Local excision for patients with stage I anal canal squamous cell carcinoma can be curative

Squamous cell carcinoma of anal canal (ACSCC) is an uncommon cancer which comprises 0.5 percent of all new cancer cases diagnosed in the United States and 8,580 new cases are expected to be diagnosed in 2018 (1). Incidence of ACSCC, however, has shown a gradual uptrend in western countries during the last several decades, up to 2.2% per year (1,2). Definitive concurrent radiation and chemotherapy (CRT) has evolved as the standard of care for all patients with localized and locally advanced ACSCC, including patients with stage I cancer. National Cancer Center Network (NCCN) and European Society For Medical Oncology (ESMO) guidelines recommend CRT as the only treatment option for all patients with stage I ACSCC, irrespective of the size of the primary tumor (3,4). However, the randomized clinical trial data (5-12) that led to the current treatment guidelines are predominantly derived from patients with stages II and III disease. A number of randomized phase III trials did not include stage I patients and the trials which included stage I patients had less than 15% of patients with stage I disease (13). Therefore, uncertainty exists if these data can be generalized to all patients with stage I disease and whether CRT is necessarily needed in all such patients, as CRT is associated with considerable short and long term toxicities which can cause significant morbidities and decline in quality of life . There may be a subset of patients within the stage I group who could be treated with local excision alone, as is typically performed for stage I anal margin squamous cell carcinoma. Historical data supports feasibility of local excision as the primary curative treatment in patients with small localized stage I tumors (14,15). However, there is limited literature to date looking at oncologic outcomes of stage I ACSCC with local excision as compared to CRT. Therefore, we sought to evaluate oncologic outcomes of stage I ACSCC patients who were treated with local excision alone compared to those treated with CRT