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Information from PDQ -- for Health Professionals
Anal cancer
208/00022
** GENERAL INFORMATION **
Anal cancer is an often curable disease. The 3 major prognostic factors are
site (anal canal versus perianal skin), size (primary tumors less than 2
centimeters in size have a better prognosis), and differentiation
(well-differentiated tumors are more favorable than poorly differentiated
tumors).
Anal cancer is an uncommon malignancy, accounting for only a small percentage
(4%) of all cancers of the lower alimentary tract. Clinical trials have
evaluated the roles of chemotherapy, radiation therapy, and surgery in the
treatment of this disease.[1,2] Information about ongoing clinical trials is
available from the NCI (http://cancer.gov/clinical_trials).
Overall, the risk of anal cancer is rising, with data suggesting that
individuals with human papillomavirus and male homosexuals, in particular, are
at increased risk of anal cancer.[3-5]
References:
1. Martenson JA, Lipsitz SR, Lefkopoulou M, et al.: Results of combined
modality therapy for patients with anal cancer (E7283): an Eastern
Cooperative Oncology Group study. Cancer 76(10): 1731-1736, 1995.
2. Fuchshuber PR, Rodriguez-Bigas M, Weber T, et al.: Anal canal and
perianal epidermoid cancers. Journal of the American College of
Surgeons 185(5): 494-505, 1997.
3. Daling JR, Weiss NS, Hislop TG, et al.: Sexual practices, sexually
transmitted diseases, and the incidence of anal cancer. New England
Journal of Medicine 317(16): 973-977, 1987.
4. Palefsky JM, Holly EA, Gonzales J, et al.: Detection of human
papillomarvirus DNA in anal intraepithelial neoplasia and anal cancer.
Cancer Research 51(3): 1014-1019, 1991.
5. Ryan DP, Compton CC, Mayer RJ: Carcinoma of the anal canal. New England
Journal of Medicine 342(11): 792-800, 2000.
** CELLULAR CLASSIFICATION **
Squamous cell (epidermoid) carcinomas make up the majority of all primary
cancers of the anus. The important subset of cloacogenic (basaloid
transitional cell) tumors constitute the remainder. These two histologic
variants are associated with human papillomavirus infection.[1]
Adenocarcinomas from anal glands or fistulae formation and melanomas are rare.
Treatment of anal melanoma is not included in this summary.
References:
1. Palefsky JM, Holly EA, Gonzales J, et al.: Detection of human
papillomarvirus DNA in anal intraepithelial neoplasia and anal cancer.
Cancer Research 51(3): 1014-1019, 1991.
** STAGE INFORMATION **
The anal canal extends from the rectum to the perianal skin and is lined by a
mucous membrane that covers the internal sphincter. The following is a staging
system for anal canal cancer that has been described by the American Joint
Committee on Cancer (AJCC) and the International Union Against Cancer.[1,2]
Tumors of the anal margin (below the anal verge and involving the perianal
hair-bearing skin) are classified with skin tumors.
-- TNM definitions --
Primary tumor (T)
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor 2 cm or less in greatest dimension
T2: Tumor more than 2 cm but not more than 5 cm in greatest dimension
T3: Tumor more than 5 cm in greatest dimension
T4: Tumor of any size that invades adjacent organ(s), e.g., vagina,
urethra, bladder (involvement of the sphincter muscle(s) alone is not
classified as T4)
Regional lymph nodes (N)
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in perirectal lymph node(s)
N2: Metastasis in unilateral internal iliac and/or inguinal lymph node(s)
N3: Metastasis in perirectal and inguinal lymph nodes and/or bilateral
internal iliac and/or inguinal lymph nodes
Distant metastasis (M)
MX: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
-- Stage 0 --
Stage 0 anal cancer is carcinoma in situ. Rarely diagnosed, it is a very early
cancer that has not spread below the limiting membrane of the first layer of
anal tissue. Stage 0 anal cancer corresponds to the following TNM grouping:
Tis, N0, M0
-- Stage I --
Stage I anal cancer is cancer that is 2 centimeters or less in greatest
dimension and that has not spread anywhere else. There is no sphincter
involvement. Stage I anal cancer corresponds to the following TNM grouping:
T1, N0, M0
-- Stage II --
Stage II anal cancer is cancer that is more than 2 centimeters and that does
not involve adjacent organs or lymph nodes. Stage II anal cancer corresponds
to the following TNM groupings:
T2, N0, M0
T3, N0, M0
-- Stage IIIA --
Stage IIIA anal cancer is cancer that has spread to perirectal lymph nodes or
to adjacent organs. Stage IIIA anal cancer corresponds to the following TNM
groupings:
T1, N1, M0
T2, N1, M0
T3, N1, M0
T4, N0, M0
-- Stage IIIB --
Stage IIIB anal cancer is cancer that has spread to internal iliac and/or
inguinal nodes (unilateral or bilateral) or has spread to both adjacent organs
and perirectal lymph nodes. Stage IIIB anal cancer corresponds to the
following TNM groupings:
T4, N1, M0
Any T, N2, M0
Any T, N3, M0
-- Stage IV --
Stage IV anal cancer is cancer that has spread to distant lymph nodes within
the abdomen or to other organs in the body. Stage IV anal cancer corresponds
to the following TNM groupings:
Any T, Any N, M1
References:
1. Anal canal. In: American Joint Committee on Cancer: AJCC Cancer Staging
Manual. Philadelphia, Pa: Lippincott-Raven Publishers, 5th ed., 1997, pp
91-95.
2. Anal canal. In: Sobin LH, Wittekind C, eds.: TNM: Classification of
Malignant Tumours. New York, NY: Wiley-Liss, Inc., 5th ed., 1997, pp
70-73.
** TREATMENT OPTION OVERVIEW **
Abdominoperineal resection leading to permanent colostomy was previously
thought to be required for all but small anal cancers below the dentate line,
with approximately 70% of patients surviving 5 or more years in single
institutions,[1] but such surgery is no longer the treatment of choice.[2,3]
Radiation therapy alone may lead to a 5-year survival rate in excess of 70%,
although high doses (6,000 cGy or greater) may yield necrosis or fibrosis.[4]
Chemotherapy concurrent with lower-dose radiation therapy has a 5-year
survival rate in excess of 70% with low levels of acute and chronic morbidity,
and few patients require surgery for dermal or sphincter toxic effects.[5-10]
The optimal dose of radiation with concurrent chemotherapy to optimize local
control and minimize sphincter toxic effects is under evaluation but appears to
be in the 45 Gy to 60 Gy range.[11,12] Analysis of an intergroup trial that
compared radiation therapy plus fluorouracil/mitomycin with radiation therapy
plus fluorouracil alone in patients with anal cancer has shown improved results
(lower colostomy rates and higher colostomy-free and disease-free survival)
with the addition of mitomycin.[13] Radiation with continuous infusion of
fluorouracil plus cisplatin is also under evaluation.[14,15] Standard salvage
therapy for those patients with either gross or microscopic residual disease
following chemoradiotherapy has been abdominoperineal resection. Alternately,
patients may be treated with additional salvage chemoradiotherapy in the form
of fluorouracil, cisplatin, and a radiation boost to potentially avoid
permanent colostomy.[13]
Because of the small number of cases, information that can only come from
patient participation in well-designed clinical trials is needed to improve the
management of anal cancer. Patients with stages II, III, and IV disease should
be considered candidates for clinical trials.
-- HIV and anal cancer --
The tolerance of patients with human immunodeficiency virus (HIV) and anal
carcinoma to standard fluorouracil/mitomycin chemoradiation is not well
defined.[16,17] Patients with pretreatment CD4 counts of less than 200 may
have increased acute and late toxic effects;[18,19] chemoradiation doses may
require modification in this subset of patients.
The designations in PDQ that treatments are "standard" or "under clinical
evaluation" are not to be used as a basis for reimbursement determinations.
References:
1. Boman BM, Moertel CG, O'Connell MJ, et al.: Carcinoma of the anal canal:
a clinical and pathologic study of 188 cases. Cancer 54(1): 114-125,
1984.
2. Stearns MW, Quan SH: Epidermoid carcinoma of the anorectum. Surgery,
Gynecology and Obstetrics 131(5): 953-957, 1970.
3. Cummings BJ: The role of radiation therapy with 5-fluorouracil in anal
canal cancer. Seminars in Radiation Oncology 7(4): 306-312, 1997.
4. Cantril ST, Green JP, Schall GL, et al.: Primary radiation therapy in the
treatment of anal carcinoma. International Journal of Radiation
Oncology, Biology, Physics 9(9): 1271-1278, 1983.
5. Leichman L, Nigro N, Vaitkevicius VK, et al.: Cancer of the anal canal:
model for preoperative adjuvant combined modality therapy. American
Journal of Medicine 78(2): 211-215, 1985.
6. Sischy B: The use of radiation therapy combined with chemotherapy in the
management of squamous cell carcinoma of the anus and marginally
resectable adenocarcinoma of the rectum. International Journal of
Radiation Oncology, Biology, Physics 11(9): 1587-1593, 1985.
7. Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and
chemotherapy for radiosensitization in management of anal carcinoma:
interim report on Radiation Therapy Oncology Group study no. 8314.
Journal of the National Cancer Institute 81(11): 850-856, 1989.
8. Cummings BJ: Anal cancer. International Journal of Radiation Oncology,
Biology, Physics 19(5): 1309-1315, 1990.
9. Zucali R, Doci R, Bombelli L: Combined chemotherapy-radiotherapy of anal
cancer. International Journal of Radiation Oncology, Biology, Physics
19(5): 1221-1223, 1990.
10. Fuchshuber PR, Rodriguez-Bigas M, Weber T, et al.: Anal canal and
perianal epidermoid cancers. Journal of the American College of
Surgeons 185(5): 494-505, 1997.
11. Fung CY, Willett CG, Efird JT, et al.: Chemoradiotherapy for anal
carcinoma: what is the optimal radiation dose? Radiation Oncology
Investigations 2(3): 152-156, 1994.
12. John M, Pajak T, Flam M, et al.: Dose escalation in chemoradiation for
anal cancer: preliminary results of RTOG 92-08. Cancer Journal from
Scientific American 2(4): 205-211, 1996.
13. Flam M, John M, Pajak TF, et al.: Role of mitomycin in combination with
fluorouracil and radiotherapy, and of salvage chemoradiation in the
definitive nonsurgical treatment of epidermoid carcinoma of the anal
canal: results of a phase III randomized intergroup study. Journal of
Clinical Oncology 14(9): 2527-2539, 1996.
14. Rich TA, Ajani JA, Morrison WH, et al.: Chemoradiation therapy for anal
cancer: radiation plus continuous infusion of 5-fluorouracil with or
without cisplatin. Radiotherapy and Oncology 27(3): 209-215, 1993.
15. Ajani JA, Radiation Therapy Oncology Group: Phase III Randomized Study
of Fluorouracil and Mitomycin With Concurrent Radiotherapy Versus
Fluorouracil and Cisplatin With Concurrent Radiotherapy in Patients With
Anal Canal Carcinoma (Summary Last Modified 09/2001), RTOG-9811,
clinical trial, active, 10/31/1998.
16. Holland JM, Swift PS: Tolerance of patients with human immunodeficiency
virus and anal carcinoma to treatment with combined chemotherapy and
radiation therapy. Radiology 193(1): 251-254, 1994.
17. Peddada AV, Smith DE, Rao AR, et al.: Chemotherapy and low-dose
radiotherapy in the treatment of HIV-infected patients with carcinoma of
the anal canal. International Journal of Radiation Oncology, Biology,
Physics 37(5):1101-1105, 1997.
18. Hoffman R, Krieg R, Klencke B: Outcome and treatment tolerance for
HIV-positive patients with anal cancer based on pretreatment CD4 count.
International Journal of Radiation Oncology, Biology, Physics 42(1
suppl): A-80, 164, 1998.
19. Place RJ, Gregorcyk SG, Huber PJ, et al.: Outcome analysis of
HIV-positive patients with anal squamous cell carcinoma. Diseases of
the Colon and Rectum 44(4): 506-512, 2001.
** STAGE 0 ANAL CANCER **
Standard treatment options:
Surgical resection is used for treatment of lesions of the perianal area not
involving the anal sphincter (approach depends on the location of the lesion in
the anal canal).
** STAGE I ANAL CANCER **
Stage I anal cancer was formerly treated with abdominoperineal resection.
Current sphincter-sparing therapies include wide local excision for small
tumors of the perianal skin or anal margin, or definitive chemoradiation
(fluorouracil and mitomycin) for cancers of the anal canal. Salvage
chemoradiotherapy (fluorouracil and cisplatin plus a radiation boost) may avoid
permanent colostomy in patients with residual tumor following initial
nonoperative therapy.[1] Radical resection is reserved for patients with
incomplete responses or recurrent disease. Therefore, continued surveillance
with rectal examination every 3 months for the first 2 years and
endoscopy/biopsy when indicated after completion of sphincter-preserving
therapy is important.
Standard treatment options:
1. Small tumors of the perianal skin or anal margin not involving the anal
sphincter may be adequately treated with local resection.[2]
2. All other stage I cancers of the anal canal that involve the anal sphincter
or are too large for complete local excision are treated with external beam
radiation therapy with or without chemotherapy.[1,3-8]
Chemotherapy with fluorouracil and mitomycin combined with primary radiation
therapy appears to be more effective than radiation therapy alone.[9] The
optimal dose of radiation with concurrent chemotherapy is under
evaluation.[10-12]
Selected tumors are also suitable for interstitial irradiation.[4]
3. Radical resection is reserved for residual or recurrent cancer in the anal
canal after nonoperative therapy.
4. Alternately, salvage chemotherapy with fluorouracil and cisplatin combined
with a radiation boost may avoid a permanent colostomy in selected patients
with small amounts of residual tumor following initial nonoperative therapy.[1]
5. Interstitial iridium-192 after external-beam radiation may convert some
patients with residual disease into complete responders.[13]
References:
1. Flam M, John M, Pajak TF, et al.: Role of mitomycin in combination with
fluorouracil and radiotherapy, and of salvage chemoradiation in the
definitive nonsurgical treatment of epidermoid carcinoma of the anal
canal: results of a phase III randomized intergroup study. Journal of
Clinical Oncology 14(9): 2527-2539, 1996.
2. Enker WE, Heilwell M, Janov AJ, et al.: Improved survival in epidermoid
carcinoma of the anus in association with preoperative multidisciplinary
therapy. Archives of Surgery 121(12): 1386-1390, 1986.
3. Papillon J, Mayer M, Montbarbon JF, et al.: A new approach to the
management of epidermoid carcinoma of the anal canal. Cancer 51(10):
1830-1837, 1983.
4. Cummings B, Keane T, Thomas G, et al.: Results and toxicity of the
treatment of anal canal carcinoma by radiation therapy or radiation
therapy and chemotherapy. Cancer 54(10): 2062-2068, 1984.
5. Leichman L, Nigro N, Vaitkevicius VK, et al.: Cancer of the anal canal:
model for preoperative adjuvant combined modality therapy. American
Journal of Medicine 78(2): 211-215, 1985.
6. James RD, Pointon RS, Martin S: Local radiotherapy in the management of
squamous carcinoma of the anus. British Journal of Surgery 72(4):
282-285, 1985.
7. Sischy B: The use of radiation therapy combined with chemotherapy in the
management of squamous cell carcinoma of the anus and marginally
resectable adenocarcinoma of the rectum. International Journal of
Radiation Oncology, Biology, Physics 11(9): 1587-1593, 1985.
8. Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and
chemotherapy for radiosensitization in management of anal carcinoma:
interim report on Radiation Therapy Oncology Group study no. 8314.
Journal of the National Cancer Institute 81(11): 850-856, 1989.
9. UKCCCR Anal Cancer Trial Working Party: Epidermoid anal cancer: results
from the UKCCCR randomised trial of radiotherapy alone versus
radiotherapy, 5-fluorouracil, and mitomycin. Lancet 348(9034):
1049-1054, 1996.
10. Fung CY, Willett CG, Efird JT, et al.: Chemoradiotherapy for anal
carcinoma: what is the optimal radiation dose? Radiation Oncology
Investigations 2(3): 152-156, 1994.
11. John M, Pajak T, Flam M, et al.: Dose escalation in chemoradiation for
anal cancer: preliminary results of RTOG 92-08. Cancer Journal from
Scientific American 2(4): 205-211, 1996.
12. Ajani JA, Radiation Therapy Oncology Group: Phase III Randomized Study
of Fluorouracil and Mitomycin With Concurrent Radiotherapy Versus
Fluorouracil and Cisplatin With Concurrent Radiotherapy in Patients With
Anal Canal Carcinoma (Summary Last Modified 09/2001), RTOG-9811,
clinical trial, active, 10/31/1998.
13. Sandhu AP, Symonds RP, Robertson AG, et al.: Interstitial iridium-192
implantation combined with external radiotherapy in anal cancer: ten
years experience. International Journal of Radiation Oncology, Biology,
Physics 40(3): 575-581, 1998.
** STAGE II ANAL CANCER **
Stage II anal cancer was formerly treated with abdominoperineal resection.
Current sphincter-sparing therapies include wide local excision for small
tumors of the perianal skin or anal margin, or definitive chemoradiation
(fluorouracil and mitomycin) for cancers of the anal canal. Salvage
chemotherapy (fluorouracil with cisplatin plus a radiation boost) may avoid
permanent colostomy in patients with residual tumor following initial
nonoperative therapy. Radical resection is reserved for patients with
incomplete responses or recurrent disease. Therefore, continued surveillance
with rectal examination every 3 months for the first 2 years and
endoscopy/biopsy when indicated after completion of sphincter-preserving
therapy is important.
Standard treatment options:
1. Small tumors of the perianal skin or anal margin not involving the anal
sphincter may be adequately treated with local resection.[1]
2. All other stage II cancers of the anal canal that involve the anal sphincter
or are too large for complete local excision are treated with external beam
radiation therapy plus chemotherapy.[2-8]
Chemotherapy with fluorouracil and mitomycin combined with primary radiation
therapy appears to be more effective than radiation therapy alone.[9] The
optimal dose of radiation with concurrent chemotherapy is under
evaluation.[10-12]
Selected tumors are also suitable for interstitial irradiation.[3,13]
3. Radical resection is reserved for continued residual or recurrent cancer
in the anal canal after nonoperative therapy.
4. Alternately, salvage chemotherapy with fluorouracil and cisplatin combined
with a radiation boost may avoid a permanent colostomy in selected patients
with small amounts of residual tumor following initial nonoperative therapy.[8]
References:
1. Enker WE, Heilwell M, Janov AJ, et al.: Improved survival in epidermoid
carcinoma of the anus in association with preoperative multidisciplinary
therapy. Archives of Surgery 121(12): 1386-1390, 1986.
2. Papillon J, Mayer M, Montbarbon JF, et al.: A new approach to the
management of epidermoid carcinoma of the anal canal. Cancer 51(10):
1830-1837, 1983.
3. Cummings B, Keane T, Thomas G, et al.: Results and toxicity of the
treatment of anal canal carcinoma by radiation therapy or radiation
therapy and chemotherapy. Cancer 54(10): 2062-2068, 1984.
4. Leichman L, Nigro N, Vaitkevicius VK, et al.: Cancer of the anal canal:
model for preoperative adjuvant combined modality therapy. American
Journal of Medicine 78(2): 211-215, 1985.
5. James RD, Pointon RS, Martin S: Local radiotherapy in the management of
squamous carcinoma of the anus. British Journal of Surgery 72(4):
282-285, 1985.
6. Sischy B: The use of radiation therapy combined with chemotherapy in the
management of squamous cell carcinoma of the anus and marginally
resectable adenocarcinoma of the rectum. International Journal of
Radiation Oncology, Biology, Physics 11(9): 1587-1593, 1985.
7. Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and
chemotherapy for radiosensitization in management of anal carcinoma:
interim report on Radiation Therapy Oncology Group study no. 8314.
Journal of the National Cancer Institute 81(11): 850-856, 1989.
8. Flam M, John M, Pajak TF, et al.: Role of mitomycin in combination with
fluorouracil and radiotherapy, and of salvage chemoradiation in the
definitive nonsurgical treatment of epidermoid carcinoma of the anal
canal: results of a phase III randomized intergroup study. Journal of
Clinical Oncology 14(9): 2527-2539, 1996.
9. UKCCCR Anal Cancer Trial Working Party: Epidermoid anal cancer: results
from the UKCCCR randomised trial of radiotherapy alone versus
radiotherapy, 5-fluorouracil, and mitomycin. Lancet 348(9034):
1049-1054, 1996.
10. Fung CY, Willett CG, Efird JT, et al.: Chemoradiotherapy for anal
carcinoma: what is the optimal radiation dose? Radiation Oncology
Investigations 2(3): 152-156, 1994.
11. John M, Pajak T, Flam M, et al.: Dose escalation in chemoradiation for
anal cancer: preliminary results of RTOG 92-08. Cancer Journal from
Scientific American 2(4): 205-211, 1996.
12. Ajani JA, Radiation Therapy Oncology Group: Phase III Randomized Study
of Fluorouracil and Mitomycin With Concurrent Radiotherapy Versus
Fluorouracil and Cisplatin With Concurrent Radiotherapy in Patients With
Anal Canal Carcinoma (Summary Last Modified 09/2001), RTOG-9811,
clinical trial, active, 10/31/1998.
13. Sandhu AP, Symonds RP, Robertson AG, et al.: Interstitial iridium-192
implantation combined with external radiotherapy in anal cancer: ten
years experience. International Journal of Radiation Oncology, Biology,
Physics 40(3): 575-581, 1998.
** STAGE IIIA ANAL CANCER **
Stage IIIA anal cancer presents clinically as stage II in most instances and is
determined to be IIIA by clinically evident perirectal nodal disease or
adjacent organ involvement. Endorectal or endoanal ultrasound may aid in
pretreatment staging.
Standard treatment options:
1. Treatment as for stage I and II disease, using radiation therapy plus
chemotherapy.[1]
2. Abdominoperitoneal resection combined with resection of femoral, inguinal,
abductor, and iliac lymph nodes, followed by postoperative radiation therapy.
References:
1. Sischy B, Doggett RL, Krall JM, et al.: Definitive irradiation and
chemotherapy for radiosensitization in management of anal carcinoma:
interim report on Radiation Therapy Oncology Group study no. 8314.
Journal of the National Cancer Institute 81(11): 850-856, 1989.
** STAGE IIIB ANAL CANCER **
The presence of inguinal nodes that are involved with metastatic disease
(unilateral or bilateral) is a poor prognostic sign, although cure of this
stage of disease is possible. Because of the poor prognosis associated with
this stage, patients should be included in clinical trials whenever possible.
Standard treatment options:
Radiation therapy plus chemotherapy (as described for stage II) with surgical
resection of residual disease at the primary site (local resection or
abdominoperineal resection) and unilateral or bilateral superficial and deep
inguinal node dissection for residual or recurrent tumor.
** STAGE IV ANAL CANCER **
Patients in this stage should be considered candidates for clinical trials.
There is no standard chemotherapy for patients with metastatic disease.
Palliation of symptoms from the primary lesion is of major importance.
Standard treatment options:
1. Palliative surgery.
2. Palliative irradiation.
3. Palliative combined chemotherapy and radiation therapy.
4. Clinical trials.
** RECURRENT ANAL CANCER **
Local recurrences after treatment with radiation therapy and chemotherapy or
surgery as the primary treatment may be controlled by using the alternate
treatment (surgical resection after radiation and vice versa).[1] Clinical
trials are exploring the use of radiation therapy with chemotherapy and/or
radiosensitizers to improve local control.
References:
1. Longo WE, Vernava AM, Wade TP, et al.: Recurrent squamous cell carcinoma
of the anal canal: predictors of initial treatment failure and results
of salvage therapy. Annals of Surgery 220(1): 40-49, 1994.
Date Last Modified: 07/2002
******************************************************************************
* This information from PDQ is reviewed regularly by members of the PDQ *
* Editorial Boards. If you have specific comments on the content of this *
* information, direct them to: PDQ Editorial Board, CIPS/NCI, 6116 *
* Executive Boulevard, Suite 3002B, MSC-8321, 20892-8321, fax: 301-480-8105.*
* *
* The PDQ database also contains listings of clinical trial protocols and *
* directories of organizations and physicians who treat cancer patients, *
* but this information is not available through CancerMail. For more *
* information on accessing PDQ, consult the CancerMail Contents List. *
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