David P. Ryan, MD, MPH

David Ryan, MD, discusses his debate with Paul H. Sugarbaker, MD, from the ASCO session “Intraperitoneal Chemotherapy and Cytoreductive Surgery in Colon Cancer” and how in his view this type of treatment, as presented to the patient, creates a certain dynamic between the surgeon and medical oncologist, one of hope vs reality.

Kauh and colleagues nicely outlinethe major problems facingclinicians who treat humanimmunodeficiency virus (HIV)-positivepatients with squamous cell carcinomaof the anus. This is a highly curabledisease with combined-modality therapy,though the HIV-positive populationpresents unique challenges. Weagree with the approaches outlined bythe authors and would also like to emphasizeseveral principles in the managementof anal cancer.

Anal cancer accounts for 1.5% of digestive system malignancies inthe United States. In the past 30 years, substantial progress has beenmade in understanding the pathophysiology and treatment of thedisease. Anal cancer was once believed to be caused by chronic localinflammation of the perianal area, and treatment was abdominoperinealresection. From epidemiologic and clinical studies, we nowknow that the development of anal cancer is associated with humanpapillomavirus infection and that the disease has a pathophysiologysimilar to that of cervical cancer. Less invasive treatments have alsobeen developed, and the majority of patients with anal cancer can nowbe cured with preservation of the anal sphincter using concurrentexternal-beam radiation therapy and fluorouracil (5-FU)/mitomycin(Mutamycin) chemotherapy. Current areas under investigation includethe incorporation of platinum agents into the chemotherapyregimen and the use of cytologic screening studies for high-riskpopulations.

The current standard of care for patients with stage T3 rectal cancer is adjuvant combined-modality treatment with radiation and fluorouracil (5-FU)-based chemotherapy. Although data from randomized phase III trials comparing