Intended for healthcare professionals

Clinical Review

Diagnosis and management of anal intraepithelial neoplasia and anal cancer

BMJ 2011; 343 doi: (Published 04 November 2011) Cite this as: BMJ 2011;343:d6818
  1. J A D Simpson, academic surgical registrar,
  2. J H Scholefield, professor of surgery
  1. 1Division of Gastrointestinal Surgery, Queens Medical Centre Campus, Nottingham University Hospital, Nottingham NG7 2UH, UK
  1. Correspondence to: J A Simpson alastairsimpson{at}
  • Accepted 5 September 2011

Summary points

  • Human papillomavirus infection increases an individual’s risk of developing squamous cell carcinoma of the anus; cigarette smoking, high number of previous sexual partners, and previous pre-cancerous lesions of the cervix or vulva (in women) are also associated with increased risk

  • Although anal cancer is not an AIDS defining cancer, its incidence is increased in HIV positive individuals and in those who are immunosuppressed

  • Anal intraepithelial neoplasia usually precedes development of invasive squamous anal carcinoma and can present in various forms.

  • The management of anal cancer has changed in recent years; chemo-irradiation rather than surgery is the first choice treatment for most lesions.

  • Surgery may be the primary treatment modality for small perianal lesions which can be locally excised, but is now usually reserved for tumours that fail to respond to chemo-irradiation or for recurrent disease.

Anal cancer accounts for about 4% of large bowel malignancies, but data from the Surveillance Epidemiology and End Results programme show a considerable rise in incidence since 19751 from 0.8 to 1.7 per 100 000. The World Health Organization recently estimated that between 350 and 500 new cases of anal squamous cell carcinoma are detected each year in England and Wales.2

Observational studies have shown that individuals with genital human papillomavirus (HPV) infection and those who are immunosuppressed, including HIV positive patients, are at increased risk of developing anal cancer.3 4 A history of cervical or vulval HPV infection and premalignant changes also increases the risk of developing anal cancer, with a reported incidence rate ratio of between 3.97 and 31.09, dependent on age at diagnosis, compared with controls.5 General practitioners and practice nurses who screen women as part of national programmes for detecting cervical malignancy should be aware of the association between HPV infection and anal cancer.

The majority of anal …

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