Vulvar and vaginal cancers


Cancer of the vagina

This section discusses risk factors, symptoms, diagnosis and treatment of primary vaginal cancer (also known as cancer of the vagina). See information about managing treatment side effects.

What is vaginal cancer?

Primary vaginal cancer is any cancer that starts in the vagina. There are several types (see below). Some cancers of the vagina have spread from a cancer elsewhere in the body. These are called secondary vaginal cancers (see below).

Types of primary vaginal cancer

Squamous cell carcinoma (SCC)

  • starts in the thin, flat (squamous) cells lining the vagina
  • most likely to occur in the upper vagina
  • usually grows slowly over many years
  • makes up about 85% of vaginal cancers

Adenocarcinoma

  • develops from the mucus-producing (glandular) cells of the vagina
  • more likely to spread to the lungs and lymph nodes
  • makes up 5-10% of vaginal cancers
  • includes clear cell carcinoma

Vaginal (mucosal) melanoma

  • starts in the cells that give the skin its colour (melanocytes), also found in the vagina's lining
  • a rare form of vaginal cancer

Sarcoma

  • develops from muscle, fat and other tissue deep in the wall of the vagina
  • a rare form of vaginal cancer

Secondary vaginal cancer

Secondary cancer in the vagina is more common than primary vaginal cancer. This means the cancer has spread from another part of the body, such as the cervix, uterus, vulva, bladder, bowel or other nearby organs. Secondary vaginal cancer is managed differently to primary vaginal cancer. For more information, see information about the original cancer and speak to your treatment team. See Living with Advanced Cancer.

What are the symptoms?

There are often no obvious symptoms of vaginal cancer. The cancer is sometimes found by a routine cervical screening test.

If symptoms occur, they may include one or more of the following:

  • bloody vaginal discharge not related to your menstrual period, which may have an offensive or unusual smell
  • pain during sexual intercourse
  • bleeding after sexual intercourse
  • pain in the pelvic area or rectum
  • a lump in the vagina
  • bladder problems, such as blood in the urine or passing urine frequently or during the night.

Not everyone with these symptoms has vaginal cancer. Other conditions can also cause these changes, but if you have any symptoms, make an appointment with your GP.

How common is it?

Vaginal cancer is one of the rarest types of cancer affecting the female reproductive system (gynaecological cancer). Each year in Australia, about 80 women are diagnosed with vaginal cancer, and it is more common in women over 60.3 However, vaginal cancer, particularly adenocarcinoma, can sometimes occur in younger women.

What are the risk factors?

The exact cause of vaginal cancer is unknown, but factors known to increase the risk of developing it include:

Vaginal intraepithelial neoplasia (VAIN)

This is a precancerous condition that often has no symptoms. It means that the cells in the lining of the vagina are abnormal and may develop into cancer after many years. However, most women with VAIN do not develop vaginal cancer.

Human papillomavirus (HPV)

Also known as the wart virus, HPV is a sexually transmitted infection that can cause women to develop VAIN. It can be many years between the initial infection with HPV and the first signs of VAIN or vaginal cancer. HPV is a common virus and most women with HPV don't develop vaginal or any other type of cancer.

Smoking

Cigarette smoking doubles the risk of developing vaginal cancer. This may be because smoking can make the immune system work less effectively.

History of gynaecological cancer

Vaginal cancer is more likely to be diagnosed in women who have had cervical cancer or early cervical cell changes that were considered to be precancerous. For more information, see Understanding Cervical Cancer.

Radiation therapy to the pelvis

If you have had radiation therapy to the pelvis for another reason, you are at a slightly higher risk of vaginal cancer. This complication is very rare.

Diethylstilboestrol (DES)

This synthetic hormone drug has been identified as a cause of a type of vaginal adenocarcinoma called clear cell carcinoma.

Between 1938 and 1971 - and occasionally beyond - DES was prescribed to pregnant women to prevent miscarriages. It is no longer prescribed to pregnant women in Australia.

The female children of women who took DES (called DES daughters) have an increased risk of developing a range of health problems. About one in 1000 DES daughters develops clear cell carcinoma of the vagina or cervix. If you are concerned about this risk, see your GP.

Vaginal cancer is not contagious and it can't be passed to other people through sexual contact. It is not caused by an inherited faulty gene. For more information on the risk factors, call Cancer Council 13 11 20.

Diagnosis

The main tests used to diagnose vaginal cancer are a physical examination, a cervical screening test, a procedure called a colposcopy, and the removal of a tissue sample (biopsy).

Physical examination

Your doctor will ask to do a physical examination of your vagina, groin and pelvic area. You will remove your clothing from the waist down and lie on a table with your knees bent and legs apart. The doctor may arrange for you to have the examination under a general anaesthetic if the area is very painful.

If you feel embarrassed or scared about this examination, let your doctor know. A nurse may be present during the examination, but you can also ask for a family member or friend to be in the room.

Cervical screening test

During the physical examination, you may have a cervical screening test to check the cells inside the vagina and cervix. See a description of this test. The results may show early cell changes in the lining of the vagina. This condition is called vaginal intraepithelial neoplasia or VAIN.

Colposcopy and biopsy

During the physical examination, the doctor may use a magnifying instrument called a colposcope to look at your vagina, cervix and vulva. This procedure is known as a colposcopy, or sometimes a vaginoscopy. The doctor may take a tissue sample (biopsy) during the colposcopy. See a description of these tests.

The tissue sample will be sent to a laboratory, and a specialist doctor called a pathologist will examine the cells under a microscope. The pathologist will be able to confirm whether the cells are cancerous.

Further tests

If the tests already described show that you have vaginal cancer, further tests may be needed to find out whether the cancer cells have spread. These may include a blood test, chest x-ray, cystoscopy, proctoscopy, and CT and MRI scans. See a description of these tests.

Staging vaginal cancer

Based on the test results, your doctor will tell you the stage of the cancer. Staging is a way to describe the size of the cancer and whether it has spread from the vagina to other parts of the body.

Stages of vaginal cancer

  • Stage I: Cancer is found only in the vagina.
  • Stage II: Cancer has begun to spread through the vaginal wall, but has not spread into the wall of the pelvis.
  • Stage III: Cancer has spread to the pelvis. It may also be in the lymph nodes close to the vagina.
  • Stage IV: Cancer has spread beyond the pelvis or into the lining of the bladder or bowel. The cancer may also have spread to distant parts of the body.

Your doctor may also tell you the grade of the cancer cells. This gives you an idea of how quickly the cancer may grow. A lowgrade (grade 1) cancer means that the cells are slow-growing and less likely to spread. High-grade (grade 3) cells look more abnormal, and are more likely to grow and spread quickly.

Knowing the stage and grade of the cancer helps your health care team recommend the most appropriate treatment.

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for anyone to predict the exact course of the disease as it varies from woman to woman. Instead your doctor can give you an idea of possible outcomes, and common issues that affect women with vaginal cancer.

Some women with vaginal cancer may want to know the statistics for women in similar situations, while others may not find the numbers helpful. Do what feels right for you.

In most cases, the earlier vaginal cancer is diagnosed, the better the chances of successful treatment. Test results, the type of vaginal cancer you have, the rate and depth of tumour growth, how well you respond to treatment, and other factors (such as age, fitness and medical history) are all important in assessing your prognosis. You will have regular check-ups to see whether the cancer has responded to treatment.

Treatment

The treatment recommended by your doctor will depend on the results of your tests, the type of cancer, where the cancer is, whether it has spread, and your general health. Treatment may involve radiation therapy, surgery and/or chemotherapy. Most women with vaginal cancer will have radiation therapy because vaginal cancer that is close to the urethra, bladder and rectum is often difficult to remove completely with surgery. Surgery may be used for small cancers found in the upper part of the vagina.

Radiation therapy

Also known as radiotherapy, this treatment uses a controlled dose of radiation, such as x-rays, to kill or damage cancer cells. Radiation therapy is a common treatment for vaginal cancer. Some women with vaginal cancer are treated with a combination of radiation therapy and chemotherapy. This is called chemoradiation or chemoradiotherapy. Radiation therapy can also be used to control symptoms of advanced cancer (palliative treatment).

There are two main ways of delivering radiation therapy: externally or internally. Most women with vaginal cancer have both types of radiation therapy. Your radiation oncologist will recommend the course of treatment most suitable for you.

Cancer Council produces information on radiation therapy, surgery and chemotherapy.

External beam radiation therapy (EBRT)

This precisely directs the radiation at the cancer from outside the body. You will lie on a treatment table under a machine called a linear accelerator, which delivers the radiation to the affected areas.

EBRT is usually given as a series of daily treatments, Monday to Friday, over 4-6 weeks. The exact number of sessions you have will depend on the type and size of the cancer, and whether it has spread to the lymph nodes. Each session takes about 20 minutes.

Radiation therapy to the vagina and groin is painless, but it can cause side effects (see below).

Internal radiation therapy

Also called brachytherapy, internal radiation therapy is a way of delivering radiation therapy directly to the tumour from inside your body. You may have this after finishing a course of external beam radiation therapy.

The main type of internal radiation therapy used for vaginal cancer is high-dose-rate (HDR) brachytherapy. With HDR, bigger doses are given in a few treatments, usually as an outpatient.

At each HDR treatment session, you will be given pain medicine to make you more comfortable. Some women receive the radiation through small probes inserted near the cancer, but in most cases HDR brachytherapy is delivered through an applicator that is put into the vagina. The applicator is hollow and shaped like a small roundended cylinder. It is connected to a machine that holds a radioactive seed. You will have to lie still while the seed goes into the applicator and the treatment is given. This takes about 10-15 minutes. The applicator is taken out after the dose is delivered. If several sessions are needed, the applicator will be reinserted each time, but the doctor can use techniques that make it easier to put the applicator in the right place.

During a brachytherapy session, the tissue around the applicator will become temporarily inflamed and swollen. This will settle by the time the applicator is removed, but the treated area will feel sore afterwards. The pain should ease over a couple of weeks. Your doctor can prescribe painkillers to help relieve the discomfort.

External beam radiation therapy and HDR brachytherapy will not make you radioactive. It is safe for you to be with both adults and children after your treatment sessions are over and when you are at home.

Side effects of radiation therapy

The side effects you experience vary depending on the radiation dose and the areas treated. Many will be short-term side effects. These often get worse during treatment and just after the course of treatment has ended, before starting to get better. Some side effects may be late effects, not appearing until many months or years after treatment.

Radiation therapy that is targeted to the vaginal area has similar side effects to radiation therapy targeted to the vulvar area. Before your treatment starts, talk to your radiation oncologist about possible side effects. See a description of common side effects.

Surgery

Some vaginal cancers may need to be removed with an operation. The surgeon will try to remove all of the cancer along with some of the surrounding healthy tissue (called a margin). This helps reduce the risk of the cancer coming back. Some lymph nodes in your pelvis may also be removed.

There are a number of different operations for vaginal cancer. The type of surgery recommended depends on the size and position of the cancer. Your gynaecological oncologist will talk to you about the risks and complications of your procedure, as well as possible side effects. Call Cancer Council 13 11 20 to find out more or see Understanding Surgery.

Removing part of the vagina (partial vaginectomy)

The affected part of the vagina is removed.

Removing the whole vagina (radical vaginectomy)

The entire vagina is removed. In some cases, a reconstructive (plastic) surgeon can make a new vagina using skin and muscle from other parts of your body. This is called vaginoplasty or vaginal reconstruction, and it may be done to restore the appearance of your genitals.

Hysterectomy

Some women also need to have their uterus and cervix removed (total hysterectomy). Your gynaecological oncologist will let you know whether it is also necessary to remove your ovaries and fallopian tubes (salpingo-oophorectomy). If you are pre-menopausal, the removal of the ovaries will bring on menopause - see ways to manage menopause.

Recovery after surgery

The length of your hospital stay and the side effects you experience will depend on the type of surgery you have. Most women are in hospital for a few days to a week. Recovery from vaginal surgery is similar to after vulvar surgery. In addition, you can expect some light vaginal bleeding, which should stop within two weeks.

Chemotherapy

Chemotherapy uses drugs known as cytotoxics to kill or slow the growth of cancer cells. It is usually given if the vaginal cancer is advanced or returns after treatment, and may be combined with surgery or radiation therapy.

The drugs are usually given by injection into a vein (intravenously) and sometimes as tablets. You will usually have several treatment sessions, with rest periods in between. Together, the session and rest period are called a cycle. Treatment can often be given to you during day visits to a hospital or clinic as an outpatient, but sometimes you may need to stay in hospital for a few nights.

Side effects of chemotherapy

Most people have some side effects from chemotherapy. There are many different types of chemotherapy drugs, and the side effects will vary depending on the drugs used. Your medical oncologist or nurse will discuss the likely side effects with you, including how they can be prevented or controlled with medicine.

Common side effects experienced after chemotherapy for vaginal cancer include feeling sick (nausea), tiredness (fatigue), hair loss, and a reduced resistance to infections. Chemotherapy may also increase any skin soreness caused by radiation therapy. Some people find that they are able to lead a fairly normal life during their treatment, while others become very tired and need to take things more slowly.

Palliative treatment

Palliative treatment helps to improve people's quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care.

Many people think that palliative treatment is for people at the end of their life, but it may be beneficial at any stage of advanced vaginal cancer. It is about living for as long as possible in the most satisfying way you can.

Sometimes treatments such as radiation therapy, chemotherapy or other drug therapies are given palliatively. The aim is to help relieve symptoms such as pain or bleeding by shrinking or slowing the growth of cancer.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs. See Understanding Palliative Care and Living with Advanced Cancer.

Key points about vaginal cancer

What it is

  • Primary vaginal cancer is cancer that starts in any part of the vagina. The main type is squamous cell carcinoma.
  • Secondary vaginal cancer is cancer that spreads to the vagina from another part of the body.

Tests

The main tests are a physical examination, a cervical screening test, a colposcopy and the removal of a tissue sample (biopsy). Other tests are not always needed but may include blood tests, imaging tests, a cystoscopy or a proctoscopy.

Main treatment

Radiation therapy is the main treatment for vaginal cancer. It uses radiation to kill or damage the cancer cells. Most women have external beam radiation therapy as well as internal radiation therapy (brachytherapy). Side effects may be short-term or long-term, or may appear later.

Other treatments

  • Surgery may be used to try to cut out the affected part of the vagina. Other organs and lymph nodes may also be removed.
  • Chemotherapy uses drugs to kill or damage cancer cells. It is usually given if the cancer is advanced or if it returns after treatment.
  • For advanced vaginal cancer, palliative treatment can help manage symptoms and improve quality of life.

Expert content reviewers:

Prof Jonathan Carter, Director, Gynaecological Oncology, Chris O'Brien Lifehouse, and Professor of Gynaecological Oncology, The University of Sydney, NSW; Ellen Barlow, Clinical Nurse Consultant, Gynaecological Cancer Centre, The Royal Hospital for Women, NSW; Dr Dani Bullen, Clinical Psychologist, Peter MacCallum Cancer Centre, VIC; Wendy Cram, Consumer; Dr Tiffany Daly, Senior Radiation Oncologist, Radiation Oncology Princess Alexandra Raymond Terrace (ROPART), South Brisbane, QLD; Kim Hobbs, Clinical Specialist Social Worker, Westmead Centre for Gynaecological Cancer, Westmead Hospital, NSW; Anya Traill, Head of Occupational Therapy and Physiotherapy, Peter MacCallum Cancer Centre, VIC.

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