Vaginal Cancer

General treatment information

After the diagnostic tests are done, your cancer care team will recommend a treatment plan. Don't feel rushed about considering your options. If there is anything you do not understand, ask to have it explained again. The choice of treatment depends on the type of cancer and stage of the disease when it is diagnosed.

Other factors might play a part in choosing the best treatment plan. These could include your age, your overall state of health, whether you plan to have more children, and other personal considerations. Be sure you understand all the risks and side effects of the various therapies before making a decision about treatment.

You may want to get a second opinion. This can provide more information and help you feel confident about the treatment plan you choose. Some insurance companies require a second opinion before they will pay for treatments.

Depending on the type and stage of your vaginal cancer, you may need more than one type of treatment. Doctors on your cancer treatment team may include:

A gynecologist: a doctor who specializes in diseases of the female reproductive tract

A gynecologic oncologist: a doctor who specializes in the treatment of cancers of the female reproductive system (including surgery and chemotherapy)

A radiation oncologist: a doctor who uses radiation to treat cancer

A medical oncologist: a doctor who uses chemotherapy and other medicines to treat cancer

Many other specialists may be involved in your care as well, including nurse practitioners, nurses, psychologists, social workers, rehabilitation specialists, and other health professionals.

There are 3 main types of treatment for invasive vaginal cancer:

Surgery for vaginal cancer

Surgery is usually only used for small stage I tumors and for cancers that were not cured by radiation. Surgery is not often used to treat squamous cell cancers of the vagina, but it is used for sarcomas and melanomas.

The extent of the surgery depends on the size and stage of the cancer.

Local excision

In this procedure, the surgeon removes the cancer along with a surrounding rim of normal tissue. This is sometimes called a wide excision. For VAIN, a local excision may be all that is needed. For small stage I cancers, treatment may include a radical wide local excision along with a procedure to evaluate the lymph nodes.

Vaginectomy

Vaginectomy is surgery to remove the vagina. If only part of the vagina is removed, it is called a partial vaginectomy. If the entire vagina is removed, it is called a total vaginectomy. A radical vaginectomy is when the vagina is removed along with the supporting tissues around it.

Trachelectomy

Vaginal cancer is most often found in the upper part of the vagina (near the cervix), so removing the cancer sometimes means also removing the cervix. If only the cervix is removed (leaving the rest of uterus behind), the operation is called a trachelectomy. This operation is rarely used to treat vaginal cancer.

Hysterectomy

Sometimes to remove a vaginal cancer, the uterus and cervix must be removed, as well. This operation is called a hysterectomy or total hysterectomy (TH). In operations done for cancer, the connective tissue that surrounds and supports the uterus is often removed as well. In that case, the operation is called a radical hysterectomy. In either case, there are 2 major ways to remove the uterus. If it is removed through the vagina it is called a vaginal hysterectomy (or VH). If the uterus is removed through an incision in the abdomen, it is called an abdominal hysterectomy (or total abdominal hysterectomy; TAH). The approach that is best for you and your cancer will be discussed with you before surgery. The fallopian tubes and ovaries are often removed in the same operation. This procedure is known as a bilateral salpingo-oophorectomy (or BSO). You may see the abbreviation TAHBSO, which stands for total abdominal hysterectomy bilateral salpingo-oophorectomy.

Vaginal reconstruction

If all or most of the vagina must be removed, it is possible to reconstruct (rebuild) a vagina with tissue from another part of the body, which will allow a woman to have sexual intercourse. A new vagina can be surgically created out of skin, intestinal tissue, or myocutaneous (muscle and skin) grafts.

A reconstructed vagina produces little or no natural lubricant when a woman becomes sexually excited. A woman should prepare for intercourse by using a lubricating gel inside the vagina. If the vagina was rebuilt using muscle and skin from the leg, touching the new vagina may make a woman feel as though her thigh is being stroked. This is because the walls of the vagina are still attached to their original nerve supply. Over time, these feelings become less distracting and may even become sexually stimulating. 

Lymphadenectomy

Lymphadenectomy is the removal of lymph nodes. It is sometimes called lymph node dissection. For vaginal cancer, lymph nodes from the groin area or from inside the pelvis near the vagina may be removed to check for cancer spread.

Removing lymph nodes in the groin or pelvis can result in poor fluid drainage from the legs. The fluid builds up, leading to leg swelling that is severe and doesn’t go down at night when you are lying down. This is called lymphedema. Support stockings or special compression devices may help reduce swelling. Women with lymphedema need to be very careful to avoid infection in the affected leg or legs. They can do this by taking these precautions:

Protect the leg and foot from sharp objects and care for any cuts, scratches, or burns right away

Avoid sunburn of the affected leg(s) and avoid cutting or tearing the cuticles of the toenails

Report any redness, swelling, or other signs of infection to the nurse or doctor without delay

Pelvic exenteration

Pelvic exenteration is an extensive operation that includes vaginectomy and removing the pelvic lymph nodes, as well as of one or more of the following structures: the lower colon, rectum, bladder, uterus, and cervix. How much has to be removed depends on how far the cancer has spread.

If the bladder is removed, a new way to store and get rid of urine is needed. Usually a short segment of intestine is used to function as a new bladder. This may be connected to the abdominal wall so that urine is drained periodically when the woman places a catheter into a small opening (called a urostomy). Or urine may drain continuously into a small plastic bag attached to the front of the abdomen over the opening. 

If the rectum and part of the colon are removed, a new way to eliminate solid waste is needed. This is done by attaching the remaining intestine to the abdominal wall so that stool can pass through a small opening (called a colostomy) into a small plastic bag worn on the front of the abdomen.  Sometimes it's possible to remove a piece of the colon and then reconnect it. In that case, no bags or external appliances are needed.

Pelvic exenteration is rarely needed to treat vaginal cancer – radiation therapy is usually used first, and then less extensive surgery may be all that is needed to control cancer that comes back. Still, this procedure might be used for vaginal cancers that have come back after treatment with radiation therapy. It is also sometimes needed to treat vaginal cancers when radiation therapy cannot be used, for example, if a woman has been treated with radiation for cervical cancer in the past. That is because treating the same area with radiation more than once can cause severe complications.

Radiation therapy for vaginal cancer

Radiation therapy uses high-energy rays (such as gamma rays or x-rays) and particles (such as electrons, protons, or neutrons) to kill cancer cells. In treating vaginal cancers, radiation is delivered from outside the body in a procedure that is much like having a diagnostic x-ray. This is called external beam radiation therapy. It is sometimes used along with chemotherapy to treat more advanced cancers to shrink them so they can be removed with surgery. Radiation alone may be used to treat lymph nodes in the groin and pelvis.

Another way to deliver radiation is to place radioactive material inside the vagina. One way to do this is called intracavitary brachytherapy. The 2 main types of intracavitary brachytherapy are low-dose rate (LDR) and high-dose rate (HDR). With these intracavitary methods, radiation mainly affects the tissue in contact with the cylinder. This often means less bladder and bowel side effects than what is seen with external beam radiation therapy.

For LDR brachytherapy, the radioactive material is inside a cylindrical container that is placed in the vagina and stays in place for a day or 2. Although gauze packing helps hold the cylinder in place, you have to remain in bed (in the hospital) during the treatment.

With HDR intracavitary brachytherapy, the radiation source is still placed in a cylinder, but it doesn't need to stay in place for long. This allows it to be given in an outpatient setting. Three or four treatments are given 1 or 2 weeks apart.

Another type of brachytherapy, called interstitial radiation, uses radioactive material inside needles that are placed directly into the cancer and surrounding tissues.

Vaginal cancer is most often treated with a combination of external and internal radiation with or without low doses of chemotherapy.

Side effects of radiation therapy

Radiation can destroy nearby healthy tissue along with the cancerous cells. Side effects depend on the area being treated, the amount of radiation, and the way the radiation is given. Side effects tend to be more severe for external beam radiation than for brachytherapy.

Common side effects of radiation therapy include tiredness, upset stomach, or loose bowels. Serious fatigue might also occur, but sometimes not until about 2 weeks after treatment begins. When radiation is given to the pelvis, diarrhea is common, but can usually be controlled with over-the-counter medicines. Nausea and vomiting may also occur, but can be treated with medicines. These side effects tend to be worse when chemotherapy is given with radiation. Pelvic radiation can lead to premature menopause. It can also weaken the bones, making them more likely to break from a fall or other trauma.

Skin changes can also be a side effect of radiation. These may range from mild temporary redness to permanent discoloration. The skin may become raw and tender. It may also release fluid, making infection more likely, so care must be taken to clean and protect the area exposed to radiation.

Radiation to the pelvis can also cause severe irritation of the intestines and rectum (called radiation colitis), leading to diarrhea and bloody stool. If severe, radiation colitis can cause holes or tears forming in the intestines (called perforations).

Pelvic radiation can also cause problems with the bladder (radiation cystitis), leading to discomfort and an urge to urinate often. In rare cases, radiation can cause abnormal connections (called fistulas) to form between the vagina and the bladder, rectum, or uterus.

Radiation can cause the normal tissue of the vagina to become irritated and sore. As it heals, scar tissue can form in the vagina. The scar tissue can make the vagina shorter or more narrow (this is called vaginal stenosis). When this happens, sex (vaginal intercourse) can become painful. Stretching the walls of the vagina a few times a week can help prevent this problem.

One way to do this is to have vaginal intercourse at least 3 to 4 times a week. Since this may be hard to do while getting cancer treatment, another option is to use a vaginal dilator. A dilator is a plastic or rubber tube used to stretch out the vagina. It feels much like putting in a large tampon for a few minutes. Even if a woman is not interested in staying sexually active, keeping her vagina normal in size allows comfortable gynecologic exams. This is an important part of follow-up after treatment. Vaginal estrogens may also be used to relieve dryness and prevent painful intercourse and help maintain the size of the vagina. Still, vaginal dryness and pain with intercourse can be long-term side effects from radiation.

Topical therapy for vaginal cancer