Treatment for vaginal cancer

Also known as radiotherapy, radiation therapy uses a controlled dose of radiation, such as x-rays, to kill or damage cancer cells. Radiation therapy is a common treatment for vaginal cancer. Some people with vaginal cancer are treated with a combination of radiation therapy and chemotherapy. This is called chemoradiation or chemoradiotherapy. Radiation therapy can also be used to control symptoms of advanced cancer (palliative treatment).

There are two main ways of delivering radiation therapy: externally and internally. Most people with vaginal cancer have both types of radiation therapy. Your radiation oncologist will recommend the course of treatment most suitable for you.

External beam radiation therapy (EBRT) – This precisely delivers radiation to the cancer from outside the body. You will lie on a treatment table under a machine called a linear accelerator, which directs radiation towards the affected areas of the pelvis.

EBRT is usually given daily, Monday to Friday, over 4–6 weeks. The exact number of treatment sessions you have will depend on the type and size of the cancer, and whether it has spread to the lymph nodes. Each session takes about 20 minutes and is painless.

Internal radiation therapy – Also called brachytherapy, internal radiation therapy delivers radiation directly to the tumour from inside your body. It can be given in fewer treatment sessions because radiation doesn’t have to travel through the body.

The main type of internal radiation therapy used for vaginal cancer is high-dose-rate (HDR) brachytherapy. You may have this after finishing a course of EBRT.

Brachytherapy can be delivered in a number of ways. The simplest way is through a vaginal cylinder, which is a hollow applicator with a rounded tip placed inside the vagina. The tube inside the cylinder is connected to a machine that delivers the radioactive seed.

Your vagina may feel stretched and uncomfortable, but the treatment is reasonably painless. You can take painkillers or you may be given a local anaesthetic to make you feel more comfortable when the cylinder is inserted. Treatment takes about 10–20 minutes. You may need to have 3–4 sessions to deliver the right amount of radiation to treat the cancer.

A more complex form of brachytherapy may be used if the cancer is still quite thick and bulky after EBRT. You will be admitted to hospital to have this type of brachytherapy. Hollow needles are inserted in and around the cancer under anaesthetic. A radioactive seed travels inside the needle and delivers radiation directly to the cancer.

The needles stay in place for 2–3 days until treatment is completed. During that time, you will be connected to the brachytherapy machine for at least three treatments and you must lie flat on a special bed until the needles are removed. You will be given pain-relieving medicine while you are in hospital. You are not radioactive between treatments, so family and friends can visit you in hospital. There are only a few centres in Australia where this treatment is available.

After brachytherapy you may feel uncomfortable in the vaginal region. Painkillers can help if needed.

Side effects of radiation therapy

The side effects you experience vary depending on the radiation dose and the areas treated. Many will be short-term side effects. These often get worse during treatment and just after the course of treatment has ended, before starting to get better. Some side effects may be late effects, not appearing until many months or years after treatment.

Radiation therapy that is targeted to the vaginal area has similar side effects to radiation therapy targeted to the vulvar area. Before your treatment starts, talk to your radiation oncologist about possible side effects.

Short-term side effects of radiation therapy

The side effects you experience will vary depending on the dose of radiation and the areas treated. Many will be short-term side effects. These often get worse during treatment and just after the course of treatment has ended.

• skin reactions – The area may become sore and swollen, and feel like a bad sunburn. It may start by being pink or red and feeling itchy, and then peel, blister or weep. Your treatment team will recommend creams and pain relief to use until the skin heals. Wash the area with lukewarm, slightly salted water, and avoid perfumed products and talcum powder.
• fatigue – Your body uses a lot of energy to recover and travelling to treatment can also be tiring. The fatigue may last for weeks after treatment ends.
• bladder and bowel problems – Radiation therapy can irritate the bladder and bowel. You may pass urine more often or with a burning sensation. Bowel motions may be more frequent, urgent or loose (diarrhoea), and you may pass more wind. Less commonly, you may have some blood in your faeces (poo). Always tell your doctor about any bleeding.
• vaginal discharge – Radiation therapy may cause or increase vaginal discharge. Let your treatment team know if it smells bad or has blood in it. Do not wash inside the vagina with douches as this may cause infection.

Long-term or late effects of radiation therapy

Side effects can take several weeks to get better, though some may continue longer. Some side effects from radiation therapy may not show up until many months or years after treatment. These are called late effects.

• hair loss – You may lose your pubic hair. Sometimes, this can be permanent. Radiation therapy will not affect the hair on your head or other body areas.
• bladder, bowel and rectal changes – Bladder changes (e.g. frequent or painful urination) and bowel changes (e.g. diarrhoea or wind) can appear months or years after radiation therapy ends. In some cases, a bowel blockage can occur. In rare cases, you may experience some bleeding from the rectum. Let your doctor know if you have pain in the abdomen, have any bleeding or cannot open your bowels.
• lymphoedema – Like surgery, radiation therapy can increase the risk of lymphoedema. If the lymph nodes and vessels have been removed during surgery or scarred during radiation therapy, lymph fluid can’t drain properly. Lymph fluid can become trapped, causing the legs, vulva or mons pubis to swell.
• narrowing of the vagina – The vagina can become drier, shorter and narrower (vaginal stenosis), which may make having sex and follow-up pelvic examinations uncomfortable or difficult. Your treatment team will suggest ways to prevent this.
• menopause – If you are premenopausal, radiation therapy to the pelvis can stop the ovaries producing hormones, which causes early menopause. Talk to your radiation oncologist about menopause or any fertility issues before starting treatment.

Download our booklet ‘Understanding Radiation Therapy’

Some vaginal cancers may need to be removed with an operation. The gynaecological oncologist will try to remove all of the cancer along with some of the surrounding healthy tissue (called a margin). This helps reduce the risk of the cancer coming back. Some lymph nodes in your pelvis may also be removed.

There are several different operations for vaginal cancer. The type of surgery recommended depends on the size and position of the cancer. Your gynaecological oncologist will talk to you about the risks and complications of your surgery, as well as possible side effects.

Removing part of the vagina (partial vaginectomy) – Only the affected part of the vagina is removed.

Removing the whole vagina (total vaginectomy) – The entire vagina is removed.

Removing the whole vagina and surrounding tissue (radical vaginectomy) – The entire vagina and surrounding tissue is removed.

In some cases, a reconstructive (plastic) surgeon can make a new vagina using skin and muscle from other parts of your body. This is called vaginal reconstruction or formation of a neovagina. It is done so you can have sexual intercourse if that is important to you and your partner.

Hysterectomy – Some people also need to have their uterus and cervix removed (total hysterectomy). Your gynaecological oncologist will let you know whether it is also necessary to remove your ovaries and fallopian tubes (salpingo-oophorectomy). If you are premenopausal, it is unlikely that the ovaries will need to be removed as vaginal cancer is not affected by hormones. Removing your ovaries would bring on menopause.

What to expect after surgery

After surgery, you will be monitored closely. You will need to take care while you recover. Your doctor will tell you when you can start regular activities again.

Recovery time – Your recovery time will depend on your age, the type of surgery you had and your general health. Most people are in hospital for a few days to a week.

Having pain relief – After an operation it is common to feel some pain, but this can be controlled. You will be given pain medicine as a tablet, through a drip into a vein (intravenously), through a drip into a space around the spinal cord (epidural), or through a button you press to give yourself a measured dose of pain relief (patient-controlled analgesia or PCA). After you go home, you can continue taking pain-relieving tablets as needed.

Bowel issues – Strong pain medicines and long periods in bed can make bowel motions difficult to pass (constipation). Avoid straining when having a bowel movement. Talk to your treatment team about taking laxatives if needed.

Stitches – Your doctor will tell you how soon you can sit up and walk after surgery and how to avoid the stitches coming apart. Stitches usually dissolve and disappear as the wound heals. Some surgeons use surgical glue instead of stitches. The glue falls off when the wound has healed.

Wound care – Infection is a risk after surgery, so keep the area clean and dry. While you are in hospital, the nurses will wash and dry the area for you a few times a day. They may also apply a cream to help prevent infection. The nurses will show you how to look after the wound at home. You will need to wash it 2–3 times a day using a handheld shower or shallow basin (sitz bath). Use a soft, squeezable plastic water bottle to rinse the area with water after urinating or having a bowel movement. Dry the area well. If the area is numb, be careful patting it dry. Report any redness, pain, swelling, wound discharge or unusual smell to your doctor or nurse.

Tubes and drains – You may have a tube called a catheter to drain urine from your bladder. This helps keep your wound clean and dry. It will be removed before you leave hospital. There may also be a surgical drain to draw fluid away from the wound. You may go home with the drain in place if there is still fluid coming out. Community nurses can help you manage the care of the drain at home until it is removed.

What to wear – While you are in bed, you may need to wear compression stockings and have blood-thinning injections to prevent blood clots forming in your legs. Wear loose-fitting clothing and avoid underwear so your wound can air.

Do not put anything into your vagina after surgery until your doctor says the area is healed (usually 6–8 weeks). This includes using tampons and having sex. 

Taking care of yourself at home after surgery

Rest – You will need to take things easy and get plenty of rest in the first week. Avoid sitting for long periods of time if it is uncomfortable, or try sitting on a pillow or doughnut cushion.

Exercise – Check with your gynaecological oncologist or nurse about when you can start doing your regular activities. You may not be able to lift anything heavy, but gentle exercise such as walking can help speed up recovery. Because of the risk of infection, avoid swimming until your doctor says you can.

Emotions – If you have lost part of your genital area, you may feel a sense of loss and grief. It may help to talk about how you are feeling with someone you trust.

Sex – Sexual intercourse needs to be avoided for about 6–8 weeks after surgery. Ask your doctor when you can have sexual intercourse again, and explore other ways you and your partner can be intimate. You may feel concerned about the impact on your sex life after surgery.

Using the toilet – If the opening to your urethra is affected, you may find that going to the toilet is different. The urine stream might spray in different directions or go to one side.

Driving – You will need to avoid driving after the surgery until your wounds have healed and you are no longer in pain. Discuss this issue with your doctor.

Download our booklet ‘Understanding Surgery’

Chemotherapy uses drugs to kill or slow the growth of cancer cells. It is usually given if the vaginal cancer is advanced or returns after treatment, and may be combined with surgery or radiation therapy.

The drugs are usually given by injection into a vein (intravenously) and sometimes as tablets. You will usually have several treatment sessions, with rest periods in between. Together, the session and rest period are called a cycle. Treatment is usually given to you during day visits to a hospital or clinic as an outpatient. Rarely, you may need to stay in hospital for a few nights.

Side effects of chemotherapy

Most people have some side effects from chemotherapy. There are many different types of chemotherapy drugs, and the side effects will vary depending on the drugs you are given. Your medical oncologist or nurse will discuss the likely side effects with you, including how they can be prevented or controlled with medicine.

Common side effects experienced after chemotherapy for vaginal cancer include feeling sick (nausea), tiredness (fatigue), hair loss and a reduced resistance to infections. Chemotherapy may also increase any skin soreness caused by radiation therapy. Some people find that they are able to lead a fairly normal life during their treatment, while others become very tired and need to take things more slowly.

Download our booklet ‘Understanding Chemotherapy’

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care.

Many people think that palliative treatment is for people at the end of their life, but it may help at any stage of advanced vaginal cancer. It is about living for as long as possible in the most comfortable way you can.

As well as slowing the spread of cancer, palliative treatment can relieve symptoms such as pain or bleeding. Treatment may include radiation therapy, chemotherapy or other drug therapies.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, social and spiritual needs.

Download our booklet ‘Understanding Palliative Care’

Download our booklet ‘Living with Advanced Cancer’