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Vaginal cancer

VAGINAL CANCER
Vaginal cancer develops when vaginal cells change and start to grow out of control. Vaginal cancer can either be primary or secondary. Primary vaginal cancer is the one that start from the vagina while secondary vaginal cancer is the one that start somewhere else in the body such as cervix and vulva, then spread to the vagina. Secondary vaginal cancer is more common compared to primary cancer.
Vagina
Vagina is an opening through which baby is born and menstrual fluid leaves the woman`s body. Vagina is part of female reproductive system and is also called birth canal. It is about 7–10 cm long and extends the cervix to the vulva. The vaginal walls are made up of flat layer of cells called Squamous epithelia. Underneath the epithelial layer are connective tissues, muscles, lymph vessels, and nerves. The moist feature of the vaginal is caused by the mucus secreted by glands near the opening of vagina.

Types of vaginal cancer
There are four main types of primary vaginal cancer.
• Squamous cells carcinoma. This is the most common type of vaginal cancer that normally develops in the upper part of vagina (near cervix). Squamous cell carcinoma of the vagina, usually grows slowly over many years.
• Adenocarcinoma. Adenocarcinoma of the vagina develops from the glandular part of the vagina (mucus producing cells of the vagina). This type include clear cell adenocarcinomas which develop to those whose mothers took the drug diethylstilbestrol (DES) during pregnancy between the late 1940s and 1971.
• Melanomas. This is type of cancer that develop from cells that gives the skin its colour (melanocytes). It is a rare type of vaginal cancer.
• Sarcomas. This is the rare type of vaginal cancer that develop from connective tissues, muscles, lymph vessels, fat tissues and other tissues deep in the wall of the vagina.

Risk factors for vaginal cancer
When it comes to cancer, anything that increases your probability of developing cancer is called a risk factor. Risk factors only influence development of cancer but it does not directly cause cancer. Sometimes people with risk factors do not develop the disease while those with no risk factors do develop the disease. Knowing risk factors will help you live your life making some better healthy choices to reduce the risk. The following factors may increase your risk of developing vaginal cancers.
• Vaginal intraepithelial neoplasia (VAIN). VAIN means that the cells in the lining of the vagina are abnormal and may develop into cancer after many years. It is a precancerous condition that often has no symptoms. However, most women with VAIN do not develop vaginal cancer.
• Diethylstilbestrol (DES). Women whose mothers took this drug during their pregnancy (the drug was used in 1940s to 1971) have an increased risk of developing vaginal cancer (clear cell adenocarcinomas). The drug was used as a medication to prevent miscarriage, premature labor and related pregnant complications.
• Smoking. Women who smoke have an increased chance of developing this type of cancer compared to non-smokers.
• Human papilloma virus (HPV). Human papilloma virus is normally transmitted through sexual activity with someone who has HPV. Studies indicate that HPV infections increase a person`s chance of developing vaginal cancer.
• History of gynecological cancers. Women with the history of gynecological cancers such as cervical and vulva cancers have an increased chance of developing vaginal cancer.
• History of radiation therapy to the pelvis. Those who had radiation therapy of other cases in a pelvic region have an increased risk of developing vaginal cancer. Although this is very rare.

Prevention of vaginal cancer
To prevent something you need first to know what causes it. Since the specific cause of vaginal cancer is still unknown, currently there is no known way of completely preventing development of vaginal cancer but there are some ways that may help reduce the risk of developing it.
• The use of HPV vaccine may reduce development of vaginal cancer as a result of HPV infection.
• Avoid or quit smoking.
• Avoid sexual intercourse with multiple partners or with someone with many partners.
• Not taking diethylstilbestrol (DES). These drugs have been banned due to their side effects that include vaginal cancer.

Early detection and screening
When it comes to cancer, early detection normally provide better treatment outcome. An early detection of vaginal cancer leads to better treatment outcome. Although many cases are not detected until they have reached an advanced stage, sometimes the disease is detected at an early stage due to some symptoms experienced patients that forces them to seek medical attention which result to detection during routine tests. For some cancers, early detection has been greatly contributed by the presence of screening programs. Screening is the process of running some tests to someone with no symptoms or signs of a certain disease with the intention of determining presence or absence of that disease. All women are advised to have annual gynecologic examination. During this exam, the doctor will perform a general physical examination of the pelvis to check for any unusual changes.

Signs and symptoms of vaginal cancer
People with vaginal cancer can experience some of the following signs and symptoms. Sometimes people with vaginal cancer do not show any of those signs and symptoms and it is possible also for those signs and symptoms to be associated with other health conditions, so the only possible way to find the truth is through examinations in hospital. Signs and symptoms of vaginal cancer include the following;
• Bleeding after having sex
• Feeling pain during sexual intercourse
• Feeling pain in the pelvic region
• Bleeding between your periods or after menopause
• Lump in the vagina
• Abnormal vaginal discharge
• Difficulty or pain during urination.

Diagnosis of vaginal cancer
cancer diagnosis
Medical diagnosis simply means identification of nature of an illness by elimination of the symptoms. Normally people don`t go to hospital knowing they have cancer but during diagnostic procedures is when doctors detect the disease. Following suspicion of the disease, doctors normally run combination of tests to determine whether there are cancerous cells in the body or not and if there are cancer cells, how far have they spread. Along with thorough medical history and physical examination, doctors normally use combination of the following tests to diagnose cancer. Laboratory tests. Laboratory tests are important in ruling out other conditions and confirming diagnosis. For cancer diagnosis laboratory tests normally include blood tests, urine tests, tumor markers and other body fluids tests.
• Blood tests. Blood tests help to reveal level of different substances in the blood which will help doctors to know if there is anything wrong in the body. From blood tests doctors can see complete blood count which indicates number, size and maturity of blood cells. Also from the blood tests doctors can analyze if kidney and liver are working properly.
• Urine tests. Urine tests (urinalysis) involve laboratory examination of urine to check presence of blood, proteins, and other substances such as drugs. For instance, blood in the urine may be an indication of benign condition, infection or other health problem.
• Tumor markers. These are biomarkers (proteins) that can be produced by both cancer cells and normal body cells in response to cancer. Tumor markers are released into the blood or urine. Although studies are still conducted to determine role of these markers in diagnosing cancer because sometimes people with benign condition will have elevated level of these proteins. Also not all tumors have their markers and some markers are not specific to one type of tumor.
• Other body fluids. Despite being rarely used, sometimes body fluids can be tested in the lab during diagnosis of cancer. For instance, the use of cerebral spinal fluid (CSF) and pleural fluid. CSF is used in diagnosis of brain tumors while pleural fluid for lung cancer.

Diagnostic imaging
Diagnostic imagings involve tests that create pictures of inside the body that help the doctor to see if there is tumor or not. There are several imaging tests used in cancer diagnosis depending on the type and location of cancer suspected. These imaging tests include;
• Computed tomography (CT) scan. CT scan machine is a donut-shaped scanner that uses x-rays to create series of pictures of body organs from different angles. This machine is linked to a computer where those series of pictures taken will be combined to create a 3D- image of inside the body. During the scanning process patient will lie still on the table which will slide into the scanner. In order to get a clear image, sometimes the doctor will inject the patient with a contrast material before scanning. From the images the doctor will be able to differentiate between healthy and unhealthy tissues.
• Magnetic resonance imaging (MRI). MRI is an imaging technique that uses powerful magnet and radio waves to take series of pictures of body organs and create a 3D image in a computer linked to a machine. Just like in CT, during MRI procedure the patient will lie on a table that will slide into a long round chamber. Also during this procedure, the doctor may inject the patient with a contrast material for clear image view.
• X-ray. This is an imaging technique that is uses low dose of radiation to create pictures of inside your body. Technician will position the patient and direct the x-ray beam to the intended part of the body.
• Ultrasound. Ultrasound is a diagnostic imaging procedure that uses high energy sound waves to produce images of organs inside the body. During the examination, a patient will lie on the table while the technician will slowly move a device called transducer on the skin over the part of the body that is being examined.
• PET scan. Positron emission tomography (PET) scan is an imaging test that uses radioactive glucose to create 3-D images of areas inside the body. Radioactive glucose is used for this test because cancer cells tend to absorb more glucose than normal body cells, so the scan will show which areas of the body has more glucose than others. Before the scan, doctor will inject the patient with tracer called radioactive glucose then during imaging the patient will be asked to lie on the table that will be moving back and forth through the scanner.
• Bone scan. Bone scan is used to examine bones. When it comes to cancer, bone scan is used for diagnosis of bone cancer or cancer that has metastasized into the bones. Before the test, patient will be injected with small amount of radioactive material that tends to collect more on abnormal parts of the bones. Then pictures that will be taken by a scan will indicate the distribution of those radioactive materials in the bones throughout the body.

Biopsy
Biopsy is a diagnostic procedure that involves removing a tissue sample from the body and examines it under microscope in the laboratory. Examination in the laboratory is normally done by a pathologist who will check if the cells in the tissue are cancerous or not. In most cancer cases, biopsy is considered to be the confirmatory test. Depending on the location and type of cancer, biopsy can be obtained in different ways. Some of them include;
• Using needle. By using a thin needle, doctors can draw same tissue or fluid for examination under microscope. This method can be used to draw some fluid (spinal tap), bone marrow (bone marrow aspiration), blood or small amount of tumor from the suspected organ such as liver and breast (fine needle aspiration).
• Surgery. Abnormal tissue samples are obtained while the doctor is performing the surgery. Tissues are then sent to the lab for examination during the surgery. If the surgeon removes just a portion of abnormal area, it is called incisional biopsy while when the entire tumor (abnormal site) is removed it is called excisional biopsy.
• Using endoscope. Endoscope is a thin, lighted tube with a camera (focusing telescope) at the end. It is used for viewing inside the body through natural openings like mouth and anus. During an examination if the doctor sees any abnormal tissue, then endoscope can also be used to take sample for that tissue. There are different kinds of endoscopy exams depending on the site of the body being examined. Some of the exams include colonoscopy (for rectum and colon), bronchoscopy (for trachea, bronchi and lungs) and esophagogastroduodenoscopy EGD (for esophagus, stomach and duodenum)
In addition to physical examination and medical history diagnosis of vaginal cancer normally involves the use of colposcopy, biopsy, CT-scan, MRI scan, X-ray, PET scan and Pap test (pap smear) which involve removing cells from the surface of the vaginal and cervix by using a small brush or swab. Then tissue sample is sent to the laboratory to check for abnormalities. Staging of vaginal cancer
Staging is a standard way used by cancer care team to explain how far the cancer has grown or spread. Staging also enables the oncology team to decide on the suitable treatment option. In this process of staging doctors normally use systems in order to describe the stage of cancer. For vaginal cancer, TNM staging system (tumor, node and metastasis) is preferred to describe stage of the disease.

TNM staging system
TNM system is the combination of three worlds, tumor, node and metastasis.
• Tumor. Tumor explains size (how large is the tumor?) and its location.
• Node. This explain lymph nodes involved
• Metastasis. Metastasis explains how far the cancer has spread

There are five stages of vaginal cancer under this system (0–IV). More discerption on this TNM system is as follows;
Tumor (T)
TX: Primary tumor cannot be evaluated.
T0: There is no evidence of primary tumor.
Tis: Tumor is carcinoma in situ (Tumor found only in 1 layer of cells that has not spread to nearby tissue).
T1: Tumor is only in the vagina.
T2: Tumor has spread through the vaginal wall and surrounding tissue, but has not reached the pelvic wall.
T3: Tumor has spread to the pelvic wall.
T4: Tumor has spread to the bladder, rectum, or other nearby structures
Node (N)
NX: Regional lymph nodes involvement can`t be evaluated.
N0: There is no evidence of regional lymph nodes involvement.
N1: Tumor has spread to the regional lymph nodes.
Metastasis (M)
MX: Metastasis cannot be evaluated.
M0: No evidence of tumor spreading to other parts of the body.
M1: Tumor has spread to another part of the body.

Stages of vaginal cancer
Stage 0 (Tis, N0, M0): Tumor is carcinoma in situ with no evidence of lymph node involvement or distant metastasis.
Stage I (T1, N0, M0): Tumor is only in the vagina and has not spread through the vaginal wall. There is no evidence of lymph node involvement or distant metastasis.
Stage II (T2, N0, M0): Tumor has spread through the vaginal wall and surrounding tissues, but has not reached the pelvic walls. There is no evidence of lymph node involvement or distant metastasis.
Stage III (T1 or T2, N1, M0): Tumor is in the vagina and may have grown into vaginal wall and surrounding tissues but not pelvic wall. There is evidence of reginal lymph node involvement but no distant metastasis.
(T3, N0, M0): Tumor has grown into pelvic wall but there is no evidence of lymph node involvement or distant metastasis.
Stage IVA (T4, any N, M0): Tumor has spread to the bladder, rectum, or other nearby Structures. There may/ may not be evidence of lymph nodes involvement but there is no evidence of distant metastasis.
Stage IVB (Any T, any N, M1): Tumor can be of any size and lymph nodes may or may not be involved but there is evidence of distant metastasis.Treatment of vaginal cancer

Following cancer diagnosis, the doctor will break the news and it is normally not very easy to accept that it is cancer. The doctor will be there to help the patient process the news and to help the patient in taking the next steps. After the patient receives and processes the news that he/she has cancer, one of the most important steps that will follow is decision making. The doctor will present to the patient (relatives/parents/guardians) with all the possible treatment options and explain what they mean. Then with the help of the doctor, the patient (relatives/parents/guardian) will have to choose which treatment option is good depending on benefits of such option. Despite all the information given by the doctor, sometimes the patient may still be unsatisfied with what he/she has been told. In such situation, the patient is free and advised to seek a second opinion. Second opinion is the opinion that the patient may seek from another specialist (doctor) regarding his/her health problem and in this case it is cancer. Second opinion may include confirmation of the diagnosis, more clarification on your primary doctor recommendations or even reassurances that all the options have been explored. In addition to standard care treatment options, sometimes there are those new treatments or drugs or combination of treatments that have not been approved yet to be used as standard care treatments for a particular cancer (disease) but have shown some promising results that they may help. These type of treatments are called clinical trials. If there are some clinical trials for your case, the doctor may present to the patient or the patient may ask if there are any clinical trials for the particular cancer case. Over the years, have improved treatments and led to better outcomes to people diagnosed with various diseases including cancer. If you have decided to take part in clinical trial, you can also withdraw at any time

Treatment options
Treatment of vaginal cancer requires a team of doctors and other health care professionals. This team work together and it is called multidisciplinary team. Team may vary depending on the treatment option for a particular case. Generally multidisciplinary team for treatment of vaginal cancer includes, surgical oncologist, gynecological oncologist, medical oncologist, radiation oncologist, radiologist, pathologist and other health care professionals like oncology nurses, women`s health physiotherapist and palliative care team. Treatment options include the following;
Surgery
Surgery is the treatment option which involve removing the tumor and some surrounding health tissues by an operation. Some pelvic lymph nodes may also be removed. This treatment option is done by surgical oncologist. There are a number of different operations for vaginal cancer depending on the size and position of the cancer. These operations include;
• Partial vaginectomy. This involve removing only the affected part of the vagina. It is done for those cases at an early stage.
• Radical vaginectomy. This is done to advanced cases. Radical vaginectomy involve removing the entire vagina. Often, a reconstructive 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.
• Hysterectomy. This is done to those with advanced cancer that has invaded other reproductive structures such as uterus, ovaries and fallopian tube. Hysterectomy involve removing those affected structures of the reproductive system.

Side effects of surgery
Side effects of vaginal cancer surgery will depend on extent of surgery itself. Some of the possible side effects include the following;
• Pain
• Bleeding
• Risk of infection
• Risk of early menopause if surgery involved removing even ovaries (hysterectomy).
Radiation therapy Radiation therapy is the treatment option that involve using high energy x-rays or other radiation particles to destroy cancer cells. This treatment option is given by a specialized doctor known as radiation oncologist. There are two main ways of delivering radiotherapy, externally (external beam radiation therapy or internally (brachytherapy). Most women with vaginal cancer have both types of radiotherapy.
• External beam radiation therapy. This is a type of radiation therapy whereby radiation dose is given to the tumor from the source (machine) placed outside the body. During treatment, you will lie on the treatment table and radiation beam will be aimed to the tumor.
• Internal radiation therapy (brachytherapy). Brachytherapy is a way of delivering radiotherapy directly to the tumor from inside your body. Brachytherapy may be given following completion of external beam radiation therapy.

Side effects of radiation therapy
Side effects of radiation therapy depends on the dose given and areas treated. Most of the side effects will last for short period of time following completion of treatment. Some of the possible side effects include the following;
• Mild skin reactions
• Fatigue
• Loose bowel movement
• Upset stomach
• Nausea and/or vomiting
• Vaginal dryness
• Vaginal stenosis. If vagina becomes narrow and short it will make it difficult for sexual intercourse. To prevent this, the vagina may need to be stretched with a plastic tube called a vaginal dilator several times a week.
Chemotherapy
Chemotherapy is the use of drugs to destroy cancer cells or slow its growth. Chemotherapy is given by a specialized doctor known as medical oncologist (gynecological oncologist). Chemotherapy may sometimes be given together with radiation therapy (chemoradiation) or in combination with surgery either before or after surgery. Drugs are given orally as pill or through injection into veins (intravenously).

Side effects of chemotherapy
Side effects of chemotherapy depend on the kind of drug used, dose and periodic time by which the drug has been used. Some of the possible side effects of chemotherapy include the following;
• Mouth sores
• Nausea and/or vomiting
• Hair loss
• Loss of appetite
• Risk of infection due to decreased white blood cells
• Feeling tired as a result of low red blood cells
• Easily bruised and bleeding

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