Practice of Radiation Therapy for Anal Cancer in Austria: A Survey on Behalf of the Austrian Radiation Oncology Society Gastrointestinal Tumor Group (ÖGRO-GIT)

PURPOSE/OBJECTIVE(S): The general indication for chemoradiation in locally confined anal cancer is widely accepted but international consensus for staging procedures, radiation technique, dose/fractionation, target volume definition, supportive care, follow-up and treatment of early lesions is less uniform. We conducted a nationwide patterns-of-care survey in Austria to evaluate areas of disagreement and to identify possible targets for further standardization. MATERIALS/METHODS: We developed an anonymous questionnaire (38 questions) for the above-mentioned issues. The survey was sent to all 14 Austrian radiation oncology departments. Results were analyzed descriptively and compared to two major international guidelines (NCCN, ESMO) in their latest version. RESULTS: We received 13 answers (response rate of 93%). Median number of treated patients per year and institution was 14. Work-up generally included DRE, endoscopy and cross-sectional imaging of chest, abdomen (mainly CT) and pelvis (mainly MRI). PET-CT was used by 38%. Screening for HIV and biopsies of suspicious lymph nodes (LN) (15% each) were infrequently used. All centers use IMRT with some kind of (mainly daily) IGRT. Median doses to the primary tumor were 54.7 Gy (50.4-59.4) for T1-2 and 59.4 Gy (55-64.4) for T3-4 lesions. Boosts are applied mainly sequentially. Doses to elective nodal areas varied from 30.6-60 Gy depending on whether the patient was cN0 or cN+, but most centers prescribe 45-50.4 Gy to all elective nodal areas. Suspicious nodes usually receive a boost independent of their size to a median dose of 54 Gy (50-60 Gy). Target delineation of elective nodal areas seems generally uniform with inclusion of the common iliac nodes as the only area of disagreement. No agreement was found for OAR delineation and dose constraints. Concurrent chemotherapy was mitomycin and 5-fluorouracil /Capecitabine in all centers with 54% favoring capecitabine. Supportive care like nutritional counseling or psycho-oncological care was infrequently offered. Intensive follow-up was performed by all institutions for at least 5 years. Treatment of T1N0 showed considerable disagreement (46% surgery, 31% RT alone, 23% chemoradiation). Median dose to primary tumor was 57.2 Gy (50-60 Gy) and 2/7 centers favoring (C)RT indicated to treat no elective nodal areas in this situation. CONCLUSION: We found a high rate of agreement between the centers and concordance with the guideline recommendations at least for the main issues of work-up, treatment and follow-up. PET-CT, routine HIV testing and biopsies of suspicious LN seem underrepresented. The largest controversy regarding elective nodal target volumes concerns inclusion of the common iliac nodes. Doses to primary tumor, suspicious LN and elective nodal areas vary to some extent and are mainly in line with the recommendations, although sometimes above. OAR delineation, dose constraints, supportive care and treatment of early anal cancer are highly variable and represent areas for further standardization.