Anal cancer is also called anal squamous cell carcinoma. This type of cancer in many ways resembles a type of skin cancer because it derives from the squamous cells, or “skin-like” cells of the anus. Like other cancers, the problem occurs when genetic mutations in these squamous cells lead to uncontrolled growth of the cells. Eventually a mass forms and the cells invade surrounding tissues and in some cases spread to other parts of the body.
Anal squamous cell cancer generally begins with subtle symptoms such as anal itching or bleeding and is diagnosed by a biopsy of the anal tissue. While it is much less common than colorectal cancer, it still afflicts over 2,500 people annually in the U.S., including more than 1,000 women. It is most common in people over 60 years old, but it can occur in young adults as well. If a biopsy does demonstrate anal squamous cell carcinoma, the treatment generally involves chemotherapy and radiation therapy. Today a protocol of combined chemotherapy and radiation has a high chance of curing the cancer successfully and completely without major surgery. In a minority of cases if the cancer is not cured or fails to resolve there may be surgery required.
Relationship to HPV
Human Papilloma Virus, or HPV, has been in the news a lot because it is now widely recognized as a causal link to cervical cancer, throat cancer, and anal cancer. The virus is spread through sexual contact or in some cases nonsexual direct contact, and virus subtype 16 is most closely associated with anal cancer. Because about 90% of anal cancers arise from HPV infection, many authorities believe it may be preventable with use of the HPV vaccine before exposure to the virus has occurred.
When to see a doctor
Any bleeding from the rectum deserves investigation to determine its cause. Additionally, symptoms such as itching and irritation which do not resolve on their own should prompt a visit to the doctor. Any mass or lump in the anal region should warrant an immediate visit to the doctor. Simple tests can determine the cause of these symptoms and exclude an anal cancer. Individuals at high risk, such as those with immunosuppression, HIV disease and known HPV exposure can undergo screening tests with a simple office swab and cell analysis.
The good news
The good news is that anal carcinoma was once a deadly disease that was only curable through major surgery and often required a permanent colostomy. Today, screening methods improve early detection and a cure is usually achieved without surgery, utilizing combined chemotherapy and radiation.
I have performed a great number of minimally invasive cancer procedures for adrenal tumors, splenic tumors, tumors of the lymph nodes, liver tumors, gastric tumors, and intestinal tumors. All types of intra-abdominal tumors lend themselves to a minimally invasive approach in skilled hands. Of course, more common than all of the above are colorectal tumors, which are removed surgically with a minimally invasive approach in nearly all cases.
The advantages of a minimally invasive approach to cancer surgery are numerous. First and foremost, in the right expert hands, it is the best surgery to treat and cure the cancer. There is no corner cutting or compromise on the cancer curing effect with minimally invasive surgery. Many years ago when laparoscopic surgery was first being developed, some worried that the technique of laparoscopy might lead to reduced cures of cancer, particularly colorectal cancer. Studies done at my alma mater, the Lahey Clinic, among other centers, demonstrated that laparoscopic cancer resection, performed by skilled minimally invasive surgeons, such as myself, resulted in at least as good a cure for colorectal cancer. This meant at least as good a harvest of a high number of lymph nodes and obtaining at least as wide margins around the tumor. Furthermore the “no touch technique” that was honored by early cancer surgical pioneers is followed meticulously in laparoscopic minimally invasive surgery, which is so much less traumatic.
So minimally invasive surgery is at least as good for cancer cure, but what else makes it better for cancer surgery? The real benefit and superiority lies in the reduced invasiveness, reduced complications, and reduced recovery time, pain and delay in returning to a full recovery. All of these issues matter a great deal. Keep in mind that one of the unsung benefits of minimally invasive cancer surgery is that it has allowed so many people to recover much more quickly so they can fight the cancer sooner and more effectively whether they are pursuing chemotherapy, medical therapy, radiation therapy or other means. The reduced “down time” after minimally invasive surgery allows the person battling cancer to get on with the battle sooner and to do so from a stronger stand point of physiologic health.
“First, do no harm” was one of the guiding principles of Hippocrates, the Greek Father of Medicine. Surgery by necessity involves some degree of invasiveness and some risk of complications, pain and recovery time during which a person is not at full capacity. Minimally invasive surgery seeks to minimize all of those effects and does so quite successfully. Today, thousands of studies have demonstrated the reduced complication risks across the board in minimally invasive surgery for abdominal cancers, colorectal cancer, thoracic cancer and many other types of cancer. Minimally invasive surgeons have succeeded in removing the tumors while markedly diminishing the risks of wound infections, wound complications, hernias, heart complications, breathing complications and other types of adverse events. Additionally, the studies demonstrate that minimally invasive surgery reduces the risk of bleeding and results in fewer blood transfusions. It also results in far less pain, thus less use of narcotics and other medications, which of course have their own side effects. So in summary, minimally invasive surgery today, in the hands of highly trained surgeons results in highly successful cancer therapy and cancer cure while minimizing the risks, complications, down time and pain. It allows the patient to return to health and activity sooner, to battling to cancer sooner, and to getting on with life sooner.
Colorectal cancers historically have been treated with an open laparotomy surgical procedure. Keep in mind that a very high percentage, nearly 90%, of the global benefit that modern medicine can bring to the disease of colorectal cancer comes from removing the tumor and its regional lymph nodes through surgery. While chemotherapy and radiation have made great strides, they still contribute a relatively small fraction of the overall benefit when measured in terms of months or years of life gained.
So, with surgery representing such an important treatment regimen for such an important disease, it stands to reason the surgery needs to evolve or improve over time, and it has.
Today, minimally invasive colorectal cancer surgery accomplishes the mission of removing the tumor and the surrounding lymph nodes and providing a cure.
Colorectal cancer is only cured with resectional surgery. While there are a few scattered reports of small rectal carcinomas shrinking and even disappearing with chemotherapy and radiation therapy prior to undergoing surgical resection, it is not considered a accepted treatment if one is seeking to cure the cancer, it has been felt that the chances of the dormant tumor cells re-growing and spreading is far too high.
So surgery is the key to treating and curing colorectal cancer and minimally invasive surgery is the most effective method with the least invasiveness, the least pain and the fewest complications. Let’s discuss a little bit why that is the case.
To begin with, a traditional or open conventional surgery involved making a larger abdominal incision. Right there begins the invasiveness that leads to pain and prolonged recovery time. The incision or wound itself is the main culprit in causing post-operative pain, which in turn leads to treatment of the pain with narcotic and other classes of drugs. These drugs in turn have their own side effects, which in some cases can be quite serious, so minimizing the incision, in fact getting rid of it all together, and instead performing the procedure with markedly smaller laparoscopy incisions results in dramatically less pain and dramatically less use of narcotic analgesic medications.
The traditional open incision was also a source of additional complications, most notably wound problems and hernias. The muscle or fascial closure of an open abdominal incision heals slowly over time, but is never as strong as Mother Nature made it. Thus, with exertion, coughing and just generally living life the incision can pull apart and the muscles can split leading to an uncomfortable bulge or hernia. This problem is minimized with laparoscopy incisions which are so small.
Perhaps the most important of all, the large open incision leads to more down time after surgery. This results from a number of effects, both direct and indirect. Indirect effects include strain on the heart and lungs as our bodies cope to heal after a more intrusive surgical procedure. The direct effects of the pain cause us to breathe more shallowly, to walk less and take more time to restore the natural physiologic functions. This means more time in the hospital. It also translates into many more weeks before one can return to work, before one can return to cancer treatments and before one can return to fun activities.
The best news is the cancer cure rate is at least as high as it was with the old conventional open surgery. Numerous studies demonstrate equivalent, if not higher capture rates and tumor margins achieved with minimally invasive surgery. So the best treatment is also the least invasive treatment.
*A trained and skilled minimally invasive surgeon can offer a great deal of experience in cancer surgery. Dr. Sasse trained at the Lahey Clinic, the premier surgical fellowship training program for colon and rectal surgery in the United States and one of the most recognized centers around the world. A great number of people fly to the Lahey Clinic from all over the world including the Middle East and Europe to undergo colorectal procedures from the renowned faculty there. The advances in minimally invasive surgery are well known and the two fellows who graduate from this program every year are among the most sought after colon and rectal surgeons in the country. Dr. Sasse performed over a thousand colon and rectal resections during his residency and fellowship training and has performed thousands more minimally invasive colorectal resections over the last twelve years. The skill set involves recognition of the boundaries of the tumor, the application of the “no touch” technique, freeing up the tumor and its surrounding tissues carefully to obtain the best oncologic cure, and performing the delicate anastomosis or reconnection of the colon with maximum safety.