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Abstract

Purpose Squamous cell carcinoma of the anal canal (SCCAC) is characterized by high locoregional failure (LRF) rates after sphincter-preserving definitive chemoradiation (CRT) and is typically associated with anogenital human papilloma virus infection. Because cetuximab enhances the effect of radiation therapy in human papilloma virus-associated oropharyngeal squamous cell carcinoma, we hypothesized that adding cetuximab to CRT would reduce LRF in SCCAC. Methods Sixty-one patients with stage I to III SCCAC received CRT including cisplatin, fluorouracil, and radiation therapy to the primary tumor and regional lymph nodes (45 to 54 Gy) plus eight once-weekly doses of concurrent cetuximab. The study was designed to detect at least a 50% reduction in 3-year LRF rate (one-sided α, 0.10; power 90%), assuming a 35% LRF rate from historical data. Results Poor risk features included stage III disease in 64% and male sex in 20%. The 3-year LRF rate was 23% (95% CI, 13% to 36%; one-sided P = .03) by binomial proportional estimate using the prespecified end point and 21% (95% CI, 7% to 26%) by Kaplan-Meier estimate in a post hoc analysis using methods consistent with historical data. Three-year rates were 68% (95% CI, 55% to 79%) for progression-free survival and 83% (95% CI, 71% to 91%) for overall survival. Grade 4 toxicity occurred in 32%, and 5% had treatment-associated deaths. Conclusion Although the addition of cetuximab to chemoradiation for SCCAC was associated with lower LRF rates than historical data with CRT alone, toxicity was substantial, and LRF still occurs in approximately 20%, indicating the continued need for more effective and less toxic therapies. 

Fig 1.

Treatment schema. FU, fluorouracil; IV, intravenous; RT, radiation therapy.​ 

Author information​

Garg MK1, Zhao F1, Sparano JA1, Palefsky J1, Whittington R1, Mitchell EP1, Mulcahy MF1, Armstrong KI1, Nabbout NH1, Kalnicki S1, El-Rayes BF1, Onitilo AA1, Moriarty DJ1, Fitzgerald TJ1, Benson AB 3rd1.

1 Madhur K. Garg, Joseph A. Sparano, and Shalom Kalnicki, Montefiore Medical Center, Albert Einstein College of Medicine, Montefiore-Einstein Center for Cancer Care, Bronx, NY; Fengmin Zhao, Dana Farber Cancer Institute, Boston, MA; Joel Palefsky, University of California, San Francisco, CA; Richard Whittington, Philadelphia VA Medical Center; Edith P. Mitchell, Thomas Jefferson University, Philadelphia, PA; Mary F. Mulcahy and Al B. Benson III, Northwestern University, Chicago, IL; Karin I. Armstrong, United Hospital, Woodbury, MN; Nassim H. Nabbout, Cancer Center of Kansas, Wichita, KS; Bassel F. El-Rayes, Emory University, Atlanta, GA; Adedayo A. Onitilo, Marshfield Clinic, Marshfield, WI; Daniel J. Moriarty, Overlook Medical Center, Summit, NJ; and Thomas J. Fitzgerald, Imaging and Radiation Oncology Core, Quality Assurance Review Center, Providence, RI.