Anal cancer pathway

The anal canal or anus is the five-centimetre-long end section of the large bowel through which solid waste exits the body. Anal cancer is a less common form of cancer affecting the anus.

Squamous cell carcinoma

Nearly all anal cancer will develop in the squamous cells which line the anal canal and margin.

Adenocarcinoma

Cancer which develops from the glandular cells that produce mucus in the anal canal.

Basal Cell Carcinoma

A type of skin cancer that starts in the area around the anus.

Melanoma – This is also a type of skin cancer and starts in cells called melanocytes. This type of anal cancer would be treated in the same way as melanomas.

Small-cell Carcinoma

A less common anal cancer, a malignant new growth made up of epithelial cells (cells that line the surfaces of the bowel and anus).

What to expect

This information describes the care you can expect from an initial concern about anal cancer and for every step afterwards
– your cancer pathway.

For more information about anal cancer

Bowel Cancer UK

Macmillan Cancer Support

Needing immediate support

Macmillan support line 0808 808 0000 (8am-8pm, 7 days a week)

Directory of Services

COVID-19 update

Please note that aspects of the cancer pathway may have changed due to the COVID-19 pandemic and these changes are highlighted throughout the pathway. If you have any concerns or questions, always speak to your GP or cancer care team.

The aim of the COVID-19 guidance is to:

  • minimise your risk by reducing investigation and visits to hospital
  • reassure you if you have low risk symptoms that you will be investigated within a safe time frame in line with national guidance
  • identify if you are at a higher risk and make sure you are investigated quickly and receive urgent surgery if required.

People you could meet on your pathway

Consultant Surgeon

A doctor who is trained to perform types of surgery, in this case they specialise in surgery of the bowel. Your colorectal (bowel) surgeon is usually the first person you will see and specialises in the diagnosis of bowel cancer as well as treatment.

Consultant Oncologist

A doctor who specialises in the diagnosis and treatment of cancer.

Consultant Radiologist

A doctor who carries out investigations to diagnose diseases using medical imaging, such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET) and ultrasound. They also perform biopsies if needed.

Clinical Nurse Specialist

A nurse who has specialised in a specific cancer site, in this case bowel cancers, and who is able to offer expert advice and information about diagnosis, treatments, ongoing care and follow up.

Cancer Support Worker

A non-clinical support worker who is part of the cancer care team and provides one-to-one support for patients and ongoing information about cancer and cancer services.

Initial investigation and referral

Within the UK around 1,200 people develop anal cancer each year. Anal cancer is slightly more common in women than men.

Risk factors for anal cancer include:

  • Human Papilloma Virus (HPV) – a common virus passed on through sexual contact
  • lowered immunity
  • sexual activity – multiple sexual partners and anal sex
  • smoking
  • age – greater risk after the age of 50
  • Anal Intraepithelial Neoplasia (AIN) – a condition which affects the skin around the anus. The severity of the condition is graded from I to III, with III being the most severe. AIN is important because some cases of AIN III can go on to develop into an anal cancer.

Please note that if you have one or more of the above risk factors it does not mean that you will get cancer.

For further information about each of these risk factors
Macmillan Cancer Support

Symptoms of anal cancer include:

  • bleeding from the anus
  • pain, discomfort and itching around the anus
  • small lumps around the anus – may be confused with piles
  • discharge of mucus from the anus
  • ulcers around the anus
  • difficulty controlling leakage from the bowel

If you are concerned about any of these symptoms, always visit your GP. There is no need to be embarrassed, they are used to seeing patients who have bowel problems.

These symptoms can be caused by conditions other than anal cancer. It is possible for anal cancer to occur without symptoms.

COVID-19 update

If you have symptoms that you are worried may be cancer, it is important to still seek advice from your GP surgery. Your symptoms do not mean you have cancer and could be caused by a number of common conditions but it is always best to get checked.

Suspected cancer

If you have any of the symptoms described, your GP will discuss your symptoms and do a rectal examination. This is when your doctor puts a gloved finger in your rectum (back passage) to feel for any lumps or swelling. They will also feel your tummy.

Your GP may arrange for you to have blood tests to check if you’re anaemic (have a low number of red blood cells) or to check how well your liver and kidneys are working.

If your GP suspects anal cancer, the next step of the pathway is an urgent referral to the hospital. This is called a fast track referral.

COVID-19 update

During the COVID-19 pandemic fast track referrals are still essential but they may be managed differently.

For more information about fast track referrals during the COVID-19 pandemic download a fast track referrals leaflet:

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Your referral will still be reviewed by the colorectal team at the hospital. You will have an appointment with a member of the colorectal team (probably a telephone or video call) and they will make an assessment based on your described symptoms

If you need a test or to be seen in person, this will be explained to you and any decisions will be made taking your overall health and safety into consideration.

It is understandable that you may be worried about going into hospital where patients with COVID-19 are being cared for but please be reassured that your safety is a priority. Hospital areas dealing with non-COVID-19 issues are kept separate from those dealing with COVID-19 positive patients and this is carefully managed for your safety.

Testing for anal cancer

Examination

Your consultant will examine the area for any signs of cancer. For women this will usually include an internal examination of the vagina. An anoscope (also called an anal speculum) is inserted into the anus to examine the anal canal and diagnose the problem.

Biopsy

If there is anything abnormal, your consultant may apply a liquid to an abnormal area to make it more visible and they will remove a small sample of cells. These will be examined under a microscope.

You may find it helpful to bring a family member or friend with you to your appointment.

COVID-19 update

Please check with the hospital to see if you can take someone with you. If it is possible, they will usually be expected to wait outside.

Please be reassured all hospitals are working hard to make sure it is safe to attend the hospital if you are advised to. Your test areas will be separated from areas where patients with COVID-19 are being treated. If you still feel unsure or concerned about attending hospital, please contact your cancer care team or your GP.

Diagnosis and staging

If you are diagnosed with anal cancer following a biopsy, you will have further tests.

Further tests may include

CT scan or computerised tomography scan

A scan which uses x-rays and a computer to create images of the inside of the body.  

Magnetic resonance imaging scan or MRI

A scan which uses strong magnetic fields and radio waves to produce a detailed image of the inside of the body.

Anal Ultrasound Scan

This scan uses sound waves to look at your anus and can show the size and position of your cancer.

Fine needle aspiration (FNA) of the lymph nodes

A thin needle is used to take a sample of cells from the lymph nodes. A lymph node is part of the lymphatic system which is a network of thin tubes and nodes that carry a clear fluid called lymph around the body.

Positron Emission Tomography (PET)-CT scan

This is a combination of a CT scan and a PET scan which gives detailed information about your cancer. The CT takes a series of x-rays from around your body and creates a three-dimensional picture. The PET scan uses a mildly radioactive drug to show up areas of your body where cells are more active than normal.

 

For further information about these tests
Bowel Cancer UK

Test results can take up to a couple of weeks to come back. This can be an anxious time and it may be helpful to talk with a partner, family members or a friend. You can always contact your clinical nurse specialist at the hospital for advice and support.

COVID-19 update

If further testing is required, your cancer care team will discuss the next steps with you. If you have any concerns or questions, please contact your cancer care team.

Staging

Staging of a cancer describes its size and if it has spread from where is started. Anal cancer is usually divided into four stages and uses either a tumour, nodes and metastasis (TNM) staging system or the number staging system.

For more information about staging
Bowel Cancer UK

Your treatment will be informed depending on which type of anal cancer you have.

Treatment

Treatment will depend on various factors including the location of the cancer in the bowel and whether it has spread to another part of the body.  

The best course of treatment for you will be discussed within a team of specialists called a multidisciplinary team (MDT).  

Multidisciplinary team

A multidisciplinary team (MDT) is a group of health care professionals who are from one or more clinical disciplines who make decisions together regarding the recommended treatment for individual patients.  

Your clinical nurse specialist or consultant will go through the different treatments and the side effects they may have.  

Treatments

You may be offered one or more of the following types of treatment.

Surgery

Surgery is used if chemoradiation does not completely get rid of the cancer. If the cancer is early stage and under two centimetres, it can sometimes be removed with just surgery.

Chemoradiation

Often the main treatment for anal cancer. This is the combination of chemotherapy and radiotherapy.

Radiotherapy

Radiotherapy is the use of carefully measured and controlled high energy x-rays to destroy any cancer cells left behind in the breast and the surrounding area after surgery. Used if you are not well enough to have chemoradiation.

Chemotherapy

The use of anti-cancer drugs to destroy cancer cells. Chemotherapy may be used after surgery or sometimes as your main treatment if the cancer has spread.

For more information about treatments for anal cancer
Bowel Cancer UK

COVID-19 update

Your treatment may be affected by the pandemic and your cancer care team will provide you with information on this. If you have any concerns or questions, please contact your hospital.

After treatment

You will have regular check-ups and your consultant will monitor your progress. You will have a care plan detailing your follow-up care based on the type of cancer and treatment you have had.

COVID-19 update

Your follow up appointments may be by telephone to minimise hospital visits.

Your GP will be sent a treatment summary from the hospital which summarises the:

  • diagnostic tests carried out
  • types of treatment you had
  • treatment plans from other involved health care professionals.

For more information about after treatment
Bowel Cancer UK

If anal cancer returns

Your cancer care team should inform you of the signs and symptoms to look out for. You should always speak to your cancer care team if you are worried about your cancer returning or if you have any questions.  

Living with and beyond cancer

Emotional impact

How you cope with your diagnosis and treatment will be specific to you. You may expect to feel relief once your hospital-based treatment ends but this is not always the case and it can be a difficult and emotional time. 

Following treatment, you may have time to reflect on the impact of your diagnosis. It is completely normal to have a mixture of emotions if you are living with or affected by cancer. There are a lot of support services available to help you through. It is important to remember you are not alone. 

You may benefit from:  

  • talking to friends and family 
  • communicating with others in the same situation
  • talking therapies and counselling – your clinical nurse specialist can refer you
  • moving forward courses
  • local support groups
  • health and wellbeing events.

For more information on dealing with your feelings and emotions
Bowel Cancer UK – Support for you
Macmillan – Emotional help
Cancer Research UK – Talk to our nurses
Bowel Cancer UK – Living well
Penny Brohn UK

 

Support groups
Directory of services

Online support – you can get support on the internet via online support groups, social networking sites, forums, chat rooms and blogs for people who are affected by cancer.

For information about counselling services
British Association for Counselling and Therapy

If you are feeling depressed or need to speak to someone immediately, please contact Samaritans 116 123

If you are struggling with how you are feeling emotionally, it is important to speak to your GP or your cancer care team, they will be able to provide you information on the treatments and support available to you.  

Side effects and symptoms

You will most likely feel very tired and may also have some side effects or be coping with symptoms. Your body will need time to recover from treatment. 

Long term side effects can include: 

  • tiredness
  • hernia 
  • nerve damage 
  • changes in bowel function 
  • changes in bladder function 
  • changes in sexual function.  

Side effects usually get better with time but they can continue for more than six months or develop years after treatment.

For more information about side effects
Bowel Cancer UK – long term and late side effects

For help with managing fatigue and sleep
Bowel Cancer UK – sleep and fatigue

For help with managing bowel habit changes
Bowel Cancer UK – change in bowel habits

Relationships and sex

Anal cancer and the treatment for cancer can affect your emotions and relationships which can then lead to issues with intimacy and sex.  

Discussing your worries with your partner and being open about the effects of treatment on your sex life can be helpful to you both and may help you to cope better. There are also professionals who can help with becoming sexually active or starting a new relationship.  

Often people find it embarrassing to talk about their sex lives but if you have any concerns or questions,  your cancer care team are used to talking openly about sexual matters.

For more information about relationships and sex
Bowel Cancer UK

Maintaining a healthy lifestyle

Following your treatment, there are many things you can do that may help to reduce the risk of lung cancer recurrence and prevent other health conditions.

You can take care of yourself by:

  • Stopping smoking
    Your cancer care team and your GP can help as well as the national stopping-smoking service.
    NHS
    Livewell Dorset
  • Managing tiredness
    Your clinical nurse specialist can discuss this with you and perhaps how family and friends could support you with day to day tasks.
  • Getting more active
    SafeFit
  • Eating well and maintaining a healthy weight
    NHS
  • Sticking to sensible drinking guidelines
    Drinkaware
  • Reducing stress

For more information about lifestyle
Macmillan Cancer Support

Learn how you can improve your general health and manage the effects of prostate cancer and its treatment
Prostate Cancer UK

You can get in contact with your GP for further information regarding maintaining a healthy lifestyle and they will be able to offer you advice and support.

Talking about cancer

It can be difficult to tell people you have cancer, however talking to your closest friends and family can make you feel more supported and reassured that the feelings you may be experiencing are normal. 

Everyone you tell may have a different reaction and it is important to be prepared for this. Some will be keen to support you but this may not always be the case as some people may find the conversation difficult and uncomfortable. This may be through lack of experience, fearing your reaction or they may go into denial.

For videos of people talking about their own experiences and coping with people’s reactions
healthtalk

It can also help to talk to people who also have cancer as they may have a better understanding of what you are going through.  

For more information on talking about cancer
Macmillan Cancer Support

Complementary therapies

Complementary therapies can be used alongside conventional bowel cancer treatments. These are not the same as alternative therapies which are used instead of conventional treatments, such as chemotherapy or radiotherapy.

Complementary therapies can give you comfort and help you feel more relaxed after treatment and diagnosis. Types of complementary therapies can include:

  • activities that improve mindfulness
  • acupuncture
  • acupressure and shiatsu
  • aromatherapy
  • healing and energy therapies
  • herbal therapies
  • hypnotherapy
  • massage
  • meditation
  • mindfulness
  • reflexology
  • special ‘cancer diets’ and dietary supplements
  • yoga, Tai Chi and Chi Gung.

You can discuss what complementary therapies are available to you with your cancer care team.

For more information about complementary therapies
Macmillan Cancer Support

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