Topical therapy puts the drug directly onto the cancer. This is another way to treat VAIN, but is not used to treat invasive vaginal cancer.
One choice is to apply the chemotherapy drug, fluorouracil (5-FU), directly to the lining of the vagina. This is repeated weekly for about 10 weeks or given nightly for 1 to 2 weeks. This treatment has drawbacks. It can cause severe vaginal and vulvar irritation. Also, it may not work as well using the laser or simply removing the lesion with surgery.
A second drug that can be used topically is called imiquimod. This drug comes in a cream to be applied to the area of VAIN. Imiquimod is not chemotherapy drug. Instead, it acts by boosting the body's immune response to the area of abnormal tissue. This treatment has led to improvement of VAIN (the lesions changed from VAIN 2 or 3 to VAIN 1). In some women, it has caused VAIN to go away completely.
Chemotherapy for vaginal cancer
Chemotherapy (chemo) uses anti-cancer drugs that are usually given intravenously (into a vein), by mouth, or applied to the skin in an ointment. Drugs taken by mouth or injected into a vein, called systemic chemotherapy, enter the bloodstream to reach throughout the body, making this treatment potentially useful for cancer that has spread to distant sites.
In systemic chemo, the drug enters the bloodstream and circulates throughout the body to reach and destroy the cancer cells. So far, systemic chemo has not been shown to work well in treating vaginal cancer. It may be helpful as a way to shrink tumors before surgery. Chemo is also sometimes given with radiation to make radiation work better.
Many chemo drugs work by attacking cells that are rapidly dividing. This is helpful in killing cancer cells, but these drugs can also affect normal cells, leading to side effects. Side effects of chemo depend on the type of drugs, the amount taken, and the length of time you are treated. Common side effects include:
Loss of appetite
Nausea and vomiting
Changes in the menstrual cycle, premature menopause, and infertility (inability to become pregnant). Most women with vaginal cancer, however, have gone through menopause.
Chemo can also affect the blood forming cells of the bone marrow, leading to low blood counts. This can cause:
Increased chance of infections (due to low white blood cells)
Easy bruising or bleeding (due to low blood platelets)
Fatigue (due to low red blood cells)
Other side effects can occur depending on which drug is used. For example, cisplatin can cause nerve damage (called neuropathy). This can lead to numbness, tingling, or even pain in the hands and feet.
Most side effects are temporary and stop when the treatment is over, but chemo drugs can have some long-lasting or even permanent effects. Ask your cancer care team about the chemo drugs you will receive and what side effects you can expect. Also be sure to talk with them about any side effects you do have so that they can be treated. For example, you can be given medicine to reduce or prevent nausea and vomiting.
In the past, chemotherapy has been mainly used to treat women with advanced cancer. Some doctors suggest that it be given along with radiation for women with less advanced disease (like it is used for cervical cancer). Some small groups of patients have been reported to have been treated this way, but using combined chemo and radiation has not yet been compared to other, more standard treatments in a clinical trial.
When chemo is given, the treatment is similar to that used for cervical cancer. Drugs that have been used include cisplatin, fluorouracil (5-FU), paclitaxel (Taxol®), and docetaxel (Taxotere®).
Laser surgery for vaginal cancer
In this treatment, a beam of high-energy light is used to vaporize the abnormal tissue. This is a very effective treatment for VAIN, and works well for large lesions. However, this is not a treatment for invasive cancer. For laser surgery to be an option, the doctor must be certain that the worst lesion was biopsied and that invasive cancer is not a concern.
Treatment options by stage and type of vaginal cancer
The type of treatment your cancer care team will recommend depends on the type of vaginal cancer you have and how far the cancer has spread. This section summarizes the choices available according to the stage of your cancer.
Vaginal intraepithelial neoplasia (VAIN)
Many cases of low-grade VAIN (VAIN 1) will go away on their own, so some doctors will choose to watch them closely without starting treatment. This means getting repeat Pap tests -- often with colposcopy if needed. If the area of VAIN doesn't go away or gets worse, treatment is started. VAIN 2 is not likely to go away on its own, so treatment is usually started right away.
VAIN is treated using topical therapy (like 5-FU or imiquimod) or laser treatment. Less often, surgery is used to remove the lesion. Surgery may be chosen if other treatments fail or if the doctor wants to be sure that the area isn't invasive cancer. Surgery may involve a wide local excision, removing the abnormal area and a rim of surrounding normal tissue. A partial vaginectomy (removal of part of the vagina) is rarely needed to treat VAIN.
Stage 0 (VAIN 3 or CIS): The usual treatment options are laser vaporization, removing the affected areas with surgery, and intracavitary radiation.
Topical chemotherapy with 5-FU cream is also an option, but this requires treatment at least weekly for 10 weeks. This treatment can severely irritate the vagina and vulva. Topical immunotherapy with imiquimod may also be used.
If the cancer comes back again after these treatments, surgery (partial vaginectomy) may be needed. The surgeon would remove the entire tumor and enough surrounding normal tissue to ensure that it doesn't come back.
Stage I: Squamous cell Cancers: Radiation therapy is used for most stage I vaginal cancers. If the cancer is less than 5 mm thick (about 3/16 inch), intracavitary radiation may be used alone. Interstitial radiation is an option for some tumors, but it is not often used. For tumors that have grown more deeply, intracavitary radiation may be combined with external beam radiation.
Removing part or the entire vagina is an option for some cancers (partial or radical vaginectomy). Reconstructive surgery to create a new vagina after treatment of the cancer is an option if a large portion of the vagina has been removed.
If the cancer is in the upper vagina, it may be treated by a radical hysterectomy, bilateral radical pelvic lymph node removal, and radical or partial vaginectomy.
Following a radical partial or complete vaginectomy, postoperative radiation (external beam) may be used to treat tiny deposits of cancer cells that have spread to lymph nodes in the pelvis.
Adenocarcinomas: For cancers in the upper part of the vagina, the treatment is surgery: a radical hysterectomy, partial or radical vaginectomy, and removal of pelvic lymph nodes. This can be followed by reconstructive surgery if needed or desired. Radiation therapy may be given as well.
For cancers lower down in the vagina, one choice is to give both either interstitial or intracavitary radiation therapy and external radiation beam therapy. The lymph nodes in the groin and/or pelvis are treated with external beam radiation therapy.
Stage II: The usual treatment is radiation, using a combination of brachytherapy and external beam radiation.
Radical surgery (radical vaginectomy or pelvic exenteration) is an option for some patients with stage II vaginal squamous cell cancer if it is small and in the upper vagina. It is also used to treat women who have already had radiation therapy for cervical cancer and who would not be able to tolerate additional radiation without severe damage to normal tissues.
Chemotherapy (chemo) with radiation may also be used to treat stage II disease.
Giving chemo to shrink the cancer before radical surgery may be helpful.
Stage III or IVA: The usual treatment is radiation therapy, often with both brachytherapy and external beam radiation. Curative surgery is generally not attempted. Chemo might be combined with radiation to help it work better.
Stage IVB: Since the cancer has spread to distant sites, it cannot be cured. Patients often receive radiation therapy to the vagina and pelvis to improve symptoms and reduce bleeding. . Chemo might also be given, but it has not been shown to help patients live longer. Because there is no accepted treatment for this stage, often the best option is to enroll in a clinical trial.
Recurrent squamous cell cancer or adenocarcinoma of the vagina
If a cancer comes back after treatment it is called recurrent. If the cancer comes back in the same area as it was in the first place, it is called a local recurrence. If it comes back in another area (like the liver or lungs), it is called a distant recurrence.
A local recurrence of a stage I or stage II vaginal cancer may be treated with radical surgery (such as pelvic exenteration). If the cancer was originally treated with surgery, radiation therapy is an option. Surgery is the usual choice when the cancer has come back after radiation therapy.
Higher-stage cancers are difficult to treat when they recur. They usually cannot be cured by currently available treatments. Care focuses mostly on relieving symptoms, although participation in a clinical trial of new treatments may be helpful.
For a distant recurrence, the goal of treatment is to help the woman feel better. Surgery, radiation, or chemo may be used. Again, a clinical trial is a good option.
Surgery is the main treatment for vaginal melanoma. Because vaginal melanoma is very rare, it hasn't been well studied. Doctors are still not certain about how much tissue needs to be removed to give the best chance of cure. One choice is to remove the cancer and a margin of the normal tissue around it. This is how a melanoma on the skin of an arm or leg would be treated. Another option is to remove the entire vagina and some tissue from nearby organs. Some (or all) of the lymph nodes that drain the area of the tumor are also removed and checked for cancer spread.
There are a few drugs that can be helpful in treating metastatic melanoma. These and other treatments are discussed in more detail in our document Melanoma Skin Cancer. Radiation therapy may also be used for melanoma that has spread. It is most often used for spread to the brain or spinal cord. A good option for women with metastatic vaginal melanoma is to receive treatment as a part of a clinical trial.
Treatment of rhabdomyosarcoma is discussed in our document called Rhabdomyosarcoma.
If treatment for vaginal cancer stops working
If cancer keeps growing or comes back after one kind of treatment, it is possible that another treatment plan might still cure the cancer, or at least shrink it enough to help you live longer and feel better. But when a person has tried many different treatments and the cancer has not gotten any better, the cancer tends to become resistant to all treatment. If this happens, it's important to weigh the possible limited benefits of a new treatment against the possible downsides. Everyone has their own way of looking at this.
This is likely to be the hardest part of your battle with cancer -- when you have been through many medical treatments and nothing's working anymore. Your doctor may offer you new options, but at some point you may need to consider that treatment is not likely to improve your health or change your outcome or survival.
If you want to continue to get treatment for as long as you can, you need to think about the odds of treatment having any benefit and how this compares to the possible risks and side effects. In many cases, your doctor can estimate how likely it is the cancer will respond to treatment you are considering. For instance, the doctor may say that more chemo or radiation might have about a 1% chance of working. Some people are still tempted to try this. But it is important to think about and understand your reasons for choosing this plan.
No matter what you decide to do, you need to feel as good as you can. Make sure you are asking for and getting treatment for any symptoms you might have, such as nausea or pain. This type of treatment is called palliative care.
Palliative care helps relieve symptoms, but is not expected to cure the disease. It can be given along with cancer treatment, or can even be cancer treatment. The difference is its purpose - the main purpose of palliative care is to improve the quality of your life, or help you feel as good as you can for as long as you can. Sometimes this means using drugs to help with symptoms like pain or nausea. Sometimes, though, the treatments used to control your symptoms are the same as those used to treat cancer. For instance, radiation might be used to help relieve bone pain caused by cancer that has spread to the bones. Or chemo might be used to help shrink a tumor and keep it from blocking the bowels. But this is not the same as treatment to try to cure the cancer.
At some point, you may benefit from hospice care. This is special care that treats the person rather than the disease; it focuses on quality rather than length of life. Most of the time, it is given at home. Your cancer may be causing problems that need to be managed, and hospice focuses on your comfort. You should know that while getting hospice care often means the end of treatments such as chemo and radiation, it doesn't mean you can't have treatment for the problems caused by your cancer or other health conditions. In hospice the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult time. You can learn more about hospice in our document called Hospice Care.
Staying hopeful is important, too. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends -- times that are filled with happiness and meaning. Pausing at this time in your cancer treatment gives you a chance to refocus on the most important things in your life. Now is the time to do some things you've always wanted to do and to stop doing the things you no longer want to do. Though the cancer may be beyond your control, there are still choices you can make.
What`s new in vaginal cancer research and treatment?
Research is under way to find new ways to prevent and treat cancer of the vagina. There are some promising new developments.
Oncogenes and tumor suppressor genes
Scientists are learning more about how certain genes called oncogenes and tumor suppressor genes control cell growth and how changes in these genes cause normal vaginal cells to become cancerous. The ultimate goal of this research is gene therapy, which replaces the damaged genes in cancer cells with normal genes to stop the abnormal behavior of these cells. For example, scientists have learned that there is an abnormality of chromosome 3 in many vaginal cancers. Better understanding of how this may play a role in the development of the cancer might lead to better treatment.
Gardasil, a vaccine against HPV, has been shown to reduce the risk of vaginal cancer. Cervarix, the other HPV vaccine currently available, might also reduce vaginal cancer risk, but this has not been proven.
Studies are under way to determine the best way to combine external beam therapy and brachytherapy to treat the cancer and limit damage to normal tissue.
Surgeons are developing new operations for repairing the vagina after radical surgery.
Doctors have found that vaginal cancer does respond to certain types of chemotherapy. Clinical trials will be needed to find out if combining chemotherapy with radiation therapy is better than radiation therapy alone.