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Treatment for vulvar cancer
Vulvar cancer usually takes many years to develop but, like other types of cancer, it is easier to treat at an early stage. Treatment may involve surgery, radiation therapy and chemotherapy. You may have one of these treatments or a combination.
The treatment recommended by your doctor will depend on the results of your tests, the type of cancer, where the cancer is, whether it has spread, your age and your general health. You’ll have regular check-ups to see whether the cancer has responded to treatment.
Surgery is the main treatment for vulvar cancer. Your gynaecological oncologist will talk to you about the most suitable type of surgery, as well as the risks and any possible complications.
The type of operation recommended depends on the stage of the cancer. The table below provides more information about the main types of surgery.
All tissue removed during surgery is examined for cancer cells by a pathologist. The results will help confirm the type of vulvar cancer you have and its stage.
Types of vulvar surgery
Depending on how far the cancer has spread, you may have one of the following types of surgery:
- Local excision
- Wide local excision – The surgeon cuts out the cancer, as well as a small border of healthy tissue (called the margin).
- Radical local excision – The surgeon cuts out the cancer with a deeper margin. May be done together with a lymph node dissection.
- Partial vulvectomy – The affected part of the vulva is removed. The surgeon may also take out a small border of healthy tissue around the cancerous tissue (a wide local excision). This may mean that a large part of the vulva is removed.
- Complete vulvectomy – The surgeon removes the entire vulva, sometimes including the clitoris. A complete radical vulvectomy also removes deep tissue around the vulva. Usually, nearby lymph nodes are also removed – this is called a lymph node dissection.
Other surgical procedures
Lymph node dissection – The lymph nodes (also called lymph glands) are part of the lymphatic system. Cancer cells can spread from the vulva to the lymph nodes in the groin, so your doctor may suggest removing these nodes from one or both sides. This is called an inguinal lymph node dissection or lymphadenectomy.
Sentinel lymph node biopsy – Before a lymph node dissection, the surgeon may perform a sentinel lymph node biopsy. This test helps to identify which lymph node the cancer is most likely to spread to first (the sentinel lymph node).
You will usually have an anaesthetic, then a small amount of radioactive dye will be injected near the site of the cancer. The dye will flow to the sentinel lymph node, and the surgeon will remove it. If a pathologist finds cancer cells in the sentinel lymph node, the remaining nodes in the area may need to be removed.
A sentinel lymph node biopsy can help the doctor avoid removing more lymph nodes than necessary and minimise side effects such as lymphoedema. Sometimes, the removal of lymph nodes in the groin can stop or slow the natural flow of lymphatic fluid. When this happens, it can cause one or both legs to swell. This is known as lymphoedema.
Your doctor will talk to you about this type of biopsy and the associated risks.
Reconstructive surgery – The surgeon will aim to remove all of the vulvar cancer while preserving as much normal tissue as possible. However, it is essential to remove a margin of healthy tissue around the cancer to reduce the risk of the cancer coming back (recurring) in the same area.
Most women will be able to have the remaining skin drawn together with stitches, but if a large area of skin is removed, you may need a skin graft or skin flap. To do this, the surgeon may take a thin piece of skin from another part of your body (usually your abdomen or thigh) and stitch it onto the operation site. It may also be possible to move flaps of skin in the vulvar area to cover the wound. The graft or flap will be done as part of the initial operation, sometimes with the assistance of a reconstructive (plastic) surgeon.
Pelvic exenteration – This operation is very rarely done for vulvar cancer, but may sometimes be considered for advanced cancer that has spread beyond the vulva. A pelvic exenteration removes all the affected organs, such as the lower bowel, bladder, uterus and vagina. Because the bladder and bowel are removed, the surgeon will make two openings (stomas) in the abdomen so that urine and faeces can be collected in stoma bags. Your surgeon will only recommend this surgery if you are fit enough to make a good recovery.
Also known as radiotherapy, this treatment uses a controlled dose of radiation, such as x-rays, to kill or damage cancer cells. Whether you have radiation therapy will depend on the stage of the cancer, its size, whether it has spread to the lymph nodes and, if so, how many nodes are affected. You can have radiation therapy:
- before surgery to shrink the cancer and make it easier to remove (neoadjuvant treatment)
- after surgery to get rid of any remaining cancer cells and reduce the risk of the cancer coming back (adjuvant treatment)
- instead of surgery
- to control symptoms of advanced cancer (palliative treatment).
External beam radiation therapy (EBRT)
This is the most common type of radiation therapy for vulvar cancer. You will lie on a treatment table while a machine, called a linear accelerator, directs radiation towards the areas of the vulva that are affected or at risk. EBRT is usually given daily, Monday to Friday, over 5–6 weeks. The exact number of sessions you have will depend on the type and size of the cancer. Each session takes about 20 minutes.
Radiation therapy to the vulva and groin is painless, but it can cause side effects. External beam radiation therapy will not make you radioactive. It is safe for you to be with other people, including children, after your treatment.
Internal radiation therapy
Also called brachytherapy, this delivers radiation therapy to the tumour from inside your body. It is not used often for vulvar cancer.
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.
Short-term side effects
- fatigue – Your body uses a lot of energy to heal itself after the treatment, 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 have a burning sensation when you pass urine. Bowel motions may be more frequent, urgent or loose (diarrhoea), or you may pass more wind than normal. Less commonly, women may have some blood in the stools (faeces). Always tell your doctor about any bleeding.
- nausea and vomiting – Because the radiation therapy is directed near your abdomen, you may feel sick (nauseous), with or without vomiting, for several hours after each treatment. Your doctor may prescribe anti-nausea medicine to help prevent this.
- 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.
- skin redness, soreness and swelling – The vulva may become sore and swollen. It may start by being pink or red and feeling itchy, and progress to peeling, blistering or weeping. Your treatment team will recommend creams and pain relief to use until the skin heals. Wash the area with lukewarm water or weak salt baths, and avoid perfumed products and talcum powder.
Long-term or late effects
- hair loss – You may lose your pubic hair. For some women, this can be permanent. It will not affect the hair on your head or other parts of your body.
- bladder and bowel problems – Bladder changes, such as frequent or painful urination, and bowel changes, such as diarrhoea or wind, can also be late effects, appearing months or years after radiation therapy finishes. In rare cases, blockage of the bowel can occur. It is important to let your doctor
know if you have pain in the abdomen and cannot open your bowels.
- lymphoedema – Radiation can scar the lymph nodes and vessels and stop them draining lymph fluid properly from the legs, making the legs swollen. This can occur months or years after radiation therapy, and it is easier to treat if diagnosed early.
- narrowing of the vagina – The vagina can become drier, shorter and narrower (vaginal stenosis), which may make sex and follow-up pelvic examinations uncomfortable or difficult. Your treatment team will suggest strategies to prevent this.
- menopause – In premenopausal women, radiation therapy to the pelvis can stop the ovaries producing hormones, and this causes early menopause. Your periods will stop, you will no longer be able to become pregnant and you may have menopausal symptoms. Talk to your radiation oncologist about menopause or any fertility issues before treatment.
Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells. For women with vulvar cancer, treatment may be given:
- during a course of radiation therapy, to make the radiation therapy treatment more effective
- to control cancer that has spread to other parts of the body
- as palliative treatment, to relieve the symptoms of the cancer.
The chemotherapy drugs are commonly given by injection into a vein (intravenously), but may also be given as tablets or in a cream applied to the vulva. Most women have several treatment sessions, with rest periods in between. Together, the session and rest period are called a cycle. Treatment can often be given to you during day visits to a hospital or clinic as an outpatient, but sometimes you may need to stay in hospital for a few nights.
Side effects of chemotherapy
There are many different types of chemotherapy drugs. The side effects will vary depending on the drugs you are given, the dosage and your individual response. Your medical oncologist or nurse will discuss the likely side effects with you, including how they can be prevented or controlled with medicine.
Most side effects are temporary. Common side effects experienced after chemotherapy for vulvar cancer include feeling sick (nausea), tiredness (fatigue), and a reduced resistance to infections.
Chemotherapy for vulvar cancer may also increase any skin soreness caused by radiation therapy. Some women find that they are able to continue with their usual activities during treatment, while others find they need to take things more slowly.
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 be beneficial at any stage of advanced vulvar cancer. It is about living for as long as possible in the most satisfying way you can.
Sometimes treatments such as radiation therapy, chemotherapy or other drug therapies are given palliatively. The aim is to relieve symptoms such as pain or bleeding by shrinking or slowing the growth of the cancer.
Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs.