Anal cancer: is neoadjuvant cisplatin chemotherapy or chemoradiotherapy friend or foe?

This Practice Point commentary discusses the findings of the Intergroup RTOG 98-11 trial, which aimed to investigate both the potential role of cisplatin as neoadjuvant chemotherapy, and also its role concurrently in combination with radiotherapy, for anal-canal carcinoma. Although chemoradiotherapy has had an important effect on the treatment of anal cancer, and allows preservation of anorectal function with survival rates similar to or better than those of surgical treatment, overall survival rates for advanced tumors are still in the region of 50-60% at 5 years. A strong theoretical rationale for cisplatin-based treatment in anal cancer exists; several phase II trials have demonstrated a high response rate with reduced colostomy rates. The Intergroup results are disappointing in that neoadjuvant chemotherapy with cisplatin and 5-fluorouracil, followed by cisplatin-based chemoradiotherapy did not improve overall survival, disease-free survival and locoregional control when compared with the standard treatment of combined 5-fluorouracil and mitomycin chemoradiotherapy.