Treatment Patterns and Survival of Non-metastatic Anal Carcinoma at Tikur Anbessa Specialized Hospital, Addis Abeba Ethiopia: A 5 Year Retrospective Study

Treatment Patterns and Survival of Non-metastatic Anal Carcinoma at Tikur Anbessa Specialized Hospital, Addis Abeba Ethiopia: A 5 Year Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Treatment Patterns and Survival of Non-metastatic Anal Carcinoma at Tikur Anbessa Specialized Hospital, Addis Abeba Ethiopia: A 5 Year Retrospective Study Birhanu T. Liyew, Damena Teshome, Sonia W. Semayneh, Feleke H. Maniso, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9080015/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract PURPOSE Concurrent chemo-radiotherapy (CCRT) is the standard treatment of non-metastatic ASCC.However, there is a limited access to radiotherapy centers to delivery standard CCRT in resource constraint countries, like Ethiopia. We evaluate the treatment pattern, and survival of patients with non-metastatic anal squamous cell carcinoma at Tikur Anbessa Specialized Hospital (TASH), a tertiary teaching hospital in Addis Ababa, Ethiopia. Methods This retrospective study reviewed medical records of patients with non-metastatic ASCC between April 2019 and April 2024. Survival status and any missing data were addressed via phone calls. Data about socio-demographics, clinical presentations, treatments, and outcomes were collected. Descriptive statistics and Kaplan-Meier survival analysis were used to analyze the data. Factors influencing survival were identified using Cox proportional hazards. Results Median age of patients was 53.3 years,66.7% were female,and 51.6% were living with HIV.Stage III disease accounts for 78.3%.Overall,88% of patients were planned for primary radical treatment but only 45% received radical treatment,and the remaining received palliative treatment(34%),and did not receive any treatment(21.3%).The 5-year overall survival(OS) for the overall population was 28%.The 2 and 5 years OS of patients received radical RT and palliative RT was 100% vs 62% and 90% vs 0%,respectively(p = 0.001).Type of treatment was an independent risk factor for death.Patients received palliative RT had an inferior outcome than those received radical RT (HR = 13.3, 95% CI:1.5–115).The mean radiotherapy waiting time was 27 weeks for radically treated patient. Conclusions The survival of non-metastatic ASCC in this study is unacceptably low. Factors contributing to poor survival include lack of treatment due to longer RT waiting times, a higher proportion of palliative treatment, and advanced stage. The findings emphasize the urgent need of strategies for management of ASCC, particularly in low-resource settings such as Ethiopia. Survival rate CCRT Anal carcinoma treatment pattern Ethiopia Figures Figure 1 Figure 2 Figure 3 Figure 4 CONTEXT Key Objective What type of treatments are used, and survival outcomes of patients with non-metastatic anal squamous cell carcinoma at Tikur Anbessa Specialized Hospital? Knowledge Generated More than half of patients, among those patients planned to have radical treatment, received palliative treatment and without any treatment. Type of treatment was an independent risk factor for death. Patients received palliative RT had inferior outcome than those received radical RT but had superior outcome than those who did not received any treatment. Relevance Patients diagnosed with non metastatic ASCC should be received their radical treatment timely if not at least they should receive palliative treatment. INTRODUCTION Anal cancer is a rare cancer, accounts for 2% all gastrointestinal tract cancer. The most common type of primary anal cancer is anal squamous cell carcinoma. The global incidence of anal squamous cell carcinoma(ASCC) is rising 1 , 2 . Treatment of anal SCC has evolved significantly in the past 4 decades.Historically, Abdomino-perineal resection(APR) was the primary treatment for ASCC 3 .However, this approach resulted in high rate of morbidity related due to the need for a permanent colostomy 4 . since 1970s, CCRT is the standard treatment of non-metastatic ASCC 5 , 6 .Majority of patients after CRT will have a clinically complete remission and do not require organ affecting surgery such as an APR. Nevertheless, APR still can play significant a role as salvage treatment 7 , 8 . Despite improved outcomes with definitive chemoradiotherapy (CCRT) for non-metastatic ASCC, there is a limited access to radiotherapy centers to delivery standard CCRT in resource constraint countries, like Ethiopia. Tikur Anbessa Specialized Hospital serves as the primary oncology center in Ethiopia. Due to longer radiotherapy waiting times, patients with non-metastatic ASCC at the hospital receive varied treatments from different clinicians. This leads to a situation including some patients receive induction chemotherapy (CT) while awaiting CCRT, and others are scheduled for CCRT but face delays in receiving the complete prescribed radiation dose. This lack of standardized treatment due to resource limitations creates uncertainty about the effectiveness of these alternative approaches compared to the gold standard CCRT. Despite all these problems faced to treat anal cancer, no published studies in Ethiopia have investigated treatment patterns and survival outcomes for non-metastatic ASCC patients. Consequently, there a critical gap in knowledge regarding the treatment, and outcomes of non-metastatic anal SCC in the region. Research directed at addressing this gap requires, that can provide valuable insights into the management and survival of anal SCC patients. The findings from this analysis will enhance the understanding of localized ASCC, and also inform clinical guidelines and policy decisions. Improved knowledge of treatment outcomes can lead to the development of tailored interventions that address the specific needs and challenges faced by anal cancer patients in low-resource countries. Additionally, it can guide resource allocation and capacity-building efforts to strengthen the healthcare system's ability to manage anal cancer effectively. The goal of this study is to bridge this gap by assess the treatment pattern and survival outcome of non-metastatic anal SCC patients at Tikur Anbesa Specialized Hospital.The study seeks to contribute to the global understanding of non metastatic ASCC management and support the development of context-specific strategies to improve patient outcomes in Ethiopia and similar settings. Materials and Methods A retrospective study of non-metastatic ASCC patients at Tikur Anbessa Specialized Hospital Oncology department in Addis Ababa, Ethiopia, was conducted from April 1, 2019 to April 1, 2024.Tikur Anbesa Hospital is one of Ethiopia's leading tertiary care centers, serving as a national referral hospital for complex cases and providing specialized care to patients from across the country. At present, the majority of anal cancer cases are diagnosed and treated within adult Oncology units. The study population were all histologically confirmed anal squamous cell cancer patients who had adequately documented stage, and managed at oncology unit of TASH during the specified study period. Patients having another primary in addition to anal cancer, histology other than ASCC, and those whose diagnosis was only documented without detailed records to diagnostic and treatment criteria were excluded. The data collection for this study was extracting from electronic medical record,and Eclipse for radiotherapy.Data was collected,regarding socio-demographic details, clinical data, diagnostic tests, Treatment details (surgery performed, type of surgery if available, chemotherapy received, specific chemotherapy drugs if available, radiotherapy received, radiotherapy dose, radiotherapy waiting time), and survival outcome.To address missing data, phone calls were made to the patients or their families to inquire.To ensure data accuracy and completeness, double data entry and cross-checking of records was implemented. Statistical Analysis The collected data were cleaned and transferred to SPSS version 27 for analysis. Descriptive Statistics was used to summarize patient demographics, clinical characteristics, and treatment patterns. Kaplan-Meier analysis was used to estimate the Overall survival (OS). Log-rank tests or Cox proportional hazards regression was used to analyze the association between patient demographics, disease characteristics, different treatment modalities on survival outcomes. Variables with a p < = 0.25 on univariate analysis were considered as a candidate for the final analysis. Predictors for survival were declared at a p-value of < 0.05. Ethical approval was obtained from the relevant Institutional Review Board (IRB) before initiating the study. Patient confidentiality was maintained throughout the study. All data was anonymized before analysis. Result Patient and clinical characteristics Between April 2019 and April 2024, we identified 60 patients.The median age was 53.3 years (IQR = 41–60),and the vast majority of patients were female (66.7%).The anal SCC was most commonly diagnosed in those age older than 30 years (98.3%) ( Table 1).The majority (51.6%) of patients were living with HIV.The CD4 count at diagnosis was available in only 12 (38.7%) patients with a mean CD4 count of 483.75cell/m3 (SD ± 38.7). Most Patients (90%) at diagnosis had good performance status (ECOG 0 or I). The average tumor size was 6.34cm (range 1 to 11cm). Forty seven out of 60 patients had AJCC stage III (78.3%). Eighty percent of patients had been symptomatic for more than 6 months before diagnosis, and only 1.7% had symptoms for less than 1 month. The diagnosis of anal SCC was made by biopsy of the primary site in 96.7% of the study participants (Table 1). Table 1 Baseline Patients’ Characteristics Patient characteristics (N = 60) Frequency (No) % Age at diagnosis (years) Median age 53.3 (IQR = 41–60) 50 31 51.7 Sex Female 40 66.7 Male 20 33.3 ECOG PS 0 ,1 54 90 >=2 6 10 Duration of symptom(month) 12 18 30 Tumor size in cm 5cm 44 73.3 T-stage T1 3 5 T2 11 18.3 T3 20 33.3 T4 26 43.3 N-stage N0 17 28.3 N1 43 71.7 Group staging Stage-I 1 1.7 Stage-II 12 20 Stage-III 47 78.3 HIV Positive 31 51.6 CD4 count Known 12 38.7 Unknown 19 61.3 CD4 level (cell/m3) 500 5 41.7 Histology diagnosis Biopsy 58 96.7 FNAC 2 3.3 Site of histology diagnosis From LN 1 1.7 Primary tumor site 59 98.3 Abbreviations: ECOG PS, Eastern Cooperative Oncology Group performance status; LN, lymph node; CD4, clusters of differentiation 4; FNAC, fine needle aspiration cytology; HIV, human immune virus. Treatment patterns The initial planned treatment after diagnosis of non metastatic ASCC was curative for 53 patients (88%), and palliative for 7 patients (12%). The most common planned curative treatment modalities were induction chemotherapy (CT) plus concurrent chemoradiotherapy (38.3%), CCRT alone (35%), Abdominoperineal resection (APR) followed by adjuvant RT with or without concurrent or induction chemotherapy for 5% of patients (Supplementary Table S1). Despite being planned to receive the above treatments at diagnosis only 27 patients (45% ) received their curative treatment according to the schedule, while 20 patients (33.3%) were treated with palliative intent and 13 patients (21.7%) did not receive any type of treatment(Supplementary Table S2).Among patients received curative treatment,the most common treatment modalities were definitive radiotherapy with or without concurrent chemotherapy (n = 19, 70.4% ),and induction chemotherapy followed by RT with or without concurrent chemotherapy (n = 8, 29.6%).Among all patients received palliative treatment,the type of treatment were palliative CT alone (35%, 7/20), palliative RT alone (35%, 7/20) ,and combined treatment with palliative RT and palliative CT (30%,6/20) (Supplementary Table S2). Among stage I patients, who received radical intent of RT, palliative treatment and no treatment were 66.6%, 85% and 92% respectively. Among 27 patients received radical radiotherapy( RT ), mean dose of radiation to total target volume was 49.5 ± 5.5 Gray(Gy), with a range of 39.6Gy to 54Gy,and the radiotherapy technique used were 3DCRT (77.8%) ,VMAT ( 11% ),and 2DRT (7.4% ).The vast majority (88.9%) of patients received radical RT had one or more days of radiation therapy interruptions,with the mean radiotherapy interruption was 8.8 days ( range : 1 to 24days). Approximately 25.9% of these patients had more than 10days of radiotherapy treatment interrupted (Supplementary Table S3). Regarding concurrent chemotherapy, about half (51.9%, 14 out of 27 patients received radical RT) received at least one cycle of concurrent CT, while concurrent CT was planned but not given or not documented in 37% of patients. The commonest chemotherapy used as concurrent was cisplatin plus capacitabine accounting for 33.3% followed by capacitabin alone. One third of patients in this study received a palliative or induction chemotherapy, the commonly used chemotherapy type was cisplatin /5-FU followed by carboplatin/taxon (Supplementary Fig.S1). The median number of cycles of induction or palliative chemotherapy given was 5 cycles, with a minimum of one cycle and a maximum of 6 cycles, respectively. The mean RT waiting time from diagnosis to first fraction,was 26.8 weeks(SD± 32weeks) with a range of 0.57 weeks to 134 weeks for the over all population,and 27weeks(SD ± 28 weeks) for radical radiotherapy.The RT waiting times among patients treated with radical RT reveled that, 44.4% and 14.8% of patients had a 6 months and 1year and above waiting time, respectively(Supplementary Table S3).The mean chemotherapy waiting time was 21 weeks with minimum of 1 week and maximum of 61 weeks. We also detected changes in the treatment modalities over the study period. The proportion of patients treated with radical intent of radiotherapy was increasing over the study period. However, the proportion of palliative RT remained relatively stable (Supplementary Fig.S2). Treatment response Among 21 patients received palliative and induction chemotherapy, only 60% of patients had a documented tumor response rate; Of those the response rate evaluation revealed that, at mid cycle of chemotherapy 39.1% of patients had an overall response rate including 4.8% complete response rate, while at end cycles of chemotherapy 15% ,10% ,25%, and 20% of patients had an overall response, partial response, stable disease, and progressive disease, respectively(Supplementary Table S4). Regarding radiotherapy treatment outcome, among 27 radically treated patients the treatment response evaluation at 3months and 6months post CCRT or RT was available in 17 and 23 patients,respectively.The response rate revealed that,at 3 months overall response rate was 62.9% with complete response rate of 29.6%,and these response rate at 6 months were increased to 81% with 63% of complete response rate.At 6months 3.7% of patients developed a progressive disease .The overall response rate at 3 month for palliative RT was 42.6%(Supplementary Table S4). Survival Median follow up time was 17.9 months (IQR 10-28.9) and 19 months for the overall population and for those patients treated with radical RT, respectively. For the overall population, the 2 and 5-year overall survival rate was 56% and 28%, respectively, with a median survival of 29 months (95% CI: 16–40.9) (Fig. 1). Patients with stage I and stage II disease had significantly longer 5-year OS compared to patients with stage III disease (Long Rank, P = O.028). The survival of patients receiving radical RT was significantly longer compared to those patients receiving palliative RT, with the 2 and 5- years OS of 100% vs 62% and 90% vs 0%, respectively (P = 0.001). The median survival was not reached for patients treated with radical RT,and the median survival was 32 months for patients treated with palliative RT with or with out palliative chemotherapy (p = 0.001) (Fig. 2). The median survival of patients received palliative radiotherapy plus palliative chemotherapy (36 months, 95% CI 25–45), palliative RT alone (22 months, 95% CI, 10–42 ), palliative CT alone (20 months, 95 CI of 14–25) tended to be prolonged compared to those without any form of treatment (10 months, 95% CI 8.3–11.6). The 2 years OS of patients received definitive treatment, palliative treatment and no treatment was 100%, 42% and 0%, respectively (Fig. 3). On uni variant analysis, intent of radiotherapy, stage and tumor size variables were a candidate for final analysis with P < = 0.25. On multivariate cox-regression analysis patients treated with palliative RT was associated with 13.3 times increased chance of poor survival as compared to those treated with radical RT (aHR = 13.3, 95% CI:1.5–115, p = 0.01). The probability of recurrence free survival for patient treated with radical intent of radiotherapy and having complete response at 6 months was evaluated from days of initiation of radiotherapy to diagnosis of recurrence or death. The estimated 5 years RFS was 72% (Fig. 4). The 5 years probability of colostomy free survival from first date of RT to date of colostomy, for those who had no colostomy before RT was 88%. Discussion To our knowledge,this is the first study conducted at the largest and only comprehensive cancer center in Ethiopia, to insight into treatment pattern and outcomes of non metastatic ASCC patients.The study found that a median age of patients was 53.3 years, which is a decade earlier than reported in Western data 9 . The majority of patients diagnosed with anal squamous cell carcinoma were female, and 51.6% were HIV positive. The incidence of HIV in this study is slightly lower compared to other Africa studies, which reported a prevalence of 64% 10 . In this study higher proportion of patient living with HIV presents at stage III disease than HIV negative patient (84% vs 71% respectively). The current first line standard of care for anal squamous cell carcinoma is radiation therapy with concurrent 5-fluorouracil/capecitabine and mitomycin-C 5,6,11 . In this study, different treatment strategies were planned at diagnosis, including CCRT plus induction CT (38%), CCRT alone (35%), and palliative treatment (12%). Despite these initial planned treatments, only 45% of patients received radical treatment, 33.3% received palliative treatment, and 21.7% didn’t receive any type of treatment. Among those patients received radical treatment, 31.7% received RT with or without concurrent chemotherapy, and 13.3% received induction CT followed by RT with or without concurrent CT. The treatment trend shows an increment of the number of patients received radical radiotherapy over time. Only 3 patients were treated with definitive RT between a year 2019–2022, while the number of patients treated with definitive RT were increased to 16 in the year 2023. However no significant changes were observed in the treatment of palliative RT. The proportion of patients treated with palliative RT or without treatments at all is higher than in another African study. A study conducted in Tanzania by Mduma et.al (2023),reported that patients treated with palliative RT was 27% 10 . The possible reasons for these discrepancies in treatment delivery could be longer RT waiting times. The average RT waiting time in our study was 26.7 weeks and 27 weeks for the overall population and for radically treated patients, respectively, and the mean chemotherapy waiting time was 21 weeks. Another study done in Nigerian by Tumba et.al (2020), the median RT waiting for cervical, prostatic and breast cancer was 40 day 12 . A study done in Ethiopia on cervical cancer RT waiting time by Jilcha et.al (2023) revealed a median RT waiting time of 477days 13 . The complete response and survival rates observed in this study are inferior to those reported in the literature 5 , 6 . In addition to the longer RT waiting times several other factors, such as lower rate of concurrent chemotherapy use, the absence of concurrent mitomycine administration, and advanced disease stage presentation may contributes to these differences 6 , 13 . Patients received radical treatments the overall and complete response rate at 3 months was 62.9% and 29.6%, respectively. At 6-month follow–up, the overall and complete response rates increased to 81% and 63%, respectively. These findings are comparable to reports from anther African study, in which complete response rate of 49% 10 . However, the response rate was lower than other western finding. In UK, ACT II clinical trial done by James et.al (2013), the complete response rate at 6 month was 84% 5–7 . This discrepancy can be explained by the lower rate of concurrent chemotherapy use in our study, with only 51% of patients receiving concurrent CT; of those, none were receiving mitomycine. The estimated 5-years OS was 28% and 90% for the overall population and radically treated patients, respectively. The estimated 2 years OS of patients received radical RT and palliative RT was 100% and 62%, respectively. The estimated 5 years RFS and CFS of patients received radical treatments were 72% and 88%, respectively. The OS and CFS in radically treated patients were higher than reported from western studies ,which was 5-years OS rates of 65–79%,disease control rates of 68–84%,and colostomy free survival rates of 65–75% 5,6 , the possible reason for this could be the shorter median follow up time in our study (19 months). In the RTOG 98 − 11 trial conducted in USA by Gunderson eta.al (2012), at a median of 5.1 years, 5 years OS, RFS and CFS were 78.3%, 67% and 71% in the 5FU/mitomycin arm, respectively 5 . In a retrospective study done in Tanzania by Mduma et.al (2023), 2-years overall survival (OS) and local recurrence-free survival were 86.4% and 91.3%, respectively 10 . In this study the median survival of patients received palliative RT alone, palliative CT and without any type of therapy was 22, 20 and 10 months, respectively. The lower OS rate in the overall population could be due to the higher proportion of non-metastatic SCC patients received palliative therapy (33.3%) and 21.3% of patients didn’t receive any form of therapy. In this study the median survival of patients received palliative therapy has comparable outcome with metastatic anal SCC patients treated with systemic therapy (carboplatin/Taxol), while patients who did not received any form of treatment has an inferior out comes. A phase II study, done by Rao et.al (2020), to compare Cisplatin/FU vs carboplatin/taxol in metastatic anal SCC, showed median survival in carboplatin /taxol arm of 20 months 14 . This study has some limitations. First, it’s retrospective nature, and this was affected by poor documentation of clinical information including outcome variables particularly, response assessment related information, that have limited the analysis. Second, the median follow up duration was short for patients treated with definitive treatment to assess survival. In conclusion, this study highlights significant challenges in the management of non-metastatic anal SCC in TASH. Despite the global standard of care involving concurrent chemoradiation therapy, a significant proportion of patients in this study received suboptimal treatment, including palliative care or no treatment at all. The estimated 5-year OS for the overall population in this study was unacceptably low. Key factors contributing to this poor outcome include a substantial number of patients did not receive timely treatment due to longer waiting times for radiation therapy, higher proportion of patients received palliative treatment and advanced disease stage presentation, further exacerbating the poor survival outcomes. However, patients who received radical treatment demonstrated promising survival outcomes, potentially influenced by shorter follow-up times. The study also revealed that the 2-year OS for untreated or treated with palliative treatment non-metastatic anal SCC is comparable or inferior to that of metastatic anal SCC, emphasizing the critical need for timely and effective treatment. Declarations Author contributions Conception/design : Birhanu T. Liyew, Sonia W. Semayneh Provision of study material or patients : Birhanu T. Liyew, Sonia Semayneh Collection and/or assembly of data : Birhanu T. Liyew, Feleke H. Maniso Data analysis and interpretation : Birhanu T. Liyew, Feleke H. Maniso, Sonia Semayneh Manuscript writing : Sonia W. Semayneh Final approval of manuscript : All authors Accountable for all aspects of the work : All authors Funding The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article. Conflicts of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Ethics approval and consent to participate Ethical approval was obtained from Research and Ethics Committee of Addis Ababa University, College of Health Sciences, Ethiopia before we started the study. The study was conducted in accordance with the principles of 1964 Helsinki declaration and its later amendments. Due to the retrospective nature of the study and the use of anonymized patient records, the requirement for informed consent to participate was waived by Research and Ethics Committee of Addis Ababa University, College of Health Sciences. Consent for publication Not applicable Data availability statement The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author. References Islami F, Ferlay J, Lortet-Tieulent J, Bray F, Jemal A. International trends in anal cancer incidence rates. Int J Epidemiol Published online Oct. 2016;27:dyw276. 10.1093/ije/dyw276 . Gondal TA, Chaudhary N, Bajwa H, Rauf A, Le D, Ahmed S. Anal Cancer: The Past, Present and Future. Curr Oncol. 2023;30(3):3232–50. 10.3390/curroncol30030246 . Perry WB, Connaughton JC. Abdominoperineal Resection: How Is It Done and What Are the Results? Clin Colon Rectal Surg. 2007;20(3):213–20. 10.1055/s-2007-984865 . Boman BM, Moertel CG, O’Connell MJ, et al. Carcinoma of the anal canal. A clinical and pathologic study of 188 cases. Cancer. 1984;54(1):114–25. 10.1002/1097-0142(19840701)54:1%3C114::aid-cncr2820540124%3E3.0.co;2-p . Gunderson LL, Winter KA, Ajani JA, et al. Long-term update of US GI intergroup RTOG 98 – 11 phase III trial for anal carcinoma: survival, relapse, and colostomy failure with concurrent chemoradiation involving fluorouracil/mitomycin versus fluorouracil/cisplatin. J Clin Oncol Off J Am Soc Clin Oncol. 2012;30(35):4344–51. 10.1200/JCO.2012.43.8085 . James RD, Glynne-Jones R, Meadows HM, et al. Mitomycin or cisplatin chemoradiation with or without maintenance chemotherapy for treatment of squamous-cell carcinoma of the anus (ACT II): a randomised, phase 3, open-label, 2 × 2 factorial trial. Lancet Oncol. 2013;14(6):516–24. 10.1016/S1470-2045(13)70086-X . Doci R, Zucali R, Bombelli L, Montalto F, Lamonica G. Combined chemoradiation therapy for anal cancer. A report of 56 cases. Ann Surg. 1992;215(2):150–6. Cyr DP, Savage P, Theodosopoulos E, Chesney TR, Swallow CJ. Outcomes of salvage surgery for anal squamous cell carcinoma: A systematic review and meta-analysis. J Clin Oncol. 2019;37(15suppl):3571–3571. 10.1200/JCO.2019.37.15_suppl.3571 . Ho VKY, Deijen CL, Hemmes B, et al. Trends in epidemiology and primary treatment of anal squamous cell carcinoma in the Netherlands (1990–2021). Int J Cancer. 2024;154(9):1569–78. 10.1002/ijc.34811 . Mduma E, Dharsee N, Samwel K, Mwita CJ, Lidenge SJ. Clinicopathological Characteristics and Outcomes of Anal Squamous Cell Carcinoma Patients With and Without HIV Infection in Sub-Saharan Africa. JCO Glob Oncol. 2023;9:e2200394. 10.1200/GO.22.00394 . Kachnic LA, Winter K, Myerson RJ, et al. RTOG 0529: a phase 2 evaluation of dose-painted intensity modulated radiation therapy in combination with 5-fluorouracil and mitomycin-C for the reduction of acute morbidity in carcinoma of the anal canal. Int J Radiat Oncol Biol Phys. 2013;86(1):27–33. 10.1016/j.ijrobp.2012.09.023 . Tumba N, Adewuyi SA, Eguzo K, Adenipekun A, Oyesegun R. Radiotherapy waiting time in Northern Nigeria: experience from a resource-limited setting. Ecancermedicalscience. 2020;14:1097. 10.3332/ecancer.2020.1097 . Feyisa JD, Woldegeorgis MA, Zingeta GT, Abegaz KH, Berhane Y. Cervical Cancer Progression in Patients Waiting for Radiotherapy Treatment at a Referral Center in Ethiopia: A Longitudinal Study. JCO Glob Oncol. 2023;9:e2200435. 10.1200/GO.22.00435 . Rao S, Sclafani F, Eng C, et al. International Rare Cancers Initiative Multicenter Randomized Phase II Trial of Cisplatin and Fluorouracil Versus Carboplatin and Paclitaxel in Advanced Anal Cancer: InterAAct. J Clin Oncol Off J Am Soc Clin Oncol. 2020;38(22):2510–8. 10.1200/JCO.19.03266 . Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Supplementary material Supplementary material is available at online Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 13 Apr, 2026 Editor invited by journal 24 Mar, 2026 Submission checks completed at journal 24 Mar, 2026 First submitted to journal 24 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9080015","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":627846999,"identity":"ffd983d0-873f-49c3-9a74-5b0c850237ae","order_by":0,"name":"Birhanu T. Liyew","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Birhanu","middleName":"T.","lastName":"Liyew","suffix":""},{"id":627847000,"identity":"4bc59028-b911-4506-9d7f-48438e52ecf4","order_by":1,"name":"Damena Teshome","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Damena","middleName":"","lastName":"Teshome","suffix":""},{"id":627847001,"identity":"86239504-b93b-47ec-9d30-1c88675cec9f","order_by":2,"name":"Sonia W. Semayneh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYJCCA0BswMDeAKIsSNHCA6YkiLfJgEEiAUQToUW+vffgYZ6Ke8YGN59f3fCjQIKBv707Ab/pZ84lHOY5U2xmcDun7GYP0GESZ85uwK9FIsfgcG5bgg1QS9oNHqAWA4lc/FrkZ8C03DyTdvMPMVoYbkC0mBncYD92myhbDM6cMTj850yCseSZHLbbMgYSPAT9It/eY/xxRkWCYd/x489uvvljI8ff3kvAYQjAYwAmiVUOAuwPSFE9CkbBKBgFIwgAAMBwSi1+hE9hAAAAAElFTkSuQmCC","orcid":"","institution":"Addis Ababa University","correspondingAuthor":true,"prefix":"","firstName":"Sonia","middleName":"W.","lastName":"Semayneh","suffix":""},{"id":627847002,"identity":"0afdf9f7-b794-4014-91c9-17736bff6b4c","order_by":3,"name":"Feleke H. Maniso","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Feleke","middleName":"H.","lastName":"Maniso","suffix":""},{"id":627847003,"identity":"18060708-4953-4db5-9cde-6adfe5a00aa9","order_by":4,"name":"Kaleegziabher Lukas","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"Kaleegziabher","middleName":"","lastName":"Lukas","suffix":""},{"id":627847004,"identity":"24888b4c-8d3a-4a2a-ac32-8111a89bf7b9","order_by":5,"name":"munir awol","email":"","orcid":"","institution":"Addis Ababa University","correspondingAuthor":false,"prefix":"","firstName":"munir","middleName":"","lastName":"awol","suffix":""}],"badges":[],"createdAt":"2026-03-10 06:40:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9080015/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9080015/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107707891,"identity":"2e17427e-fb99-4f17-ad48-9117fea78841","added_by":"auto","created_at":"2026-04-24 09:21:22","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":64449,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival curve for the overall patients with non-metastatic ASCC in TASH, Addis Ababa Ethiopia, 2024.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-9080015/v1/5ccd43b3cbba060ac4dc6aec.png"},{"id":107706391,"identity":"075e27b4-b3d6-4dec-8791-39751e84e40b","added_by":"auto","created_at":"2026-04-24 09:18:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64214,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival curve radical and palliative intent of RT for patients with non-\u003c/p\u003e\n\u003cp\u003emetastatic ASCC at TASH, Addis Ababa Ethiopia, 2024.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9080015/v1/cfabc1587d1bdb35644bc93c.png"},{"id":107675240,"identity":"f292b12e-03dd-4abb-aa14-060e88f1759d","added_by":"auto","created_at":"2026-04-24 00:41:41","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51692,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier survival curve for definitive treatment, palliative treatment and no treatment in patient with anal SCC at TASH, Addis Ababa Ethiopia, 2024\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9080015/v1/f2edb3a2890982cba4a7a4f1.png"},{"id":107675242,"identity":"bd6e5570-7f1f-41f6-abf7-bb4ba936a01f","added_by":"auto","created_at":"2026-04-24 00:41:42","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":36626,"visible":true,"origin":"","legend":"\u003cp\u003eEstimated 5-years RFS for patients with non metastatic ASCC received a radical treatment and having complete response after 6months of treatment completion in TASH\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9080015/v1/503896165f55abfac9f257de.png"},{"id":107709333,"identity":"174fa908-cd65-44c0-a0fa-1d59e7cd34a2","added_by":"auto","created_at":"2026-04-24 09:35:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":410908,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9080015/v1/e9bd6a73-85b6-414d-bf83-8252ee7da573.pdf"},{"id":107675237,"identity":"1cecee48-de05-4701-b60d-d85c603cd9d2","added_by":"auto","created_at":"2026-04-24 00:41:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17977,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSupplementary material is available at online\u003c/p\u003e","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-9080015/v1/47c16c893e45a34a793781d0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eTreatment Patterns and Survival of Non-metastatic Anal Carcinoma at Tikur Anbessa Specialized Hospital, Addis Abeba Ethiopia: A 5 Year Retrospective Study\u003c/p\u003e","fulltext":[{"header":"CONTEXT","content":"\u003cp\u003e\u003cstrong\u003eKey Objective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhat type of treatments are used, and survival outcomes of patients with non-metastatic anal squamous cell carcinoma at Tikur Anbessa Specialized Hospital?\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKnowledge Generated\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMore than half of patients, among those patients planned to have radical treatment, received palliative treatment and without any treatment. Type of treatment was an independent risk factor for death. Patients received palliative RT had inferior outcome than those received radical RT but had superior outcome than those who did not received any treatment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRelevance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients diagnosed with non metastatic ASCC should be received their radical treatment timely if not at least they should receive palliative treatment.\u003c/p\u003e"},{"header":"INTRODUCTION","content":"\u003cp\u003eAnal cancer is a rare cancer, accounts for 2% all gastrointestinal tract cancer. The most common type of primary anal cancer is anal squamous cell carcinoma. The global incidence of anal squamous cell carcinoma(ASCC) is rising \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTreatment of anal SCC has evolved significantly in the past 4 decades.Historically, Abdomino-perineal resection(APR) was the primary treatment for ASCC\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e .However, this approach resulted in high rate of morbidity related due to the need for a permanent colostomy\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. since 1970s, CCRT is the standard treatment of non-metastatic ASCC\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.Majority of patients after CRT will have a clinically complete remission and do not require organ affecting surgery such as an APR. Nevertheless, APR still can play significant a role as salvage treatment\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite improved outcomes with definitive chemoradiotherapy (CCRT) for non-metastatic ASCC, there is a limited access to radiotherapy centers to delivery standard CCRT in resource constraint countries, like Ethiopia. Tikur Anbessa Specialized Hospital serves as the primary oncology center in Ethiopia. Due to longer radiotherapy waiting times, patients with non-metastatic ASCC at the hospital receive varied treatments from different clinicians. This leads to a situation including some patients receive induction chemotherapy (CT) while awaiting CCRT, and others are scheduled for CCRT but face delays in receiving the complete prescribed radiation dose. This lack of standardized treatment due to resource limitations creates uncertainty about the effectiveness of these alternative approaches compared to the gold standard CCRT.\u003c/p\u003e \u003cp\u003eDespite all these problems faced to treat anal cancer, no published studies in Ethiopia have investigated treatment patterns and survival outcomes for non-metastatic ASCC patients. Consequently, there a critical gap in knowledge regarding the treatment, and outcomes of non-metastatic anal SCC in the region. Research directed at addressing this gap requires, that can provide valuable insights into the management and survival of anal SCC patients. The findings from this analysis will enhance the understanding of localized ASCC, and also inform clinical guidelines and policy decisions. Improved knowledge of treatment outcomes can lead to the development of tailored interventions that address the specific needs and challenges faced by anal cancer patients in low-resource countries. Additionally, it can guide resource allocation and capacity-building efforts to strengthen the healthcare system's ability to manage anal cancer effectively.\u003c/p\u003e \u003cp\u003eThe goal of this study is to bridge this gap by assess the treatment pattern and survival outcome of non-metastatic anal SCC patients at Tikur Anbesa Specialized Hospital.The study seeks to contribute to the global understanding of non metastatic ASCC management and support the development of context-specific strategies to improve patient outcomes in Ethiopia and similar settings.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e A retrospective study of non-metastatic ASCC patients at Tikur Anbessa Specialized Hospital Oncology department in Addis Ababa, Ethiopia, was conducted from April 1, 2019 to April 1, 2024.Tikur Anbesa Hospital is one of Ethiopia's leading tertiary care centers, serving as a national referral hospital for complex cases and providing specialized care to patients from across the country. At present, the majority of anal cancer cases are diagnosed and treated within adult Oncology units. The study population were all histologically confirmed anal squamous cell cancer patients who had adequately documented stage, and managed at oncology unit of TASH during the specified study period. Patients having another primary in addition to anal cancer, histology other than ASCC, and those whose diagnosis was only documented without detailed records to diagnostic and treatment criteria were excluded.\u003c/p\u003e \u003cp\u003eThe data collection for this study was extracting from electronic medical record,and Eclipse for radiotherapy.Data was collected,regarding socio-demographic details, clinical data, diagnostic tests, Treatment details (surgery performed, type of surgery if available, chemotherapy received, specific chemotherapy drugs if available, radiotherapy received, radiotherapy dose, radiotherapy waiting time), and survival outcome.To address missing data, phone calls were made to the patients or their families to inquire.To ensure data accuracy and completeness, double data entry and cross-checking of records was implemented.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe collected data were cleaned and transferred to SPSS version 27 for analysis. Descriptive Statistics was used to summarize patient demographics, clinical characteristics, and treatment patterns. Kaplan-Meier analysis was used to estimate the Overall survival (OS). Log-rank tests or Cox proportional hazards regression was used to analyze the association between patient demographics, disease characteristics, different treatment modalities on survival outcomes. Variables with a p\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;0.25 on univariate analysis were considered as a candidate for the final analysis. Predictors for survival were declared at a p-value of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003ewas obtained from the relevant Institutional Review Board (IRB) before initiating the study. Patient confidentiality was maintained throughout the study. All data was anonymized before analysis.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Result","content":"\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003ePatient and clinical characteristics\u003c/h2\u003e\n \u003cp\u003eBetween April 2019 and April 2024, we identified 60 patients.The median age was 53.3 years (IQR\u0026thinsp;=\u0026thinsp;41\u0026ndash;60),and the vast majority of patients were female (66.7%).The anal SCC was most commonly diagnosed in those age older than 30 years (98.3%) ( Table\u0026nbsp;1).The majority (51.6%) of patients were living with HIV.The CD4 count at diagnosis was available in only 12 (38.7%) patients with a mean CD4 count of 483.75cell/m3 (SD\u0026thinsp;\u0026plusmn;\u0026thinsp;38.7). Most Patients (90%) at diagnosis had good performance status (ECOG 0 or I). The average tumor size was 6.34cm (range 1 to 11cm). Forty seven out of 60 patients had AJCC stage III (78.3%). Eighty percent of patients had been symptomatic for more than 6 months before diagnosis, and only 1.7% had symptoms for less than 1 month. The diagnosis of anal SCC was made by biopsy of the primary site in 96.7% of the study participants (Table\u0026nbsp;1).\u003c/p\u003e\n \u003cdiv\u003e\n \u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv\u003eTable 1\u003c/div\u003e\n \u003cdiv\u003e\n \u003cp\u003eBaseline Patients\u0026rsquo; Characteristics\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePatient characteristics (N\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eFrequency (No)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eAge at diagnosis (years)\u003c/p\u003e\n \u003cp\u003eMedian age 53.3 (IQR\u0026thinsp;=\u0026thinsp;41\u0026ndash;60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;=30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e30\u0026ndash;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e46.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e51.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eECOG PS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e0 ,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;=2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eDuration of symptom(month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;=1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e1\u0026ndash;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e6\u0026ndash;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eTumor size in cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;=5cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e26.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;5cm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e73.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eT-stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e18.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e33.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e43.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eN-stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eN0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e28.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e71.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eGroup staging\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eStage-I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eStage-II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eStage-III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e78.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHIV Positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e51.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCD4 count\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eKnown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e38.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e61.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eCD4 level (cell/m3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026lt;==200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e200\u0026ndash;500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003e\u0026gt;\u0026thinsp;500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e41.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eHistology diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eBiopsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e96.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFNAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eSite of histology diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eFrom LN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003ePrimary tumor site\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003e98.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003eAbbreviations: ECOG PS, Eastern Cooperative Oncology Group performance status; LN, lymph node; CD4, clusters of differentiation 4; FNAC, fine needle aspiration cytology; HIV, human immune virus.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003ch3\u003eTreatment patterns\u003c/h3\u003e\n\u003cp\u003eThe initial planned treatment after diagnosis of non metastatic ASCC was curative for 53 patients (88%), and palliative for 7 patients (12%). The most common planned curative treatment modalities were induction chemotherapy (CT) plus concurrent chemoradiotherapy (38.3%), CCRT alone (35%), Abdominoperineal resection (APR) followed by adjuvant RT with or without concurrent or induction chemotherapy for 5% of patients (Supplementary Table S1).\u003c/p\u003e\n\u003cp\u003eDespite being planned to receive the above treatments at diagnosis only 27 patients (45% ) received their curative treatment according to the schedule, while 20 patients (33.3%) were treated with palliative intent and 13 patients (21.7%) did not receive any type of treatment(Supplementary Table S2).Among patients received curative treatment,the most common treatment modalities were definitive radiotherapy with or without concurrent chemotherapy (n\u0026thinsp;=\u0026thinsp;19, 70.4% ),and induction chemotherapy followed by RT with or without concurrent chemotherapy (n\u0026thinsp;=\u0026thinsp;8, 29.6%).Among all patients received palliative treatment,the type of treatment were palliative CT alone (35%, 7/20), palliative RT alone (35%, 7/20) ,and combined treatment with palliative RT and palliative CT (30%,6/20) (Supplementary Table S2). Among stage I patients, who received radical intent of RT, palliative treatment and no treatment were 66.6%, 85% and 92% respectively.\u003c/p\u003e\n\u003cp\u003eAmong 27 patients received radical radiotherapy( RT ), mean dose of radiation to total target volume was 49.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5 Gray(Gy), with a range of 39.6Gy to 54Gy,and the radiotherapy technique used were 3DCRT (77.8%) ,VMAT ( 11% ),and 2DRT (7.4% ).The vast majority (88.9%) of patients received radical RT had one or more days of radiation therapy interruptions,with the mean radiotherapy interruption was 8.8 days ( range : 1 to 24days). Approximately 25.9% of these patients had more than 10days of radiotherapy treatment interrupted (Supplementary Table S3).\u003c/p\u003e\n\u003cp\u003eRegarding concurrent chemotherapy, about half (51.9%, 14 out of 27 patients received radical RT) received at least one cycle of concurrent CT, while concurrent CT was planned but not given or not documented in 37% of patients. The commonest chemotherapy used as concurrent was cisplatin plus capacitabine accounting for 33.3% followed by capacitabin alone.\u003c/p\u003e\n\u003cp\u003eOne third of patients in this study received a palliative or induction chemotherapy, the commonly used chemotherapy type was cisplatin /5-FU followed by carboplatin/taxon (Supplementary Fig.S1). The median number of cycles of induction or palliative chemotherapy given was 5 cycles, with a minimum of one cycle and a maximum of 6 cycles, respectively.\u003c/p\u003e\n\u003cp\u003eThe mean RT waiting time from diagnosis to first fraction,was 26.8 weeks(SD\u0026plusmn; 32weeks) with a range of 0.57 weeks to 134 weeks for the over all population,and 27weeks(SD\u0026thinsp;\u0026plusmn;\u0026thinsp;28 weeks) for radical radiotherapy.The RT waiting times among patients treated with radical RT reveled that, 44.4% and 14.8% of patients had a 6 months and 1year and above waiting time, respectively(Supplementary Table S3).The mean chemotherapy waiting time was 21 weeks with minimum of 1 week and maximum of 61 weeks.\u003c/p\u003e\n\u003cp\u003eWe also detected changes in the treatment modalities over the study period. The proportion of patients treated with radical intent of radiotherapy was increasing over the study period. However, the proportion of palliative RT remained relatively stable (Supplementary Fig.S2).\u003c/p\u003e\n\u003ch3\u003eTreatment response\u003c/h3\u003e\n\u003cp\u003eAmong 21 patients received palliative and induction chemotherapy, only 60% of patients had a documented tumor response rate; Of those the response rate evaluation revealed that, at mid cycle of chemotherapy 39.1% of patients had an overall response rate including 4.8% complete response rate, while at end cycles of chemotherapy 15% ,10% ,25%, and 20% of patients had an overall response, partial response, stable disease, and progressive disease, respectively(Supplementary Table S4).\u003c/p\u003e\n\u003cp\u003eRegarding radiotherapy treatment outcome, among 27 radically treated patients the treatment response evaluation at 3months and 6months post CCRT or RT was available in 17 and 23 patients,respectively.The response rate revealed that,at 3 months overall response rate was 62.9% with complete response rate of 29.6%,and these response rate at 6 months were increased to 81% with 63% of complete response rate.At 6months 3.7% of patients developed a progressive disease .The overall response rate at 3 month for palliative RT was 42.6%(Supplementary Table S4).\u003c/p\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003eSurvival\u003c/h2\u003e\n \u003cp\u003eMedian follow up time was 17.9 months (IQR 10-28.9) and 19 months for the overall population and for those patients treated with radical RT, respectively. For the overall population, the 2 and 5-year overall survival rate was 56% and 28%, respectively, with a median survival of 29 months (95% CI: 16\u0026ndash;40.9) (Fig.\u0026nbsp;1). Patients with stage I and stage II disease had significantly longer 5-year OS compared to patients with stage III disease (Long Rank, P\u0026thinsp;=\u0026thinsp;O.028).\u003c/p\u003e\n \u003cp\u003eThe survival of patients receiving radical RT was significantly longer compared to those patients receiving palliative RT, with the 2 and 5- years OS of 100% vs 62% and 90% vs 0%, respectively (P\u0026thinsp;=\u0026thinsp;0.001). The median survival was not reached for patients treated with radical RT,and the median survival was 32 months for patients treated with palliative RT with or with out palliative chemotherapy (p\u0026thinsp;=\u0026thinsp;0.001) (Fig.\u0026nbsp;2).\u003c/p\u003e\n \u003cp\u003eThe median survival of patients received palliative radiotherapy plus palliative chemotherapy (36 months, 95% CI 25\u0026ndash;45), palliative RT alone (22 months, 95% CI, 10\u0026ndash;42 ), palliative CT alone (20 months, 95 CI of 14\u0026ndash;25) tended to be prolonged compared to those without any form of treatment (10 months, 95% CI 8.3\u0026ndash;11.6). The 2 years OS of patients received definitive treatment, palliative treatment and no treatment was 100%, 42% and 0%, respectively (Fig.\u0026nbsp;3).\u003c/p\u003e\n \u003cp\u003eOn uni variant analysis, intent of radiotherapy, stage and tumor size variables were a candidate for final analysis with P\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;0.25. On multivariate cox-regression analysis patients treated with palliative RT was associated with 13.3 times increased chance of poor survival as compared to those treated with radical RT (aHR\u0026thinsp;=\u0026thinsp;13.3, 95% CI:1.5\u0026ndash;115, p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e\n \u003cp\u003eThe probability of recurrence free survival for patient treated with radical intent of radiotherapy and having complete response at 6 months was evaluated from days of initiation of radiotherapy to diagnosis of recurrence or death. The estimated 5 years RFS was 72% (Fig.\u0026nbsp;4). The 5 years probability of colostomy free survival from first date of RT to date of colostomy, for those who had no colostomy before RT was 88%.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge,this is the first study conducted at the largest and only comprehensive cancer center in Ethiopia, to insight into treatment pattern and outcomes of non metastatic ASCC patients.The study found that a median age of patients was 53.3 years, which is a decade earlier than reported in Western data\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The majority of patients diagnosed with anal squamous cell carcinoma were female, and 51.6% were HIV positive. The incidence of HIV in this study is slightly lower compared to other Africa studies, which reported a prevalence of 64%\u003csup\u003e10\u003c/sup\u003e. In this study higher proportion of patient living with HIV presents at stage III disease than HIV negative patient (84% vs 71% respectively).\u003c/p\u003e \u003cp\u003eThe current first line standard of care for anal squamous cell carcinoma is radiation therapy with concurrent 5-fluorouracil/capecitabine and mitomycin-C\u003csup\u003e5,6,11\u003c/sup\u003e. In this study, different treatment strategies were planned at diagnosis, including CCRT plus induction CT (38%), CCRT alone (35%), and palliative treatment (12%). Despite these initial planned treatments, only 45% of patients received radical treatment, 33.3% received palliative treatment, and 21.7% didn\u0026rsquo;t receive any type of treatment. Among those patients received radical treatment, 31.7% received RT with or without concurrent chemotherapy, and 13.3% received induction CT followed by RT with or without concurrent CT. The treatment trend shows an increment of the number of patients received radical radiotherapy over time. Only 3 patients were treated with definitive RT between a year 2019\u0026ndash;2022, while the number of patients treated with definitive RT were increased to 16 in the year 2023. However no significant changes were observed in the treatment of palliative RT.\u003c/p\u003e \u003cp\u003eThe proportion of patients treated with palliative RT or without treatments at all is higher than in another African study. A study conducted in Tanzania by Mduma et.al (2023),reported that patients treated with palliative RT was 27%\u003csup\u003e10\u003c/sup\u003e. The possible reasons for these discrepancies in treatment delivery could be longer RT waiting times. The average RT waiting time in our study was 26.7 weeks and 27 weeks for the overall population and for radically treated patients, respectively, and the mean chemotherapy waiting time was 21 weeks. Another study done in Nigerian by Tumba et.al (2020), the median RT waiting for cervical, prostatic and breast cancer was 40 day\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. A study done in Ethiopia on cervical cancer RT waiting time by Jilcha et.al (2023) revealed a median RT waiting time of 477days\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eThe complete response and survival rates observed in this study are inferior to those reported in the literature\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. In addition to the longer RT waiting times several other factors, such as lower rate of concurrent chemotherapy use, the absence of concurrent mitomycine administration, and advanced disease stage presentation may contributes to these differences\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePatients received radical treatments the overall and complete response rate at 3 months was 62.9% and 29.6%, respectively. At 6-month follow\u0026ndash;up, the overall and complete response rates increased to 81% and 63%, respectively. These findings are comparable to reports from anther African study, in which complete response rate of 49%\u003csup\u003e10\u003c/sup\u003e. However, the response rate was lower than other western finding. In UK, ACT II clinical trial done by James et.al (2013), the complete response rate at 6 month was 84%\u003csup\u003e5\u0026ndash;7\u003c/sup\u003e. This discrepancy can be explained by the lower rate of concurrent chemotherapy use in our study, with only 51% of patients receiving concurrent CT; of those, none were receiving mitomycine.\u003c/p\u003e \u003cp\u003eThe estimated 5-years OS was 28% and 90% for the overall population and radically treated patients, respectively. The estimated 2 years OS of patients received radical RT and palliative RT was 100% and 62%, respectively. The estimated 5 years RFS and CFS of patients received radical treatments were 72% and 88%, respectively. The OS and CFS in radically treated patients were higher than reported from western studies ,which was 5-years OS rates of 65\u0026ndash;79%,disease control rates of 68\u0026ndash;84%,and colostomy free survival rates of 65\u0026ndash;75%\u003csup\u003e5,6\u003c/sup\u003e, the possible reason for this could be the shorter median follow up time in our study (19 months). In the RTOG 98\u0026thinsp;\u0026minus;\u0026thinsp;11 trial conducted in USA by Gunderson eta.al (2012), at a median of 5.1 years, 5 years OS, RFS and CFS were 78.3%, 67% and 71% in the 5FU/mitomycin arm, respectively\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In a retrospective study done in Tanzania by Mduma et.al (2023), 2-years overall survival (OS) and local recurrence-free survival were 86.4% and 91.3%, respectively\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eIn this study the median survival of patients received palliative RT alone, palliative CT and without any type of therapy was 22, 20 and 10 months, respectively. The lower OS rate in the overall population could be due to the higher proportion of non-metastatic SCC patients received palliative therapy (33.3%) and 21.3% of patients didn\u0026rsquo;t receive any form of therapy. In this study the median survival of patients received palliative therapy has comparable outcome with metastatic anal SCC patients treated with systemic therapy (carboplatin/Taxol), while patients who did not received any form of treatment has an inferior out comes. A phase II study, done by Rao et.al (2020), to compare Cisplatin/FU vs carboplatin/taxol in metastatic anal SCC, showed median survival in carboplatin /taxol arm of 20 months\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has some limitations. First, it\u0026rsquo;s retrospective nature, and this was affected by poor documentation of clinical information including outcome variables particularly, response assessment related information, that have limited the analysis. Second, the median follow up duration was short for patients treated with definitive treatment to assess survival.\u003c/p\u003e \u003cp\u003eIn conclusion, this study highlights significant challenges in the management of non-metastatic anal SCC in TASH. Despite the global standard of care involving concurrent chemoradiation therapy, a significant proportion of patients in this study received suboptimal treatment, including palliative care or no treatment at all. The estimated 5-year OS for the overall population in this study was unacceptably low. Key factors contributing to this poor outcome include a substantial number of patients did not receive timely treatment due to longer waiting times for radiation therapy, higher proportion of patients received palliative treatment and advanced disease stage presentation, further exacerbating the poor survival outcomes. However, patients who received radical treatment demonstrated promising survival outcomes, potentially influenced by shorter follow-up times. The study also revealed that the 2-year OS for untreated or treated with palliative treatment non-metastatic anal SCC is comparable or inferior to that of metastatic anal SCC, emphasizing the critical need for timely and effective treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConception/design\u003c/strong\u003e: Birhanu T. Liyew, Sonia W. Semayneh\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvision of study material or patients\u003c/strong\u003e: Birhanu T. Liyew, Sonia Semayneh\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCollection and/or assembly of data\u003c/strong\u003e: Birhanu T. Liyew, Feleke H. Maniso\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis and interpretation\u003c/strong\u003e: Birhanu T. Liyew, Feleke H. Maniso, Sonia Semayneh\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManuscript writing\u003c/strong\u003e: Sonia W. Semayneh\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinal approval of manuscript\u003c/strong\u003e: All authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAccountable for all aspects of the work\u003c/strong\u003e: All authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from Research and Ethics Committee of Addis Ababa University, College of Health Sciences, Ethiopia before we started the study. The study was conducted in accordance with the principles of 1964 Helsinki declaration and its later amendments. Due to the retrospective nature of the study and the use of anonymized patient records, the requirement for informed consent to participate was waived by Research and Ethics Committee of Addis Ababa University, College of Health Sciences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIslami F, Ferlay J, Lortet-Tieulent J, Bray F, Jemal A. International trends in anal cancer incidence rates. Int J Epidemiol Published online Oct. 2016;27:dyw276. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ije/dyw276\u003c/span\u003e\u003cspan address=\"10.1093/ije/dyw276\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGondal TA, Chaudhary N, Bajwa H, Rauf A, Le D, Ahmed S. Anal Cancer: The Past, Present and Future. Curr Oncol. 2023;30(3):3232\u0026ndash;50. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/curroncol30030246\u003c/span\u003e\u003cspan address=\"10.3390/curroncol30030246\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerry WB, Connaughton JC. Abdominoperineal Resection: How Is It Done and What Are the Results? Clin Colon Rectal Surg. 2007;20(3):213\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-2007-984865\u003c/span\u003e\u003cspan address=\"10.1055/s-2007-984865\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoman BM, Moertel CG, O\u0026rsquo;Connell MJ, et al. Carcinoma of the anal canal. A clinical and pathologic study of 188 cases. Cancer. 1984;54(1):114\u0026ndash;25. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/1097-0142(19840701)54:1%3C114::aid-cncr2820540124%3E3.0.co;2-p\u003c/span\u003e\u003cspan address=\"10.1002/1097-0142(19840701)54:1%3C114::aid-cncr2820540124%3E3.0.co;2-p\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGunderson LL, Winter KA, Ajani JA, et al. Long-term update of US GI intergroup RTOG 98\u0026thinsp;\u0026ndash;\u0026thinsp;11 phase III trial for anal carcinoma: survival, relapse, and colostomy failure with concurrent chemoradiation involving fluorouracil/mitomycin versus fluorouracil/cisplatin. J Clin Oncol Off J Am Soc Clin Oncol. 2012;30(35):4344\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.2012.43.8085\u003c/span\u003e\u003cspan address=\"10.1200/JCO.2012.43.8085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJames RD, Glynne-Jones R, Meadows HM, et al. Mitomycin or cisplatin chemoradiation with or without maintenance chemotherapy for treatment of squamous-cell carcinoma of the anus (ACT II): a randomised, phase 3, open-label, 2 \u0026times; 2 factorial trial. Lancet Oncol. 2013;14(6):516\u0026ndash;24. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S1470-2045(13)70086-X\u003c/span\u003e\u003cspan address=\"10.1016/S1470-2045(13)70086-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoci R, Zucali R, Bombelli L, Montalto F, Lamonica G. Combined chemoradiation therapy for anal cancer. A report of 56 cases. Ann Surg. 1992;215(2):150\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCyr DP, Savage P, Theodosopoulos E, Chesney TR, Swallow CJ. Outcomes of salvage surgery for anal squamous cell carcinoma: A systematic review and meta-analysis. J Clin Oncol. 2019;37(15suppl):3571\u0026ndash;3571. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.2019.37.15_suppl.3571\u003c/span\u003e\u003cspan address=\"10.1200/JCO.2019.37.15_suppl.3571\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHo VKY, Deijen CL, Hemmes B, et al. Trends in epidemiology and primary treatment of anal squamous cell carcinoma in the Netherlands (1990\u0026ndash;2021). Int J Cancer. 2024;154(9):1569\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijc.34811\u003c/span\u003e\u003cspan address=\"10.1002/ijc.34811\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMduma E, Dharsee N, Samwel K, Mwita CJ, Lidenge SJ. Clinicopathological Characteristics and Outcomes of Anal Squamous Cell Carcinoma Patients With and Without HIV Infection in Sub-Saharan Africa. JCO Glob Oncol. 2023;9:e2200394. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/GO.22.00394\u003c/span\u003e\u003cspan address=\"10.1200/GO.22.00394\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKachnic LA, Winter K, Myerson RJ, et al. RTOG 0529: a phase 2 evaluation of dose-painted intensity modulated radiation therapy in combination with 5-fluorouracil and mitomycin-C for the reduction of acute morbidity in carcinoma of the anal canal. Int J Radiat Oncol Biol Phys. 2013;86(1):27\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijrobp.2012.09.023\u003c/span\u003e\u003cspan address=\"10.1016/j.ijrobp.2012.09.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTumba N, Adewuyi SA, Eguzo K, Adenipekun A, Oyesegun R. Radiotherapy waiting time in Northern Nigeria: experience from a resource-limited setting. Ecancermedicalscience. 2020;14:1097. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3332/ecancer.2020.1097\u003c/span\u003e\u003cspan address=\"10.3332/ecancer.2020.1097\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeyisa JD, Woldegeorgis MA, Zingeta GT, Abegaz KH, Berhane Y. Cervical Cancer Progression in Patients Waiting for Radiotherapy Treatment at a Referral Center in Ethiopia: A Longitudinal Study. JCO Glob Oncol. 2023;9:e2200435. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/GO.22.00435\u003c/span\u003e\u003cspan address=\"10.1200/GO.22.00435\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRao S, Sclafani F, Eng C, et al. International Rare Cancers Initiative Multicenter Randomized Phase II Trial of Cisplatin and Fluorouracil Versus Carboplatin and Paclitaxel in Advanced Anal Cancer: InterAAct. J Clin Oncol Off J Am Soc Clin Oncol. 2020;38(22):2510\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.19.03266\u003c/span\u003e\u003cspan address=\"10.1200/JCO.19.03266\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Survival rate, CCRT, Anal carcinoma, treatment pattern, Ethiopia","lastPublishedDoi":"10.21203/rs.3.rs-9080015/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9080015/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePURPOSE\u003c/h2\u003e \u003cp\u003eConcurrent chemo-radiotherapy (CCRT) is the standard treatment of non-metastatic ASCC.However, there is a limited access to radiotherapy centers to delivery standard CCRT in resource constraint countries, like Ethiopia. We evaluate the treatment pattern, and survival of patients with non-metastatic anal squamous cell carcinoma at Tikur Anbessa Specialized Hospital (TASH), a tertiary teaching hospital in Addis Ababa, Ethiopia.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study reviewed medical records of patients with non-metastatic ASCC between April 2019 and April 2024. Survival status and any missing data were addressed via phone calls. Data about socio-demographics, clinical presentations, treatments, and outcomes were collected. Descriptive statistics and Kaplan-Meier survival analysis were used to analyze the data. Factors influencing survival were identified using Cox proportional hazards.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMedian age of patients was 53.3 years,66.7% were female,and 51.6% were living with HIV.Stage III disease accounts for 78.3%.Overall,88% of patients were planned for primary radical treatment but only 45% received radical treatment,and the remaining received palliative treatment(34%),and did not receive any treatment(21.3%).The 5-year overall survival(OS) for the overall population was 28%.The 2 and 5 years OS of patients received radical RT and palliative RT was 100% vs 62% and 90% vs 0%,respectively(p\u0026thinsp;=\u0026thinsp;0.001).Type of treatment was an independent risk factor for death.Patients received palliative RT had an inferior outcome than those received radical RT (HR\u0026thinsp;=\u0026thinsp;13.3, 95% CI:1.5\u0026ndash;115).The mean radiotherapy waiting time was 27 weeks for radically treated patient.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe survival of non-metastatic ASCC in this study is unacceptably low. Factors contributing to poor survival include lack of treatment due to longer RT waiting times, a higher proportion of palliative treatment, and advanced stage. The findings emphasize the urgent need of strategies for management of ASCC, particularly in low-resource settings such as Ethiopia.\u003c/p\u003e","manuscriptTitle":"Treatment Patterns and Survival of Non-metastatic Anal Carcinoma at Tikur Anbessa Specialized Hospital, Addis Abeba Ethiopia: A 5 Year Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-24 00:41:37","doi":"10.21203/rs.3.rs-9080015/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-26T11:37:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316828776264349768279362477450551985086","date":"2026-04-16T17:39:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319997224472214421682844507403327224630","date":"2026-04-15T11:56:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T10:57:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-13T06:30:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-24T07:29:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-24T07:22:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2026-03-24T07:16:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4f3d95a4-7b16-4e40-889f-8b95da07bebd","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T00:41:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 00:41:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9080015","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9080015","identity":"rs-9080015","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}