Vaginal Cancer

Definition

Vaginal cancer refers to an abnormal, cancerous growth in the tissues of the birth canal (vagina).

Description

Vaginal cancer is rare and accounts for only 1% to 2% of all gynecologic cancers. In the United States, there are approximately 2, 000 cases of vaginal cancer diagnosed, and approximately 600 deaths, each year. Vaginal cancer can be either primary or metastatic. Cancer that originates in the vagina is called primary vaginal cancer; if cancer spreads to the vagina from another site, it is called metastatic cancer. Eighty-percent of vaginal cancers are metastatic. Metastatic cancers carry the name of the primary cancer site. For instance, cancer that has spread from the cervix to the vagina would be called "metastatic cervical cancer, " not "vaginal cancer."

The vagina is a short tube that extends from the outer female genitalia (vulva) to the opening to the uterus (cervix). It serves to receive the penis during sexual intercourse, as an outlet for shed tissue and blood during menstruation, and as a passageway for a baby during childbirth. Most cancers are located in the upper third of the vagina.

Squamous carcinoma is the most common type of vaginal cancer and accounts for 85% of cases. Infrequent types of vaginal cancer include adenocarcinomas, melanoma, and sarcomas. Adenocarcinoma is usually found in young women (ages 12 to 30 years) while squamous cell cancer (squamous carcinoma) is usually found in older women (ages 60 to 80 years). Although vaginal melanoma can afflict adult women of any age, women are on average in their fifties at the time of diagnosis.

Demographics

Vaginal cancer is most common in women who are between the ages of 60 and 80.

Causes and symptoms

Cancer is caused when the normal mechanisms that control cell growth become disturbed, causing cells to grow and divide without stopping. This is usually the result of damage to the genetic material of the cell (deoxyribonucleic acid, or DNA). The cause of vaginal cancer is not known.

Symptoms of vaginal cancer appear when the cancer has become more advanced. Approximately 20% of vaginal cancer cases are asymptomatic (produce no symptoms) and are diagnosed following an abnormal Pap test. Symptoms of vaginal cancer include:

  • abnormal vaginal bleeding or discharge
  • pain during intercourse
  • pain in the pelvic area
  • difficult or painful urination
  • constipation

Diagnosis

The diagnosis of vaginal cancer is made by physical examination and laboratory analysis of tissue samples. During the physical examination, the physician will place one or two fingers into the vagina and press down on the lower abdomen with his or her free hand to feel (palpate) the reproductive organs and any masses. During a routine speculum examination, the physician will obtain a sample of cervical and vaginal cells (using a swab, brush, or wooden applicator) for laboratory analysis (Pap test).

A special magnifying instrument, called a colpo-scope, may be used to view the vagina. Additionally, the surface of the vagina may be treated with a dilute solution of acetic acid, which causes some abnormal areas to turn white. Squamous carcinoma and adenocarcinoma usually appear as a growth on the surface of the vagina. Squamous carcinoma may present as an open sore (ulcer). Adenocarcinoma may lie deeper so that it is not visible and detected only by palpation. Vaginal melanoma appears as a brown or black skin tag (polypoid), growth attached to the vaginal wall by a stem (pedunculated), nipple-like growth (papillary), or fungus-like growth (fungating). Sarcomas often appear as a grape-like mass.

If any area appears abnormal, a tissue sample (biopsy) will be taken. The biopsy can be performed in the doctor's office with the use of local anesthetic. A small piece of tissue, which contains the suspect lesion with some surrounding normal skin and the underlying skin layers and connective tissue, will be removed. Small lesions will be removed in their entirety (excisional biopsy). The diagnosis of cancer depends on a microscopic analysis of this tissue by a pathologist.

Chest x rays and routine blood work are commonly employed in the diagnosis of any cancer. Endoscopic examination of the bladder (cystoscopy) and/or rectum (proctoscopy) may be performed if it is suspected that the cancer has spread to these organs.

Treatment team

The treatment team for vaginal cancer may include a gynecologist, gynecologic oncologist, radiation oncolo-gist, plastic surgeon, gynecologic nurse oncologist, sexual therapist, psychiatrist, psychological counselor, and social worker.

Clinical staging, treatments, and prognosis

Clinical staging

The International Federation of Gynecology and Obstetrics (FIGO) has adopted a clinical staging system for vaginal cancer that is used by most gynecologic oncologists. Vaginal cancer is categorized into five stages (0, I, II, III, and IV) that may be further subdivided (A and B) based on the depth or spread of cancerous tissue. The FIGO stages for vaginal cancer are:

  • Stage 0. Cancer is confined to the outermost layer (epithelium) of vaginal cells and is called carcinoma in situ or vaginal intraepithelial neoplasia (VAIN).
  • Stage I. Cancer is confined to the vagina.
  • Stage II. Cancer has spread to the tissues near the vagina.
  • Stage III. Cancer has spread to the bones of the pelvis, local lymph nodes, and/or other reproductive organs.
  • Stage IV. Cancer has spread to the bladder, rectum, or other parts of the body.

Treatments

The treatment of vaginal cancer varies considerably and depends on the type of cancer, stage of cancer, and the patient's age and overall health. Surgery is the most common treatment for vaginal cancer. Radiation therapy and chemotherapy are often used as adjuvant therapy to complement the surgical treatment.

SURGERY.

The amount of tissue removed depends upon the stage and type of cancer. The local lymph nodes may also be removed (lymphadenectomy). Laser surgery, which destroys the cancerous cells, may be used in the treatment of stage 0 vaginal cancer. With a wide local excision, the cancerous tissue and some surrounding healthy tissue is cut out. Wide local excisions may require skin grafts to repair the vagina.

For more extensive cancer, the vagina may be removed (vaginectomy). Following vaginectomy, skin grafts and plastic surgery are used to create an artificial vagina. Vaginal cancer that has spread to the other reproductive organs would be treated by radical hysterectomy in which the uterus, fallopian tubes, and ovaries are removed. Cancer that has spread beyond the reproductive organs may be treated by pelvic exenteration, in which the vagina, cervix, uterus, fallopian tubes, ovaries, and, as necessary, the lower colon, bladder, or rectum are removed.

Surgical complications include urinary tract infection, wound infection, temporary nerve injury, fluid accumulation (edema) in the legs, urinary incontinence, falling or sinking of the genitals (genital prolapse), and blood clots (thrombi).

RADIATION THERAPY.

Radiation therapy may be used as the sole treatment of vaginal cancer or as an adjuvant therapy to aid surgery. Radiation therapy uses high-energy radiation from x rays and gamma rays to kill the cancer cells. Radiation given from a machine that is outside the body is called external radiation therapy. Radiation given internally is called internal radiation therapy or brachytherapy. Sometimes applicators containing radioactive compounds are placed inside the vagina (intracavitary radiation) or directly into the cancerous lesion (interstitial radiation). External and internal radiation may be used in combination to treat vaginal cancer.

The skin in the treated area may become red and dry and may take as long as a year to return to normal. Fatigue, upset stomach, diarrhea, and nausea are also common complaints of women having radiation therapy. Radiation therapy in the pelvic area may cause the vagina to become narrow as scar tissue forms. This phenomenon, known as vaginal stenosis, makes intercourse painful.

CHEMOTHERAPY.

Chemotherapy is not very a very successful treatment of vaginal cancer and is generally reserved for patients with advanced disease. Chemotherapy uses anticancer drugs to kill the cancer cells. The drugs are usually given by mouth (orally) or intravenously. They enter the bloodstream and can travel to all parts of the body to kill cancer cells. Generally, a combination of drugs is given because it is more effective than a single drug in treating cancer. For vaginal cancer, anticancer drugs may be put into the vagina (intravaginal chemotherapy).

The side effects of chemotherapy are significant and include stomach upset, vomiting, appetite loss (anorexia), hair loss (alopecia), mouth or vaginal sores, fatigue, menstrual cycle changes, and premature menopause. There is also an increased chance of infections.

Prognosis

Survival is related to the stage and type of vaginal cancer. The five-year survival rates for squamous carcinoma and adenocarcinoma of the vagina are: 96%, stage 0; 73%, stage I; 58%, stage II; 36%, stage III; and 36%, stage IV. With a five-year survival rate of less than 20%, melanoma has a poor prognosis. Vaginal cancer most commonly spreads (metastasizes) to the lungs, but may spread to the liver, bone, or other sites.

Alternative and complementary therapies

Although alternative and complementary therapies are used by many cancer patients, very few controlled studies on the effectiveness of such therapies exist. Mind-body techniques such as prayer, biofeedback, visualization, meditation, and yoga have not shown any effect in reducing cancer but can reduce stress and lessen some of the side effects of cancer treatments.

Clinical studies of hydrazine sulfate found that it had no effect on cancer and even worsened the health and well-being of the study subjects. One clinical study of the drug amygdalin (Laetrile) found that it had no effect on cancer. Laetrile can be toxic and has caused death. Shark cartilage, although highly touted as an effective cancer treatment, is an improbable therapy that has not been the subject of clinical study.

The American Cancer Society has found that the "metabolic diets" pose serious risk to the patient. The effectiveness of the macrobiotic, Gerson, and Kelley diets and the Manner metabolic therapy has not been scientifically proven. The Food and Drug Administration (FDA) was unable to substantiate the anticancer claims made about the popular Cancell treatment.

There is no evidence for the effectiveness of most over-the-counter herbal cancer remedies. However, some herbals have shown an anticancer effect. Some studies have shown that polysaccharide krestin (PSK), a substance from the mushroom Coriolus versicolor, has some effectiveness against cancer. In a small study, the green alga Chlorella pyrenoidosa has been shown to have anti-cancer activity. In a few small studies, evening primrose oil has shown some benefit in the treatment of cancer. Herbals can disrupt conventional treatment; patients must discuss herbal use with their physician.

For more comprehensive information, the patient should consult the book on complementary and alternative medicine published by the American Cancer Society listed in the Resources section.

Coping with cancer treatment

The patient should consult her treatment team regarding any side effects or complications of treatment. Vaginal stenosis can be prevented and treated by vaginal dilators, gentle douching, and sexual intercourse. A water-soluble lubricant may be used to make sexual intercourse more comfortable. Women with a reconstructed vagina will need to use a water-soluble lubricant during sexual intercourse. Many of the side effects of chemotherapy can be relieved by medications. Women may wish to consult a psychotherapist and/or join a support group to deal with the emotional consequences of cancer and vaginectomy.

Clinical trials

As of 2001, there are no clinical trials underway that were specific for vaginal cancer. Women should consult with their treatment team to determine if they are candidates for any ongoing studies.

Prevention

Risk factors for vaginal cancer include:

  • Diethylstilbestrol (DES). Young women whose mothers took DES during pregnancy are at a higher risk of developing vaginal cancer, particularly clear cell carcinoma. Between 1945 and 1970, DES was prescribed to pregnant women who were at risk of miscarriage.
  • Cervical cancer. Women with a history of cervical cancer have a high risk of developing vaginal cancer.
  • Hysterectomy. Up to half of all patients with vaginal cancer have had a hysterectomy. Their vaginal cancer may actually represent an earlier spread from the cervix.
  • Chronic irritant vaginitis. Chronic irritation to the vagina, particularly from use of a vaginal pessary, is associated with vaginal cancer. A pessary is an instrument that is placed into the vagina to support the uterus or prevent pregnancy (contraception).
  • Vaginal adenosis. This condition, in which cells that resemble those of the uterus are found in the vaginal lining, places a woman at a higher risk of developing vaginal cancer.
  • Human papilloma virus (HPV) infection. Infection by this sexually transmitted virus, the cause of genital warts, increases a woman's risk of developing squamous carcinoma.
  • Smoking. There appears to be an association between tobacco use and vaginal cancer.

All women, even those who have had a hysterectomy or are past menopause, should get an annual pelvic examination and Pap test. Women who had a hysterectomy because of cancer may benefit from more frequent Pap tests. The earlier that precancerous abnormalities or vaginal cancer are detected, the better the prognosis. Women whose mothers took DES during pregnancy and those with vaginal adenosis should be screened regularly. Women can reduce the risk of contracting HPV by avoiding sexual intercourse with individuals who have had many sexual partners, limiting their number of sexual partners, and delaying first sexual activity until an older age. Avoiding tobacco products may reduce a woman's risk of developing vaginal cancer.

Special concerns

Of special concern to women undergoing treatment of vaginal cancer is the effect surgery and/or radiation therapy will have on sexual functioning. Women of childbearing age may worry about their fertility and whether or not they will be able to bear children. Depression, due to the affects of surgery on body image and sexuality, may occur. Complications, both short term and long term, following extensive surgical treatment of vaginal cancer are not uncommon.

See Also Cystoscopy; Fertility issues

Resources

BOOKS

Bruss, Katherine, Christina Salter, and Esmeralda Galan, eds. American Cancer Society's Guide to Complementary and Alternative Cancer Methods. Atlanta: American Cancer Society, 2000.

Eifel, Patricia, Jonathan Berrek, and James Thigpen. "Cancerof the Cervix, Vagina, and Vulva." In Cancer: Principles & Practice of Oncology. DeVita, Vincent T., Samuel Hellman, and Steven Rosenberg, eds. Philadelphia: Lippincott Williams & Wilkins, 2001.

Garcia, Agustin, and J. Tate Thigpen. "Tumors of the Vulva and Vagina." In Textbook of Uncommon Cancer. Raghavan, D., M. Brecher, D. Johnson, N. Meropol, P. Moots, and J.Thigpen, eds. Chichester, UK: John Wiley & Sons, 1999.

Primack, Aron. "Complementary/Alternative Therapies in the Prevention and Treatment of Cancer." In Complementary/Alternative Medicine: An Evidence-Based Approach. Spencer, John, and Joseph Jacobs, eds. St. Louis: Mosby, 1999.

PERIODICALS

Creasman, William, Jerri Phillips, and Herman Menck. "The National Cancer Data Base Report on Cancer of the Vagina." Cancer 83 (September 1998): 1033-40.

ORGANIZATIONS

American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA30329. (800) ACS-2345. <http://www.cancer.org>.

Cancer Research Institute. 681 Fifth Ave., New York, NY10022. (800) 992-2623. <http://www.cancerresearch.org>.

Gynecologic Cancer Foundation. 401 North Michigan Ave., Chicago, IL 60611. (800) 444-4441 or (312) 644-6610.<http://www.wcn.org/gcf>.

National Institutes of Health, National Cancer Institute. 9000Rockville Pike, Bethesda, MD 20982. (800) 4-CANCER.<http://cancernet.nci.nih.gov>.

Belinda Rowland, Ph.D.

Adjuvant therapy

—A treatment that is intended to aid the primary treatment. Adjuvant treatments for vaginal cancer are radiation therapy and chemotherapy.

Biopsy

—Removal of a small piece of tissue for microscopic examination. This is done under local anesthesia and removed by either using a scalpel or a punch, which removes a small cylindrical portion of tissue.

Colposcope

—An instrument used for examination of the vagina and cervix. The instrument includes a light and magnifying lens for better visualization.

Intracavitary radiation

—Radiation therapy for vaginal cancer in which a cylindrical container holding a radioactive substance is placed into the vagina for one or two days.

Metastasis

—The movement of cancer cells from one area of the body to another. This occurs through the blood vessels or the lymph vessels.

Pelvic exenteration

—Surgical removal of the organs of the pelvis which includes the uterus, vagina, and cervix.

Squamous cells

—Scale-like cells that cover some body surfaces and cavities.

Vaginectomy

—Surgical removal of the vagina. An artificial vagina can be constructed using grafts of skin or intestinal tissue.

QUESTIONS TO ASK THE DOCTOR

  • What type of cancer do I have?
  • What stage of cancer do I have?
  • What is the five-year survival rate for women with this type and stage of cancer?
  • Has the cancer spread?
  • What are my treatment options?
  • How much tissue will you be removing? Can you remove less tissue and complement my treatment with adjuvant therapy?
  • What are the risks and side effects of these treatments?
  • What medications can I take to relieve treatment side effects?
  • Are there any clinical studies underway that would be appropriate for me?
  • What effective alternative or complementary treatments are available for this type of cancer?
  • How debilitating is the treatment? Will I be able to continue working?
  • Are there any restrictions regarding sexual activity?
  • How is a vaginal reconstruction performed?
  • How will a vaginal reconstruction affect sexual functioning?
  • Are there any local support groups for vaginal cancer patients?
  • What is the chance that the cancer will recur?
  • Is there anything I can do to prevent recurrence?
  • How often will I have follow-up examinations?