Vaginal cancer is a rare cancer of the female reproductive system. Only 3% of gynecologic cancer cases are vaginal. The vagina (birth canal) is the opening through which menstrual fluid leaves the body and babies are born. It is connected to the cervix (the opening of the uterus or womb) and the vulva (folds of skin around its opening).
The vaginal walls have a thin layer of cells called the epithelium, which contains cells called squamous epithelial cells. The vaginal wall, underneath the epithelium, consists of connective and involuntary muscle tissue, lymph vessels, and nerves.
Usually, the vagina is in a collapsed position with its walls touching. The walls have many folds that allow the vagina to open and expand during sexual intercourse and vaginal childbirth. The vaginal lining is kept moist by mucus released by glands in the cervix.
Vaginal cancer begins when normal cells in the vagina begin to change, grow uncontrollably, and no longer die, forming a mass called a tumor. Tumors can be benign (noncancerous) or malignant (cancerous). There are four types of vaginal cancer:
Squamous cell carcinoma. Squamous cell carcinoma is a type of skin cancer that begins in the cells lining the vagina, most often in the area closest to the cervix. Squamous cell cancer makes up 85% to 90% of vaginal cancer cases. It develops slowly through a precancerous condition (changes in cells that may, but do not always, become cancer) called vaginal intraepithelial neoplasia (VAIN).
Adenocarcinoma. Adenocarcinoma begins in the vaginal gland tissue. It accounts for 5% to 10% of vaginal cancer cases.
Clear cell adenocarcinoma. This cancer occurs in young women whose mothers took the drug diethylstilbestrol (DES) during pregnancy between the late 1940s and 1971. It is estimated that one woman in 1,000 exposed to DES will develop vaginal cancer.
Melanoma. Melanoma is another type of skin cancer that is usually found on skin exposed to the sun, but it can begin on the skin of the vagina or other internal organs. Melanoma often appears as a dark-colored tumor on the lower or outer parts of the vagina. Learn more in the Cancer.Net Guide to Melanoma.
Statistics
Vaginal cancer is rare. In 2008, an estimated 2,210 women in the United States will be diagnosed with vaginal cancer. It is estimated that 760 deaths from this disease will occur this year.
Cancer statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a woman how long she will live with vaginal cancer. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer.
Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2008.
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices.
The following factors may raise a woman's risk of developing vaginal cancer:
Age. Squamous cell carcinoma most often occurs in women between 50 and 70 years old; approximately half of all cases are diagnosed in women over 60 years old.
Human papillomavirus (HPV) infection. HPV is passed from one person to another during sexual intercourse. There are many types of HPV, and some are linked with genital or anal cancer in men and women. Many types of cancer caused by HPV are associated with precancerous conditions that develop before the cancer.
Smoking. Smoking may increase a woman’s risk of developing vaginal cancer.
DES. Women whose mothers took this drug during their pregnancy between the late 1940s and 1971 are at increased risk for clear cell adenocarcinoma. The average age of diagnosis is 19. Because most women of mothers who took DES are between 30 and 60, the number of cases has declined. However, the long-term risks of DES exposure are not known.
Cervical cancer. Women who have had cervical cancer or cervical precancerous conditions have an increased risk of vaginal cancer.
Radiation therapy. Women who have had radiation therapy in the vaginal area have an increased risk of vaginal cancer.
Hysterectomy. Women who have had a hysterectomy (removal of part or all of the uterus) have an increased risk of vaginal cancer.
Pessary. Long-term vaginal irritation in women using a pessary (a device used to keep a sagging uterus in place) can increase the risk of vaginal cancer.
All women should have an annual gynecologic examination. The doctor will take a family medical history and perform a general physical examination. Research has shown that certain factors can help prevent vaginal cancer.
Delaying first sexual intercourse until the late teens or older
Avoiding sexual intercourse with multiple partners
Avoiding sexual intercourse with someone who has had many partners
Practicing safe sex
Having regular Pap tests to detect and treat precancerous conditions
Vaginal cancer does not often cause symptoms in the early stages, but cancer in more advanced stages can cause symptoms. Even precancerous conditions, such as VAIN, may not cause symptoms. However, many cases of VAIN and early vaginal cancer can be found through regular gynecologic examinations or Pap tests.
Women with vaginal cancer may experience the following symptoms. Sometimes, women with vaginal cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor.
The most common symptom of vaginal cancer is abnormal vaginal bleeding. Vaginal bleeding during menopause is not common and can be a sign of a problem.
Other symptoms of vaginal cancer include:
Abnormal vaginal discharge
Difficulty or pain when urinating
Pain during sexual intercourse
Pain in the pelvic area (the lower part of the abdomen between the hip bones)
Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized. Your doctor may consider these factors when choosing a diagnostic test:
Age and medical condition
The type of cancer suspected
Severity of symptoms
Previous test results
In addition to a physical examination, the following tests may be used to diagnose vaginal cancer:
Pelvic examination. The doctor feels the uterus, vagina, ovaries, fallopian tubes, bladder, and rectum to check for any unusual changes.
Pap test. The doctor gently scrapes the outside of the cervix and vagina and takes sample cells for testing. During the process, there is some pressure but seldom pain.
Colposcopy. The doctor may do a colposcopy to check the vagina and cervix for abnormal areas. A special instrument called a colposcope (an instrument that magnifies the cells of the cervix and vagina, similar to a microscope) is used. The colposcope gives the doctor a lighted, magnified view of the tissues of the vagina and the cervix. The colposcope is not inserted into the woman’s body and the examination is not painful, can be done in the doctor’s office, and has no side effects. It can be performed on pregnant women.
Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). The type of biopsy performed will depend on the location of the cancer.
If the biopsy indicates that vaginal cancer is present, the doctor will refer the woman to a gynecologic oncologist, a doctor who specializes in treating this type of cancer. The specialist may suggest the following tests to see if the cancer has spread beyond the vagina.
Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (special dye) is injected into a patient’s vein to provide better detail.
Endoscopy. This test allows the doctor to see inside the body. The patient may be sedated, and the doctor inserts a thin, lighted, flexible tube called an endoscope through the mouth, anus, vagina, urethra, or a small surgical opening.
Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.
Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images.
X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs.
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer.
One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.
TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
How large is the primary tumor and where is it located? (Tumor, T)
Has the tumor spread to the lymph nodes? (Node, N)
Has the cancer metastasized to other parts of the body? (Metastasis, M)
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below.
TX: The primary tumor cannot be evaluated.
T0: There is no evidence of cancer in the vagina.
Tis: The tumor is carcinoma in situ (early cancer found only in one layer of cells and has not spread to nearby tissue).
T1: This describes a tumor in the vagina that has not spread through the vaginal wall or to other parts of the body.
T2: This describes a tumor that has spread through the vaginal wall and surrounding tissues, but not to the walls of the pelvis.
T3: This describes a tumor that has spread to the pelvic wall.
T4: This describes a tumor that has spread to the bladder, rectum, or other areas of the body.
Node.The "N" in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the pelvis and groin are called regional lymph nodes. Depending on the exact location of the tumor (upper third, middle third, or lower third of the vagina), the lymph nodes near the hips or upper thighs may also be involved. Lymph nodes in other parts of the body are called distant lymph nodes.
NX: The lymph nodes cannot be evaluated.
N0: Cancer has not spread to the regional lymph nodes.
N1: Cancer has spread to the regional lymph nodes.
Distant metastasis. The "M" in the TNM system indicates whether the cancer has spread to other parts of the body.
MX: Metastasis cannot be evaluated.
M0: The cancer has not metastasized.
M1: There is metastasis to another part of the body.
Cancer stage grouping
Doctors assign the stage of the cancer by combining the T, N, and M classifications.
Stage 0: The tumor is called carcinoma in situ. In other words, the cancer is found only in the first layer of cells lining the vagina, not in the deeper tissue (Tis, N0, M0).
Stage I: The tumor has not spread through the vaginal wall or to other parts of the body (T1, N0, M0).
Stage II: The tumor has spread through the vaginal wall, but not to the walls of the pelvis (T2, N0, M0).
Stage III: Vaginal cancer is called stage III in either of these conditions:
Cancer has spread to the lymph nodes in the pelvis regardless of how far the tumor has spread (T1, T2, or T3; N1, M0).
Cancer has spread to the pelvic wall (except the bladder), but not the lymph nodes (T3, N0, M0).
Stage IVA: Cancer has spread to the bladder, rectum, or beyond the pelvis. The lymph nodes may or may not be involved (T4, any N, M0).
Stage IVB: Cancer has spread to the lymph nodes and other parts of the body (any T, any N, M1).
Tumor grade. Doctors also describe a primary tumor by its grade, which is determined using a microscope to examine tissue from a tumor. The doctor compares the tumor tissue with normal tissue. Normal tissue contains many different types of cells grouped together, which is called differentiated. Tissue from a tumor usually has cells that look more alike, called poorly differentiated. Generally, the more differentiated the tissue, the better the prognosis.
GX: The tumor grade cannot be evaluated.
G1: The tumor cells are well differentiated (contains many healthy-looking cells).
G2: The tumor cells are moderately differentiated (more cells appear abnormal than healthy).
G3: The tumor cells are poorly differentiated (most of the cells appear abnormal).
G4: The tumor cells are undifferentiated (the cells barely resemble normal cells).
Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
The treatment of vaginal cancer depends on the size and location of the tumor, whether the cancer has spread, and the woman's overall health. In addition, treatment may also be based on whether the woman plans to have children. In many cases, a team of doctors (gynecologic oncologist, surgeon, and radiation oncologist) will work with the woman to determine the best treatment plan.
Vaginal cancer is most often treated with one or a combination of treatments: surgery, radiation therapy, and/or chemotherapy.
Surgery
Surgery is the primary treatment for vaginal cancer. The goal of surgery is to remove the tumor.
Laser surgery. Laser surgery (uses a focused beam of light that burns the cancer off the skin) can be used to remove precancerous cells or a tumor. Additional tissue may be removed to be certain that all cancer has been destroyed.
Excision. This is the removal of the tumor and some of the surrounding healthy tissue (called a margin). Vaginal repair using skin from other parts of the woman's body may be necessary.
Vaginectomy. This is the removal of the vagina, which may include the pelvic lymph nodes. Often, a plastic surgeon can create a new vagina with grafts of tissue from other parts of the woman’s body. The woman will be able to have sexual intercourse, but she will need to use a lubrication aid.
Radical hysterectomy. If the cancer has spread to other parts of the woman’s reproductive system, the uterus, ovaries, and fallopian tubes, as well as lymph nodes may be removed.
If the cancer has spread to other parts of the body, it may be necessary to also remove the lower colon, rectum, or bladder (removal of the bladder is called a cystectomy). If the woman's bladder is removed, a small piece of intestine will be attached to the abdominal wall, allowing her to periodically drain urine by placing a slim, hollow tube into a surgically created opening. A plastic bag worn at the front of the stomach can be used for continual draining. If the woman's rectum or part of her colon is removed, the remaining intestine will be attached to the abdominal wall, so solid waste can pass through a small opening into a bag worn at the front of the stomach (called a colostomy).
Coping with vaginal surgery
Many women experience a range of feelings after vaginal surgery, such as loss, sadness, or anxiety. Some women may feel that they have lost their identity as women. Others have questions about whether sexual intercourse can continue after surgery.
Before surgery, it is important to ask the surgeon about the procedure, the possible side effects, and when sexual intercourse can resume. Women should talk with their doctors about finding additional information or support in coping with this surgery.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Radiation therapy may be used alone or after surgery. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body.
When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. One method is intracavity radiation therapy, in which tiny tubes of a radioactive substance are placed in the vagina for one to two days. The woman must stay in bed during this time. Another method is interstitial radiation therapy, in which radioactive material is injected directly into the tumor.
Side effects depend on the dose used, the area targeted, and the type of radiation (internal or external) therapy. Specific side effects may include the narrowing of the vagina, damage to healthy vaginal tissue, irritation of the intestines, and diarrhea. The vagina may shorten and narrow so much that sexual intercourse is not possible. To prevent this, the vagina may need to be stretched with a plastic tube called a vaginal dilator several times a week.
For more information about radiation therapy, see the American Society for Therapeutic Radiology and Oncology's pamphlet, Radiation Therapy for Gynecologic Cancers.
Chemotherapy
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The goal of chemotherapy can be to destroy cancer remaining after surgery, slow tumor growth, or reduce side effects.
Although chemotherapy can be given orally (by mouth), when chemotherapy is used to treat vaginal cancer, most drugs are given intravenously (IV). IV chemotherapy is either injected directly into a vein or through a catheter, a thin tube temporarily put into a large vein to make injections easier. Intravaginal chemotherapy (the drugs are put directly into the vagina) may be used to treat early stage vaginal cancer.
Because chemotherapy affects normal cells as well as cancer cells, many women experience side effects from treatment. The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. Other potential side effects include the inability to become pregnant and symptoms of premature menopause. Most side effects go away when treatment is complete.
The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.
Excision with the removal of lymph nodes followed by internal radiation therapy
Stage II
Combined internal radiation therapy and external-beam radiation therapy
Surgery, followed by possible radiation therapy
Stage III
Combined internal radiation therapy and external-beam radiation therapy
Surgery, followed by possible radiation therapy
Stage IVA (advanced)
Combined internal radiation therapy and external-beam radiation therapy
Surgery, followed by possible radiation therapy
Stage IVB
Radiation therapy
Chemotherapy
Participation in a clinical trial
Recurrent vaginal cancer
Recurrent cancer is cancer that comes back after treatment. Surgery may be performed to remove the cervix, uterus, lower colon, rectum, or bladder, depending on where the recurrence began and the type of surgery previously performed. Radiation therapy and/or chemotherapy may also be used for treatment. Participation in clinical trials is another treatment option.
Advanced vaginal cancer
Stage IV vaginal cancer is the most advanced stage of the disease. At this stage, the cancer has spread beyond the vagina to the bladder, rectum, lymph nodes of the pelvis, or other organs, such as the bones or lungs. The symptoms of advanced vaginal cancer are similar to those experienced when the disease was first diagnosed.
Unusual vaginal bleeding
Abnormal vaginal discharge
Difficulty or pain when urinating
Pain during sexual intercourse
Pain in the pelvic area
Pain in the back or legs
Nausea and vomiting
Abnormal bowel function
Women with advanced vaginal cancer that has spread to the bladder and rectum may receive internal radiation therapy and external-beam radiation therapy or surgery, which may be combined with radiation therapy.
Treatment for advanced vaginal cancer that has spread to other parts of the body may include radiation therapy to relieve symptoms and chemotherapy. Patients with stage IV vaginal cancer may consider participating in clinical trials.
Doctors and scientists are always looking for better ways to treat patients with vaginal cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.
Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating vaginal cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with vaginal cancer.
To join a clinical trial, patients must complete a learning process known as informed consent. During informed consent, the doctor should list all of the patient's options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about Clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials.
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur.
Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person's overall health.
Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with your doctor about side effects you experience during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net's section on Managing Side Effects, based on ASCO's curriculum.
In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer.Net's section on Caring for the Whole Patient.
For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.
After treatment for vaginal cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. Although no specific guidelines have been defined, follow-up care is essential for women who have finished vaginal cancer treatment. Patients should visit their doctors regularly for physical and pelvic examinations and a Pap test. The doctor may also conduct other tests, including periodic x-rays, CT scans, ultrasound studies, or MRI scans. Tell your doctor about any new symptoms.
Women recovering from vaginal cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about Healthy Living After Cancer.
Research for vaginal cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor.
Relieving symptoms of radiation therapy. One side effect of pelvic radiation therapy is diarrhea. A drug currently under investigation, called octreotide (Sandostatin), may relieve this symptom in women with vaginal cancer.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking your doctor the following questions:
What type of vaginal cancer do I have?
Can you explain my pathology report to me?
What is the stage of my cancer? What does this mean?
What are my treatment options?
What clinical trials are open to me?
What treatment do you recommend? Why?
Who will be doing the surgery? How experienced is this person with this type of cancer?
Will I need reconstructive surgery?
What are the side effects of treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform any usual activities?
Will I be able to resume my sex life after treatment?
Will this treatment affect my ability to have children?
How can I keep myself as healthy as possible during treatment?
What are the chances that the cancer will recur?
What follow-up tests will I need, and how often will I need them?
What support services are available for me? For my family?
Patient Information ResourcesGynecologic Cancer Foundation (GCF) 230 W Monroe, Ste. 2528
Chicago, IL 60606
Toll Free: 800-444-4441
Phone: 312-578-1439 www.thegcf.org www.wcn.org
Rare Cancer Alliance
1649 N. Pacana Way
Green Valley, AZ 85614 www.rare-cancer.org
National Organization for Rare Disorders
55 Kenosia Ave.
P.O. Box 1968
Danbury, CT 06813
Toll Free: 800-999-6673
Phone: 203-744-0100 www.rarediseases.org
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