), large tumors, and cisplatin-based chemotherapy.

Outcomes of perineal reconstruction with inferior gluteal artery myocutaneous flaps and primary closure following abdominoperineal resection

BACKGROUND

Perineal wound morbidity following abdominoperineal resection (APR) is a significant challenge. Myocutaneous flap-based techniques have been developed to overcome morbidity associated with perineal reconstruction. We reviewed outcomes for patients undergoing APR in a hospital that performs inferior gluteal artery myocutaneous (IGAM) island transposition flaps and primary closure (PC) for perineal reconstruction.

METHODS

A retrospective study of patients who underwent APR for malignancy between January 2012 and March 2020 was performed and outcomes between IGAM reconstruction and PC compared. Primary outcomes were wound infection and dehiscence. Secondary outcomes included return to theatre, operative time, length of stay, flap loss and perineal hernia incidence.

RESULTS

One-hundred and two patients underwent APR, with 50 (49%) who had PC and 52 (51%) had IGAM flap reconstructions. There were no differences between each group with regards to wound infection (23 vs. 22%, P = 0.55) or wound dehiscence (25 vs. 24%, P = 0.92). Thirteen (25%) IGAM patients required a return to theatre compared to three PC patients (6%) (P = 0.008). IGAM procedures required twice the overall operative time (506 vs. 240 min, P = 0.001) with no differences between groups when comparing the APR component (250 vs. 240 min, P = 0.225). The IGAM group had a longer length of stay (median 13 days vs. 9 days, P = 0.001). Only one IGAM flap was lost and no symptomatic hernias were identified.

CONCLUSION

Perineal closure technique did not affect the incidence of wound infection or dehiscence. Closure technique should be tailored to underlying patient characteristics and surgical pathology.

Demographics and incidence of anal squamous cell carcinoma in people living in high HIV prevalence geographical areas

OBJECTIVES

Anal squamous cell carcinoma (ASCC) is an uncommon cancer that is rapidly increasing in incidence. HIV is a risk factor in the development of ASCC, and it is thought that the rapidly increasing incidence in men is related to increasing numbers of people living with HIV (PLWH). We undertook a population-based study comparing the demographics and incidence of ASCC in patients residing high HIV prevalence areas in England to patients living in average HIV prevalence areas in England.

METHODS

This is a cross-sectional study following the 'Strengthening the Reporting of Observational Studies in Epidemiology' statement. Demographic data and incidence rates of ASCC within Clinical Commissioning Groups (CCGs) between 2013 and 2018 were extracted from the Cancer Outcomes and Services Dataset. CCGs were then stratified by HIV prevalence from data given by Public Health England, and high HIV prevalence geographical areas were compared with average HIV geographical areas.

RESULTS

Patients in high HIV areas were more likely to be young and male with higher levels of social deprivation. Incidence rates in men between 2013 and 2017 were higher in high HIV areas than average HIV areas with a rapidly increasing incidence rates in early-stage disease and a 79.1% reduction in incidence of metastatic stage 4 disease.Whereas women in high HIV areas had lower ASCC incidence than the national average and a low incidence of early-stage disease; however, metastatic disease in women had quintupled in incidence in high HIV areas since 2013.

CONCLUSIONS

Patients presenting with ASCC in high HIV geographical areas have different demographics to patients presenting in average HIV geographical areas. This may be related to screening programmes for PLWH in high HIV areas.

Comparing and contrasting clinical consensus and guidelines for anal intraepithelial neoplasia in different geographical regions

Anal Squamous Cell Carcinoma (ASCC) is an uncommon cancer with a recognised precursor Anal Intraepithelial Neoplasia (AIN). Although there are consistent evidence-based guidelines for the management of ASCC, historically this has not been the case for AIN and as a result there have been geographical variations in the recommendations for the treatment of AIN. More recently there have been updates in the literature to the recommendations for the management of AIN. To assess whether we are now closer to achieving an international consensus, we have completed a systematic scoping review of available guidelines for the screening, treatment and follow-up of AIN as a precursor to ASCC. MEDLINE and EMBASE were systematically searched for available clinical guidelines endorsed by a recognised clinical society that included recommendations on either the screening, treatment or follow-up of AIN. Nine clinical guidelines from three geographical areas were included. The most recent guidelines agreed that screening for AIN in high-risk patients and follow-up after treatment was necessary but there was less consensus on the modality of screening. Six Guidelines recommended the treatment of high-grade AIN and four guidelines describe a follow-up protocol of patients diagnosed with AIN. There appears to be increasing consensus on the treatment and follow-up of patients despite a poor evidence base. There is still significant discrepancy in guidance on the method to identify patients at risk of ASCC and AIN despite consensus between geographical regions on which patient subgroups are at the highest risk.

The Role of Demographics, Social Deprivation and Ethnicity on Anal Squamous Cell Carcinoma Incidence in England

Anal Squamous Cell Carcinoma (ASCC) is an HPV-related malignancy with increasing incidence in high-income economies. Although ethnicity and social deprivation are known to be risk factors in other malignancies, little is known about socioeconomic status and risk of ASCC. This is a cross-sectional study following the STROBE Statement. Demographic data from the English Clinical Outcomes and Services Dataset (COSD) were extracted for all patients diagnosed with ASCC in England between 2013 and 2018. Outcomes included ethnicity, social deprivation, staging and treatment. This study included 5457 patients. Incidence increased by 23.4% in 5 years, with female incidence increasing more rapidly than male incidence (28.6% vs. 13.5%). Men were more likely to present with early staging (p < 0.001) and have surgery as their only treatment (p < 0.001). The rate of incidence of Stage 1 tumours in men was 106.9%; however, women had the greatest increase in metastatic tumours (76.1%). Black Caribbean and Black African patients were more likely to present at an earlier age with later staging (p < 0.001) and social deprivation was associated with younger age (p < 0.001). ASCC incidence is rapidly increasing in patterns consistent with two separate populations: one male with early staging, the other female and related to social deprivation and ethnicity factors.

Local excision and treatment of early node-negative anal squamous cell carcinomas in a highly HIV prevalent population

Background

Anal squamous cell carcinoma (ASCC) is an uncommon cancer associated with human immunodeficiency virus (HIV) infection. There has been increasing interest in providing organ-sparing treatment in small node-negative ASCC’s, however, there is a paucity of evidence about the use of local excision alone in people living with HIV (PLWH). The aim of this study was to evaluate the efficacy of local excision alone in this patient population.

Methods

We present a case series of stage 1 and stage 2 ASCC in PLWH and HIV negative patients. Data were extracted from a 20-year retrospective cohort study analysing the treatment and outcomes of patients with primary ASCC in a cohort with a high prevalence of HIV.

Results

Ninety-four patients were included in the analysis. Fifty-seven (61%) were PLWH. Thirty-five (37%) patients received local excision alone as treatment for ASCC, they were more likely to be younger (p = 0.037, ANOVA) and have either foci of malignancy or well-differentiated tumours on histology (p = 0.002, Fisher’s exact test).

There was no statistically significant difference in 5-year disease-free survival and recurrence between treatment groups, however, patients who had local excision alone and PLWH were both more likely to recur later compared to patients who received other treatments for ASCC. (72.3 months vs 27.3 months, p = 0.06, ANOVA, and 72.3 months vs 31.8 months, p = 0.035, ANOVA, respectively).

Conclusions

We recommend that local excision be considered the sole treatment for stage 1 node-negative tumours that have clear margins and advantageous histology regardless of HIV status. However, PLWH who have local excision alone must have access to an expert long-term surveillance programme after treatment to identify late recurrences.

Clinical Practice Guideline: Anal Cancer—Diagnosis, Treatment and Follow-up

BACKGROUND

The number of anal cancer diagnoses has been rising steadily, so that the incidence has doubled in the past 20 years. Almost all anal cancers are induced by persistent infection with human papillomaviruses. Hitherto the care of patients with anal cancer has been heterogeneous and little experience exists with the primary management of anal cancer.

METHODS

The guideline was developed in accordance with the requirements of the German Guideline Program in Oncology. In line with the GRADE approach, the certainty of the evidence was assessed on the outcome level following a systematic literature search. Interdisciplinary working groups were set up to compile suggestions for recommendations, which were discussed and agreed upon in a formal consensus conference.

RESULTS

Ninety-three recommendations and statements were developed. No high-quality evidence was available to support recommendations for or against the treatment of stage I anal cancer with local excision alone as an alternative to chemoradiotherapy. Chemoradiotherapy is the gold standard in the treatment of stages II–III. Among other aspects regarding the timing and extent of response evaluation after chemoradiotherapy, the guideline panel recommended against obtaining a biopsy in the event of complete clinical response. Owing to lack of confidence in the available evidence, only open recommendations were given for treatment of stage IV.

CONCLUSION

This evidence-based clinical practice guideline provides a sound basis for optimizing the interdisciplinary, cross-sector care of anal cancer patients. Among other areas, gaps in research were identified with respect to the care of patients with early-stage or metastatic anal cancer. Approaches such as chemoradiotherapy combined with regional deep hyperthermia require further investigation. The role for immunotherapy in the management of metastasized anal cancer has also been insufficiently explored to date.

Anal cancer and precancerous lesions: a call for improvement

Anal squamous cell carcinoma is the most common type of anal cancer and is largely associated with anal human papillomavirus infection. The incidence of anal squamous cell carcinoma is increasing, and although still uncommon in the general population, a high incidence has been noted in specific population groups (eg, patients with HIV, men who have sex with men [MSM], recipients of solid organ transplants, women with genital neoplasia, and patients with systemic lupus erythematosus or inflammatory bowel disease). The higher incidence among individuals who are HIV-positive makes anal squamous cell carcinoma one of the most common non-AIDS-defining cancers among HIV-positive individuals. Anal cancer screening in high-risk groups aims to detect high-grade squamous intraepithelial lesions, which are considered anal precancerous lesions, and for which identification can provide an opportunity for prevention. A blind anal cytology is normally the first screening method, and for patients with abnormal results, this approach can be followed by an examination of the anal canal and perianal area under magnification, along with staining-a technique known as high-resolution anoscopy. Digital anorectal examination can enable early anal cancer detection. Several societies are in favour of screening for HIV-positive MSM and recipients of transplants. There are no current recommendations for screening of anal precancerous lesions via endoscopy, but in high-risk groups, a careful observation of the squamocolumnar junction should be attempted. Several treatments can be used to treat high-grade squamous intraepithelial lesions, including argon plasma coagulation or radiofrequency ablation, which are largely limited by high recurrence rates. Gastroenterologists need to be aware of anal squamous cell carcinoma and anal precancerous lesions, given that patients at high risk are frequently encountered in the gastroenterology department. We summarise simple procedures that can help in early anal squamous cell carcinoma detection.

Vascular calcification and response to neoadjuvant therapy in locally advanced rectal cancer: an exploratory study

Purpose

Patients with locally advanced rectal cancer (LARC) may experience a clinical complete response (cCR) to neoadjuvant chemoradiotherapy (NACRT) and opt for non-operative management. Pathological factors that relate to NACRT response have been well described. Host factors associated with response, however, are poorly defined. Calcification of the aortoiliac (AC) vessels supplying the rectum may influence treatment response.

Methods

Patients with LARC having NACRT prior to curative surgery at Glasgow Royal Infirmary (GRI) and St Mark’s hospital (SMH) between 2008 and 2016 were identified. AC was scored on pre-treatment CT imaging. NACRT response was assessed using pathologic complete response (pCR) rates, tumour regression grades (TRGs), the NeoAdjuvant Rectal score and T-/N-downstaging. Associations were assessed using Chi-squared, Mantel–Haenszel and Fisher’s exact tests.

Results

Of 231 patients from GRI, 79 (34%) underwent NACRT for LARC. Most were male (58%), aged over 65 (51%) with mid- to upper rectal tumours (56%) and clinical T3/4 (95%), node-positive (77%) disease. pCR occurred in 10 patients (13%). Trends were noted between higher clinical T stage and poor response by Royal College of Pathologist’s TRG (p = 0.021) and tumour height > 5 cm and poor response by Mandard TRG (0.068). In the SMH cohort, 49 of 333 (15%) patients underwent NACRT; 8 (16%) developed a pCR. AC was not associated with NACRT response in either cohort.

Conclusions

AC was not associated with NACRT response in this cohort. Larger contemporary cohorts are required to better assess host determinants of NACRT response and develop predictive models to improve patient selection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03570-1.

Outcomes following local excision of early anal squamous cell carcinomas of the anal canal and perianal margin

AIM

There is a paucity of data on outcomes from local excision (LE) of early anal squamous cell carcinomas (ASCCs). This study aimed to assess survival outcomes according to tumour location, perianal (PAT) or anal canal (ACT), and to determine factors associated with R1 excision and outcomes according to T-category.

METHODS

This was a retrospective cohort study of consecutive patients with early ASCC treated by LE from 2007 to 2019. Data were collected on baseline demographics, tumour location, staging, excision histology, adjuvant treatment, site and timing of recurrence. The main outcome measures were R1 resection, locoregional recurrence (LRR), disease-free survival and overall survival.

RESULTS

Of 367 patients treated for ASCC, 39 (10.6%) patients with complete follow-up data underwent LE: 15 ACTs and 24 PATs. R1 resections were obtained in 27 patients (69.2%) and occurred more frequently in ACTs than PATs (93.3% vs. 54.2%, P = 0.006). Eighteen of 27 patients (66.7%) received adjuvant therapy (chemoradiotherapy [n = 11], radiotherapy alone [n = 7]) for R1 excision or re-excision, following which LRR developed in one of 10 (10.0%) patients in the ACT cohort and one of eight (12.5%) patients in the PAT cohort. There was no difference in 5-year LRR-free survival (82.0% vs. 70.1%, P = 0.252), disease-free survival (58.2% vs. 78.4%, P = 0.200) or overall survival (86.2% vs. 95.7%, P = 0.607) between the ACT and PAT cohorts.

CONCLUSIONS

LE is a feasible treatment option for early ASCCs of the perianal margin but not the anal canal. Acceptable long-term outcomes can still be achieved with adjuvant therapy in the presence of a positive margin. Larger prospective studies to assess LE as a treatment strategy, such as the ACT3 trial, are warranted.

Anal squamous cell carcinoma in a high HIV prevalence population

Anal Squamous Cell Carcinoma (ASCC) is a rare cancer that has a rapidly increasing incidence in areas with highly developed economies. ASCC is strongly associated with HIV and there appears to be increasing numbers of younger male persons living with HIV (PLWH) diagnosed with ASCC. This is a retrospective cohort study of HIV positive and HIV negative patients diagnosed with primary ASCC between January 2000 and January 2020 in a demographic group with high prevalence rates of HIV. One Hundred and seventy six patients were included, and clinical data was retrieved from multiple, prospective databases. A clinical subgroup was identified in this cohort of younger HIV positive males who were more likely to have had a prior diagnosis of Anal Intraepithelial Neoplasia (AIN). Gender and HIV status had no effect on staging or disease-free survival. PLWH were more likely to develop a recurrence (p < 0.000) but had a longer time to recurrence than HIV negative patients, however this was not statistically significant (46.1 months vs. 17.5 months; p = 0.077). Patients known to have a previous diagnosis of AIN were more likely to have earlier staging and local tumour excision. Five-year Disease-Free Survival was associated with tumour size and the absence of nodal or metastatic disease (p < 0.000).

Evaluating the efficacy of treatment options for anal intraepithelial neoplasia: a systematic review

PURPOSE

Anal intraepithelial neoplasia (AIN) is the accepted precursor of anal squamous cell carcinoma (ASCC). There has long been a hypothesis that treating AIN may prevent ASCC. Many different treatment modalities have been suggested and studied. We conducted this systematic review to evaluate their efficacy and the evidence as to whether we can prevent ASCC by treating AIN.

METHODS

MEDLINE and EMBASE were electronically searched using relevant search terms. All studies investigating the use of a single treatment for AIN that reported at least one end outcome such as partial or complete response to treatment, recurrence after treatment and/or ASCC diagnosis after treatment were included.

RESULTS

Thirty studies were included in the systematic review investigating 10 treatment modalities: 5% imiquimod, 5-fluorouracil, cidofovir, trichloroacetic acid, electrocautery, surgical excision, infrared coagulation, radiofrequency ablation, photodynamic therapy and HPV vaccination. All treatment modalities demonstrated some initial regression of AIN after treatment; however, recurrence rates were high especially in HIV-positive patients. Many of the studies suffered from significant bias which prevented direct comparison.

CONCLUSIONS

Although the theory persists that by inducing the regression of AIN, we may be able to reduce the risk of ASCC, there was no clinical evidence within the literature advocating that treating AIN does prevent ASCC.

Hellenic society of medical oncology (HESMO) guidelines for the management of anal cancer

Despite considerable improvement in the management of anal cancer, there is a great deal of variation in the outcomes among European countries, and in particular among different hospital centres in Greece and Cyprus. The aim was to elaborate a consensus on the multidisciplinary management of anal cancer, based on European guidelines (European Society of Medical Oncologists-ESMO), considering local special characteristics of our healthcare system. Following discussion and online communication among members of an executive team, a consensus was developed. Guidelines are proposed along with algorithms of diagnosis and treatment. The importance of centralisation, care by a multidisciplinary team (MDT) and adherence to guidelines are emphasised.

High-Resolution Anoscopy Surveillance After Anal Squamous Cell Carcinoma: High-Grade Squamous Intraepithelial Lesion Detection and Treatment May Influence Local Recurrence

BACKGROUND

Local recurrence is a significant risk after anal squamous cell carcinoma.

OBJECTIVES

This study aimed to examine the occurrence of high-grade squamous intraepithelial lesions and local recurrence after anal cancer at surveillance with high-resolution anoscopy.

DESIGN

This is a retrospective observational study.

SETTING

This study was conducted at an anogenital neoplasia referral center.

PATIENTS

There were 76 anal/perianal cancers from 1998 to 2018. Sixty-three patients were eligible and 3 were excluded, for a total of 60 patients; 35 of 60 (58%) patients were male.

INTERVENTION

High-resolution anoscopy after chemoradiation or excision only for anal squamous cell carcinoma was performed.

MAIN OUTCOME MEASURES

The primary outcomes measured were local recurrence and high-grade squamous intraepithelial lesion detection rates.

RESULTS

Sixty patients, 27% HIV positive, underwent surveillance over a median 42 (range 7-240) months of follow-up. Seven had had a prior local recurrence at study entry so were analyzed separately. Thirty of 53 underwent chemoradiation (57%) and 23 of 53 underwent excision alone (43%); 33 had perianal cancer and 20 had anal cancer. Ten of 30 of the chemoradiation group had had stage 1 (33%) disease in comparison with 22 of 23 of the excision only group (96%, p < 0.001).

OUTCOMES

High-grade squamous intraepithelial lesions were detected in 4 of 30 (13%) patients after chemoradiation and in 17 of 23 (74%) patients after excision only (p < 0.001). Twenty of 21 (95%) high-grade lesions were treated with ablation. Six of 7 (86%) patients with prior local recurrence had high-grade squamous intraepithelial lesions over a median of 21 months follow-up. One local recurrence (T1N0M0) occurred during surveillance after primary chemoradiation (0.56/1000 person-months), none occurred after excision only, and 2 of 7 with prior local recurrence developed further local recurrence (6.86/1000 person-months). All 3 local recurrences occurred after treatment of high-grade squamous intraepithelial lesions. There were no metastases, abdominoperineal excisions, or deaths from anal squamous cell carcinoma.

LIMITATIONS

Retrospective data were used for this study.

CONCLUSIONS

High-grade squamous intraepithelial lesions after anal squamous cell carcinoma are more common after excision only than after chemoradiation. Local recurrence is low in this high-resolution anoscopy surveillance group in which high-grade squamous intraepithelial disease was ablated. Excision of small perianal cancers appears safe; however, a subset of patients is at excess risk. See Video Abstract at http://links.lww.com/DCR/B285. VIGILANCIA POR ANOSCOPÍA DE ALTA RESOLUCIÓN EN CASOS DE CARCINOMA ANAL A CÉLULAS ESCAMOSAS: LA DETECCIÓN Y TRATAMIENTO DE UNA LESIÓN INTRAEPITELIAL ESCAMOSA DE ALTO GRADO (HSIL) PUEDE INFLUIR EN LA RECURRENCIA LOCAL: La recurrencia local tiene un riesgo significativo después del carcinoma anal a células escamosas.Evaluar la aparición de lesiones intraepiteliales escamosas de alto grado (HSIL) y su recurrencia local durante la vigilancia con anoscopía de alta resolución en casos de cancer anal.Estudio observacional retrospectivo.Centro de referencia de neoplasia anogenital.Se diagnosticaron 76 cánceres anales / perianales entre 1998 y 2018. Un total de 63 pacientes fueron elegidos, 3 excluidos (n = 60), 35/60 (58%) fueron varones.Anoscopía de alta resolución después de la quimio-radioterapia, o solo excisión en casos de carcinoma anal a células escamosas.Recurrencia local primaria y tasas de detección de lesión intraepitelial escamosa de alto grado.Sesenta pacientes, 27% VIH positivos, fueron sometidos a vigilancia durante una mediana de 42 (rango 7-240) meses de seguimiento. Siete habían tenido una recurrencia local antes de ser incluidos en el estudio, por lo que se analizaron por separado. Treinta de 53 se sometieron a quimio-radioterapia (57%) y 23/53 solo a excisión (43%). 33 eran lesiones perianales, 20 de canal anal. 10/30 del grupo de quimio-radioterpia se encontraban en Fase 1 (33%) comparados con 22/23 del grupo de excisión (96%, p <0.001).Se detectaron lesiones intraepiteliales escamosas de alto grado en 4/30 (13%) después de la quimio-radioterapia, y en 17/23 (74%) solo después de la excisión (p < 0.001). 20/21 (95%) lesiones de alto grado fueron tratadas con ablación. Seis de siete (86%) con recurrencia local previa tenían lesiones intraepiteliales escamosas de alto grado durante una mediana de seguimiento de 21 meses. Se produjo una recurrencia local (T1N0M0) durante la vigilancia después de la quimio-radioterapia primaria (0.56/1000 persona-meses), ninguna después de la excisión sola y 2/7 con recurrencia local previa desarrollaron una recurrencia local adicional (6.86/1000 persona-meses). Las 3 recidivas locales ocurrieron después del tratamiento de las lesiones intraepiteliales escamosas de alto grado. No hubieron metástasis, excisiones abdominoperineales o muertes por carcinoma anal a células escamosas.Datos retrospectivos.Las lesiones intraepiteliales escamosas de alto grado en casos de carcinoma escamocelular anal son más comunes después de la excisión sola que después de la quimio-radioterapia. La recurrencia local es baja en este grupo de vigilancia de anoscopía de alta resolución en el que se retiró la enfermedad intraepitelial escamosa de alto grado. La excisión de pequeños cánceres perianales parece segura; sin embargo, un subconjunto de pacientes tiene un riesgo excesivo. Consulte Video Resumen en http://links.lww.com/DCR/B285. (Traducción-Dr. Xavier Delgadillo).

Measuring importance of outcomes to patients: a cross-sectional survey for the German anal cancer guideline

OBJECTIVE

We aimed to generate evidence on patients' values and preferences to inform the development of the German national Evidence-based Anal Cancer Guideline.

STUDY DESIGN AND SETTING

We developed a list of health outcomes based on a systematic search. We then asked anal cancer patients and experts of the guideline development group in an online survey to (a) rate the relative importance of the outcomes in different clinical situations using a nine-point, three-category scale, and (b) select seven outcomes they considered most important for decision-making in each situation.

RESULTS

Participants rated almost half of the outcomes (45%) as critical for decision-making, and more than half (53%) as important. Only two outcomes (2%) were rated as low in importance. Agreement between expert and patient ratings was low to fair, and we found important discrepancies in how the relative importance of the outcomes was perceived. However, the rankings of outcomes were highly correlated.

CONCLUSION

Determining the relative importance placed by anal cancer patients on outcomes provided useful information for developing guideline recommendations. Our approach may be useful for guideline developers who aim to include the patient perspective. Moreover, our findings may help health professionals caring for anal cancer patients in joint decision-making.

Temporal improvements in loco-regional failure and survival in patients with anal cancer treated with chemo-radiotherapy: treatment cohort study (1990-2014)

Background

We evaluated oncological changes in patients with squamous cell carcinoma of the anus (SCCA) treated by chemoradiotherapy (CRT) from a large UK institute, to derive estimates of contemporary outcomes.

Methods

We performed a treatment-cohort analysis in 560 patients with non-metastatic SCCA treated with CRT over 25 years. The primary outcomes were 3-year loco-regional failure (LRF), 5-year overall survival (OS), and 5-year cancer-specific survival (CSS). We developed prediction models; and overlaid estimates on published results from historic trials.

Results

Age distributions, proportions by gender and cT stage remained stable over time. The median follow-up was 61 (IQR: 36–79) months. Comparing the first period (1990–1994) with the last period (2010–2014), 3-year LRF declined from 33 to 16% (P_trends < 0.001); 5-year OS increased from 60% to 76% (P_trends = 0.001); and 5-year CCS increased from 62% in to 80% (P_trends = 0.001). For 2020, the models predicted a 3-year LRF of 14.7% (95% CIs: 0–31.3); 5-year OS of 74.7% (95% CIs: 54.6–94.9); and 5-year CSS of 85.7% (95% CIs: 75.3–96.0). Reported oncological outcomes from historic trials generally underestimated contemporary outcomes.

Conclusions

Current and predicted rates for 3-year LRF and 5-year survivals are considerably improved compared with those in historic trials.

The Prognostic Significance of Isolated Tumor Cells Detected Within Lateral Lymph Nodes in Rectal Cancer Patients After Laparoscopic Lateral Lymph Node Dissection

Background: To clarify the definite incidence of isolated tumor cells (ITCs) in lateral lymph nodes (LLNs) and its prognostic significance in rectal cancer patients after laparoscopic lateral lymph node dissection (lap-LLND). Methods: Consecutive rectal cancer patients who underwent standard total mesorectal excision (TME) and lap-LLND were included. All the LLNs were re-examined by hematoxylin and eosin (H&E) stain and immunohistochemistry (IHC) with a monoclonal antibody against cytokeratin 20 to confirm the status of ITCs, micrometastasis, and overt metastasis. Clinicopathological characteristics and oncological outcomes were analyzed. Results: Forty-six patients with TME and lap-LLND were included. Twelve (26.1%) patients with overt metastasis were identified. A total of 705 LLNs from 46 patients were re-examined by H&E with IHC, and ITCs were detected in 27 (3.8%) lymph nodes from 11 (23.9%) patients. No LLNs micrometastasis was found. Patients with overt metastasis had more advanced N stage and more perirectal lymph nodes metastasis. Three patients with LLNs recurrence were identified and lung metastasis was the most common metastatic site. Compared with patients with ITCs and without any metastasis, patients with overt metastasis had worse 3-year cumulative overall survival (85.7%, 83.9%, and 53.3%, respectively) and 3-year cumulative disease-free survival (85.7%, 85.2%, and 43.8%, respectively). Patients with ITCs had higher overall recurrence than patients without any metastasis (42.9% versus 11.5%, P = .035). Multivariate analysis showed that ITC status in LLNs was a significant prognostic factor (hazard ratio 2.689, 95% confidence interval 1.072-6.747; P = .035). Conclusion: ITCs in LLNs detected by the IHC method like overt metastasis detected by H&E staining contributed to higher overall recurrence.

Human Papilloma Virus Infection and Anal Squamous Intraepithelial Lesions

This article addresses the natural history of the human papilloma virus (HPV) infection to anal squamous intraepithelial lesions, and onto squamous cell carcinoma of the anus. This article provides overviews of the virology, pathophysiology, nomenclature, classification, historical terms, risk factors, clinical evaluation, differential diagnosis, and treatment of HPV infection and its sequelae.

The Emperor's New Clothes: a Critical Appraisal of Evidence-based Medicine

Evidence-Based Medicine (EBM) is the way we are expected to deliver our healthcare in the 21st century. It has been described as the integration of information from best available evidence with the doctor's experience and the patient's point of view. Unfortunately, the original meaning of EBM has been lost and the worldwide medical community has shifted the paradigm to Guidelines-Based Medicine, that has displaced the figures of the doctor and the patient from the decision-making process and relegated them to mere executor and final target of decisions taken by someone else. Problems related to the reliability of evidence and to the way guidelines are constructed, implemented and followed are discussed in detail. It is mandatory that the whole medical community takes responsibility and tries to reverse this apparently inexorable process so to re-establish a proper evidence-based care, where patients and their healing relation with practitioners are at the centre and where doctors are able to critically evaluate the available evidence and use it in light of their personal experience and knowledge.

Nodal stage migration and prognosis in anal cancer: a systematic review, meta-regression, and simulation study

BACKGROUND

In patients with squamous cell carcinoma of the anus (SCCA), lymph node positivity (LNP) indicates poor prognosis for survival and is central to radiotherapy planning. Over the past three decades, LNP proportion has increased, mainly reflecting enhanced detection with newer imaging modalities; a process known as nodal stage migration. If accompanied by constant T stage distributions, prognosis for both lymph node-positive and lymph node-negative groups may improve without any increase in overall survival for individual patients; a paradox termed the Will Rogers phenomenon. Here, we aim to systematically evaluate the impact of nodal stage migration on survival in SCCA and address a novel hypothesis that this phenomenon results in reduced prognostic discrimination.

METHODS

We did a systematic review and meta-regression to quantify changes in LNP over time and the impact of this change on survival and prognostic discrimination. We searched MEDLINE, Embase, and the Cochrane Library to identify randomised trials and observational studies in patients with SCCA published between Jan 1, 1970, and Oct 11, 2016. Studies were eligible if patients received chemoradiotherapy or radiotherapy as the main treatment, reported LNP proportions (all studies), and reported overall survival (not necessarily present in all studies). We excluded studies with fewer than 50 patients. We extracted study-level data with a standardised, piloted form. The primary outcome measure was 5-year overall survival. To investigate scenarios in which reduced prognostic discrimination might occur, we simulated varying true LNP proportions and true overall survival, and compared these with expected observed outcomes for varying levels of misclassification of true nodal state.

FINDINGS

We identified 62 studies reporting LNP proportions, which included 10 569 patients. From these, we included 45 studies (6302 patients) with whole cohort 5-year overall survival, 11 studies with 5-year survival stratified by nodal status, and 20 studies with hazard ratios in our analyses of temporal changes. In 62 studies, the LNP proportions increased from a mean estimate of 15·3% (95% CI 10·5-20·1) in 1980 to 37·1% (34·0-41·3) in 2012 (p<0·0001). In 11 studies with prognostic data, increasing LNP was associated with improved overall survival in both lymph node-positive and lymph node-negative categories, whereas the proportions with combined tumour stage T3 and T4 remained constant. In 20 studies, across a range of LNP proportions from 15% to 40%, the hazard ratios for overall survival of lymph node-positive versus lymph node-negative patients decreased significantly from 2·5 (95% CI 1·8-3·3) at 15% LNP to 1·3 (1·2-1·9; p=0·014) at 40% LNP. The simulated scenarios reproduced this effect if the true LNP proportions were 20% or 25%, but not if the true LNP proportions were 30% or greater.

INTERPRETATION

We describe a consequence of staging misclassification in anal cancer that we have termed reduced prognostic discrimination. We used this new observation to infer that the LNP proportions of more than 30% seen in modern clinical series (11 out of 15 studies with a median year since 2007) are higher than the true LNP proportion. The introduction of new staging technologies in oncology might misclassify true disease stage, spuriously informing disease management and ultimately increasing the risk of overtreatment.

FUNDING

Bowel Disease Research Foundation.