Treatment by vaginal cancer stage

• A quick guide to what's on this page
• VAIN (Stage 0)
• Stage 1 vaginal cancer
• Stage 2, 3 and 4a vaginal cancer

• Stage 4b vaginal cancer
• Vaginal melanoma
• If vaginal cancer comes back after treatment
• Controlling symptoms

VAIN (vaginal intraepithelial neoplasia) is not cancer, but there are areas of abnormal cells in the lining of the vagina that could become cancerous. Some doctors call it precancer. VAIN is graded as VAIN 1, 2, or 3. VAIN 1 means one third of the thickness of the outer layer of the vagina (the lining) contains abnormal cells. VAIN 3 means the full thickness of the lining of the vagina has abnormal cells. Women who have VAIN 1 do not usually need any treatment. The cancerous cells often disappear after a while. Your doctor will arrange regular check ups to make sure this has happened.

If you have VAIN 2 or 3 your doctor may recommend treating the abnormal cells. This aims to prevent cancer developing. Treatments for VAIN include

• Laser treatment
• Surgery
• Radiotherapy
• Creams

Laser treatment

A laser is a very strong, hot beam of light that burns away the abnormal cells. Your doctor will use local anaesthetic to numb the area before you have this treatment.

Surgery

You might be treated with surgery, especially if the cancerous cells have come back. Your doctor may cut out the abnormal cells and some surrounding healthy tissue. This is called ‘wide local excision’. The tissue that is removed is then sent to the laboratory and the cells are looked at under the microscope.

Sometimes the surgeon removes the area of abnormal cells with a small loop of wire that has an electric current. This is also called loop diathermy or LEEP and can cut out tissue and stop bleeding at the same time. The surgeon also removes a surrounding area of healthy tissue to lower the risk of the abnormal cells coming back.

Radiotherapy

You might have radiotherapy if the precancerous cells have come back after treatment or if the abnormal cells are in several areas of your vagina. You usually have this as internal radiotherapy (brachytherapy). This means a radioactive object called a ‘source’ is placed inside your vagina, to treat the local area. You may have this treatment over several hours or a few days. There is information about having this type of treatment in the section about radiotherapy for vaginal cancer.

Creams

Creams are not standard treatment for VAIN and are usually used as part of clinical trials. Sometimes a chemotherapy cream is used, usually fluorouracil. But this needs to be applied often and can irritate the delicate skin of the vagina. So it is rarely used. Newer creams being tested for VAIN include

• Imiquimod cream - an antiviral drug that boosts the immune system to destroy the abnormal cells
• Cidofovir - an antiviral drug

Radiotherapy is the first treatment for many women with stage 1 vaginal cancers. Internal radiotherapy is used to treat small tumours on the inner lining of the vagina. If the tumour is in the deeper vaginal tissues then external radiotherapy may be used as well. You may also have chemotherapy treatment alongside radiotherapy.

Some women with stage 1 cancer need to have surgery. If the cancer is on the upper part of your vagina it is sometimes necessary to remove the womb. This operation is called radical hysterectomy. You will have lymph nodes removed from around the womb and part of the vagina taken away (radical partial vaginectomy).

If the cancer is in the lower or middle part of your vagina you may need to have the whole of your vagina removed (radical vaginectomy). Your surgeon may then surgically make a new vagina for you. This is called vaginal reconstruction. You will probably have external radiotherapy after surgery to try to make sure that any cancer cells left behind are killed off.

Doctors are trying to develop a new treatment for women who are young and want to keep their fertility. It involves removing less vaginal tissue than usual and then having internal radiotherapy. The research so far seems to show that this will be as successful as radical surgery or very high doses of radiotherapy for treating cancer of the vagina. But it isn't standard treatment in the UK at the moment.

Stage 2, 3 and 4a vaginal cancer are all treated in a similar way. Radiotherapy is the main treatment - both internal radiotherapy and external radiotherapy. You may also have chemotherapy treatment alongside radiotherapy. You might be offered surgery if you have had previous radiotherapy treatment. There is a limit to the amount of radiotherapy you can have to any one part of the body. Too much causes damage to healthy tissues. In rare cases, your doctor may suggest you have an operation to move healthy bowel out of the radiotherapy treatment area. You would normally only need to have this done in the following situations

• You need particularly high radiotherapy doses
• You have had surgery to your bowel in the past, which has left you with internal scar tissue (adhesions)

Stage 4B means that the cancer has spread to another part of your body. This stage is not likely to be curable. But radiotherapy can relieve symptoms such as pain, swelling or bleeding. Your specialist may suggest chemotherapy if you are fit enough for the treatment. If there is a suitable clinical trial running, your specialist may ask you to join it. Your specialist would not suggest this unless they are convinced you would receive suitable treatment within the trial. Vaginal cancer is rare and so it is quite difficult to research. Taking part in the trial may help to improve treatment in the future for other women with vaginal cancer.

Surgery is the main treatment for vaginal melanoma. Radiotherapy and chemotherapy generally do not work well for melanoma. Because this type of vaginal cancer is so rare, it has been difficult to find out which type of surgery is the best. The aim of the surgery is to remove all of the melanoma cells. But doctors don't know if they need to remove the whole of the vagina. Or whether it is just as good to remove only the melanoma, with a surrounding border of healthy tissue that is free of cancer cells. This border is called a 'healthy margin'. It also isn't clear how many lymph nodes should be removed.

It may seem rather frightening to hear that doctors don't know how much treatment is best. But your doctor will make sure you have enough treatment to be as safe as possible. Their concern is that some women could have too much treatment and cause unnecessary side effects. Future research may lead to smaller operations for this type of cancer.

Your treatment will depend on whether you have had radiotherapy or surgery in the past.

If you had radiotherapy for stage 1 or 2 vaginal cancer the first time round, and the cancer came back in the same place, your doctors will probably suggest surgery. Depending on where the cancer is, you may need quite a big operation, such as pelvic exenteration.

If you had surgery the first time round, then you are most likely to have radiotherapy, chemotherapy, or combined chemotherapy and radiotherapy as part of a clinical trial.

Treatment to control symptoms is called ‘palliative treatment’. It aims to make you more comfortable. It will not cure your cancer, although it may control it for a time. If your cancer has spread too far to be cured, or has come back after it was first treated, you may have radiotherapy, chemotherapy, or both, to help control any symptoms it is causing.