Anal Cancer Clinical Practice Guidelines (ESMO, 2021)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

August 11, 2021

Updated guidelines on diagnosis, treatment, and follow-up of anal cancer were published on May 18, 2021 by the European Society for Medical Oncology (ESMO) in  Annals of Oncology.[1]


Digital anorectal examination (DRE) is essential for detection of anal lesions, and biopsy is mandatory to confirm squamous cell carcinoma of the anus (SCCA).

Mandatory studies in patients with SCCA include:

  • High-resolution pelvic magnetic resonance imaging

  • Computed tomography (CT) scan of thorax, abdomen, and pelvis

  • Anoscopy/proctoscopy

  • In female patients, screening for synchronous cervical, vulvar, and vaginal intraepithelial neoplasia


Radiation therapy (RT) with concomitant 5-fluorouracil (5-FU) and mitomycin C is recommended as standard of care for patients with localized SCCA. Capecitabine can be possibly used as an alternative to 5-FU.

Neoadjuvant or adjuvant chemotherapy is generally not recommended.

Elderly patients who can tolerate treatment should be treated with curative chemoradiotherapy (CRT). Patients who cannot tolerate CRT may benefit from RT for local control.

Intensity-modulated RT (IMRT), volumetric modulated arc therapy (VMAT), or 3D conformal RT are the recommended RT techniques, with RT dose constraints to normal tissue.

In patients with chemotherapy-naive advanced anal cancer, carboplatin plus paclitaxel should be considered a new standard of care. Cisplatin/5-FU/capecitabine, carboplatin, or docetaxel-based combinations are alternatives.

Programmed cell death ligand 1 (PD-L1) inhibitors may be considered in patients who have progressed on first-line therapy in clinical trials.


Patients in complete remission should be evaluated every 3-6 months for a period of 2 years, and every 6-12 months until 5 years, with clinical examination including DRE and palpation of the inguinal lymph nodes.

For more information, please go to Anal Cancer. For more Clinical Practice Guidelines, please go to Guidelines.


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