Monitoring

Patients treated for anal cancer need to be followed carefully, because those with recurrent disease after chemoradiation are amenable to salvage abdominoperineal resection and can achieve long-term survival. Most recurrences occur within the first 3 years. Patients who achieve remission after chemoradiation should be evaluated with digital rectal examination, anoscopy, and inguinal lymph node examination every 3-6 months for 5 years.[8]​ Annual imaging of the pelvis, abdomen, and chest is recommended for the first 3 years for patients with stage 2 or stage 3 disease.​[8]

After abdominoperineal resection, patients should be evaluated with clinical examination every 3-6 months for 5 years.[8]​ Annual imaging of the pelvis, abdomen, and chest is recommended for the first 3 years.​[8]

Women should have a careful gynaecological examination as part of their routine follow-up, to evaluate for cervical, vaginal, or vulvar dysplasia.[4]​​​[8]​ These conditions are also associated with human papillomavirus infection.

Patients should be counselled to achieve and maintain a healthy weight, keep physically active, eat a healthy diet (high in vegetables, fruits, and whole grains, and low in red and cured meats and highly processed foods, especially those high in excess fats and sugars), consume alcohol sparingly or abstain, and stop smoking. Immunisations should be offered according to national guidelines.[73]

Patients should be monitored for late sequelae of treatment, which can have a significant negative impact on their quality of life. These may include:​[8]

  • Bowel dysfunction (increased stool frequency, rectal urgency, flatulence, and faecal incontinence)

  • Bladder dysfunction

  • Sexual dysfunction (dyspareunia, impotence, reduced libido).

Other more general long-term problems which can affect survivors of all types of cancers should also be screened for regularly and addressed if present. These include:[73]

  • Increased cardiovascular disease (CVD) risk. CVD is a leading cause of death in cancer survivors. This is likely due to shared risk factors for both cancer and CVD (e.g., smoking, obesity), as well as cardiotoxic side effects from systemic cancer treatments. Physicians should provide CVD risk assessment and counseling on CVD risk factor management to all cancer survivors.

  • Psychological problems, including anxiety, depression, trauma, and distress. These are common in cancer survivors due to worries about recurrence, health problems, body and sexuality changes, financial difficulties, or other concerns. Psychotherapy, pharmacologic treatments, and specialist mental health team referral should be considered.

  • Lymphoedema. Patients who have had radiation to the inguinal lymph nodes are at risk for lymphoedema, resulting in lower limb swelling and associated discomfort, as well as an increased risk of localised infection and psychological distress. Affected patients should be referred to a lymphedoema specialist team.

  • Chronic pain. More than one-third of post-treatment cancer survivors experience chronic pain, which often leads to psychological distress; decreased activity, motivation, and personal interactions; and an overall poor quality of life. The National Comprehensive Cancer Network (NCCN) has published guidelines for the assessment and management of cancer pain syndromes.[73]

  • Fatigue. This is a common complaint in patients undergoing treatment for cancer and can be a persistent problem for some cancer survivors in the months and years after diagnosis. Referral to rehabilitation services including physical therapy, occupational therapy, and physical medicine should be considered. The NCCN has published guidelines for the assessment and management of cancer-related fatigue.[74]

  • Sleep disorders. Sleep disturbances are common, affecting 30% to 50% of patients with cancer and survivors, often in combination with pain, fatigue, anxiety, and/or depression. They have been shown to be a risk factor for suicide. Available treatments include sleep hygiene education, physical activity, psychological interventions (e.g., cognitive behavioural therapy), and drugs.

A periodic assessment of at least annually is recommended for all cancer survivors to determine any needs and necessary interventions. Shared coordinated care between oncology, primary care, and colorectal cancer specialists is encouraged.[73]

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