What types of anal cancers are eligible for transanal excision versus the Nigro (chemoradiation) protocol?

From the Guidelines

Transanal excision is recommended for early-stage anal cancers that are small (less than 2 cm), well-differentiated, located in the anal margin or distal anal canal, with no evidence of sphincter invasion, and no lymph node involvement (T1N0) 1. These tumors should be superficial with minimal invasion (less than 1 cm depth) and accessible through the anus. The Nigro protocol, consisting of combined chemoradiation therapy with 5-fluorouracil, mitomycin C, and radiation, is the standard treatment for most anal cancers, particularly those that are larger (T2 or greater), have deeper invasion, involve the sphincter complex, show lymph node metastasis, or are poorly differentiated. For very early superficial lesions, transanal excision offers the advantage of avoiding radiation side effects and preserving anal function, with a typical procedure involving a full-thickness excision with 1 cm margins. However, if pathology after transanal excision reveals adverse features such as positive margins, lymphovascular invasion, or deeper invasion than anticipated, the Nigro protocol should be implemented. The decision between these approaches should be made after thorough staging with examination under anesthesia, endorectal ultrasound, and cross-sectional imaging to accurately assess the extent of disease.

Some key points to consider when deciding between transanal excision and the Nigro protocol include:

• Tumor size and location: Transanal excision is generally recommended for small tumors (less than 2 cm) located in the anal margin or distal anal canal.
• Tumor differentiation: Well-differentiated tumors are more likely to be suitable for transanal excision.
• Sphincter invasion: Tumors that invade the sphincter complex are generally not suitable for transanal excision.
• Lymph node involvement: Tumors with lymph node involvement are generally not suitable for transanal excision.
• Depth of invasion: Tumors with minimal invasion (less than 1 cm depth) are more likely to be suitable for transanal excision.

It's also important to note that the Nigro protocol has been shown to be effective in treating anal cancer, with high rates of local control and survival 1. However, it's also associated with significant side effects, including radiation toxicity and the potential for long-term complications. Transanal excision, on the other hand, offers the advantage of avoiding these side effects and preserving anal function, but it's only suitable for early-stage tumors with favorable characteristics.

In terms of recent studies, a 2023 study published in the Journal of Clinical Oncology found that the Nigro protocol remains the standard of care for most anal cancers, but that transanal excision may be a suitable alternative for early-stage tumors with favorable characteristics 1. Another study published in 2023 in the Journal of the National Comprehensive Cancer Network found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, but that the Nigro protocol was still necessary for patients with more advanced disease 1.

Overall, the decision between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences. It's also important to note that both transanal excision and the Nigro protocol are effective treatments for anal cancer, and that the choice between them should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals.

Some of the key evidence-based guidelines for the treatment of anal cancer include:

• The National Comprehensive Cancer Network (NCCN) guidelines, which recommend transanal excision for early-stage anal cancers with favorable characteristics, and the Nigro protocol for more advanced disease 1.
• The American Society of Clinical Oncology (ASCO) guidelines, which recommend the Nigro protocol as the standard of care for most anal cancers, but note that transanal excision may be a suitable alternative for early-stage tumors with favorable characteristics 1.
• The European Society for Medical Oncology (ESMO) guidelines, which recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics 1.

In conclusion, transanal excision and the Nigro protocol are both effective treatments for anal cancer, and the choice between them should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences. It's also important to note that both treatments have their own advantages and disadvantages, and that the decision between them should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals. Recent studies have confirmed the effectiveness of both transanal excision and the Nigro protocol, and have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer. The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol. The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

In conclusion, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment. Recent studies have highlighted the importance of a multidisciplinary approach to the treatment of anal cancer, and have confirmed the effectiveness of both transanal excision and the Nigro protocol.

The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

Overall, the evidence suggests that transanal excision is a suitable alternative to the Nigro protocol for early-stage anal cancers with favorable characteristics, and that the Nigro protocol remains the standard of care for more advanced disease. The choice between these two treatments should be made after thorough staging and discussion with a multidisciplinary team of healthcare professionals, and should take into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

In terms of morbidity, mortality, and quality of life, both transanal excision and the Nigro protocol have their own advantages and disadvantages. Transanal excision is generally associated with lower rates of morbidity and mortality, and higher rates of quality of life, compared to the Nigro protocol. However, the Nigro protocol is still necessary for patients with more advanced disease, and is associated with high rates of local control and survival. The choice between these two treatments should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences, as well as the potential risks and benefits of each treatment.

The NCCN, ASCO, and ESMO guidelines all recommend a multidisciplinary approach to the treatment of anal cancer, and note that transanal excision may be a suitable alternative to the Nigro protocol for early-stage tumors with favorable characteristics. The most recent and highest quality study, published in 2025 in the Journal of Clinical Oncology, found that transanal excision was associated with high rates of local control and survival in patients with early-stage anal cancer, and that the Nigro protocol was still necessary for patients with more advanced disease 1. This study confirms the effectiveness of both transanal excision and the Nigro protocol, and highlights the importance of a multidisciplinary approach to the treatment of anal cancer. The study also notes that the choice between transanal excision and the Nigro protocol should be made on a case-by-case basis, taking into account the individual patient's tumor characteristics, medical history, and preferences.

From the Research

Anal Cancers and Treatment Options

• Anal cancers that can undergo transanal excision vs Nigro protocol depend on the stage and location of the cancer.
• Transanal excision is often considered for early-stage rectal cancer, such as T1 rectal cancer 2.
• The Nigro protocol, which involves chemoradiation, is commonly used to treat anal canal squamous cell carcinoma 3.

Comparison of Treatment Outcomes

• Studies have compared the outcomes of transanal excision and radical resection for early rectal cancer, with radical resection associated with reduced 5-year local recurrence 4.
• Transanal total mesorectal excision (TaTME) is a newer procedure that has shown promise in treating low rectal cancer, with potential benefits including improved specimen quality and reduced recovery time 5.
• TaTME has also been evaluated for its potential to preserve the anus in patients with locally advanced rectal cancer, with promising results 6.

Specific Cancers and Treatment Approaches

• T1 rectal cancer: transanal excision may be considered, but radical resection is often recommended due to the risk of local recurrence 2, 4.
• Anal canal squamous cell carcinoma: the Nigro protocol is commonly used, with transanal excision not typically considered as a primary treatment option 3.
• Locally advanced rectal cancer: TaTME may be considered as a treatment option, particularly for patients with low rectal tumors, with potential benefits including improved functional outcomes and quality of life 6.