About Cancer of the Vulva
Vulval cancer grows on the outer surface of the female genitalia. The vulva is the area of skin that surrounds the urethra (the tube out of which GP), the vagina, clitoris and labia.
There is of course Cervical screening for early detection of cancer of the cervix now that began in the mid-1960s and was introduced as a National screening programme in 1988 for women aged 25 – 65. Unfortunately, there is no similar program in relation to vulval cancer presently.
Early detection of lesions on the vulva that might lead to cancerous changes is very important because early treatment of cancer of the vulva can lead to a full recovery and excellent the future outlook.
Monitoring in women who carry risks of developing cancerous lesions in the vulva is important and with the proper attention by primary carers (such as GPs) appropriate referrals can be made to hospitals for monitoring under the care of gynaecology or dermatology if it is as suspected that a female patient is at risk.
Risk factors for developing vulval cancer
Patients are at increased risk of developing cancer of the vulva in respect of the following:
- Getting older. It can occur at any age but the average age of diagnosis is 65.
- Carrying HPV (human papilloma virus). This is sexually transmitted infection that increases the risk of several cancers, not just vulval cancer, also cervical cancer. It is common for young, sexually active people to be exposed to this virus. Mostly the infection resolves but in some cases it can lead to cell changes, increasing the risk of developing cancer in the future.
- Smoking – it is known that this increases the risk of vulval cancer.
- Having a weakened immune system. This applies if you take medications to suppress your immune system, commonly for organ transplant patients. Also, there are other medical conditions that we can the immune system, such as HIV.
- Having a history of precancerous conditions of the vulva. Most cases of vulva intraepithelial neoplasia will never develop into cancer but a small number do. Therefore, you might need treatment to remove the area of abnormal cells and check-ups at regular intervals in the future.
- Having a skin condition involving the vulva. Lichen sclerosus causes the vulva skin to become thin and itchy and increases the risk of vulval cancer.
What is Lichen sclerosis?
Lichen sclerosus is a relatively common dermatological problem affecting the vulva . It mostly affects women after menopause. It leads to itching and soreness, which can be made worse if urine comes into contact with the sore areas. Of course there can also be other causes of itching and soreness in the vulva, such as thrush and intertrigo (a type of dermatitis, an inflammatory condition aggravated by heat, moisture, friction etc). However, these other conditions classically respond to treatment with antibiotic or antifungal creams.
Women who develop lichen sclerosus are at risk of developing vulval cancer but statistically the risk is low at 2 – 4%. However, clearly if you experience regular itching and soreness in the vulva it’s important to set any embarrassment aside and let your GP know whenever these episodes are occurring. Many women experience dryness, and consequently itching, purely as a side-effect of menopause, but in other cases, it is important that lichen sclerosis is identified in its early stages.
Lichen sclerosus can be treated with topical steroids. At times, women will need quite strong steroids to control their symptoms. Most GPs are not familiar with the presentation and management of lichen sclerosus and will refer women with a suspicion of this problem to gynaecologists or a dermatologist for management. Dermovate is commonly prescribed. It is applied every night for a month, then reduced to alternative nights for a subsequent month and then the steroid is used once or twice a week as a maintenance dose.
Steroid treatment will alleviate 70 – 80% of the symptoms that women with lichen sclerosus complain. Control of the symptoms commonly occurs 4 – 6 months after starting the treatment. Once control has been achieved, the patient will then be referred back to their own GP. The GP is advised to continue with the Dermovate prescription.
Does steroid treatment of lichen sclerosis prevent vulval cancer?
There is no evidence that steroid treatment will actually prevent 2 – 4% of patients with lichen sclerosus from developing cancer. However, the really important point is that patients with risk factors don’t ignore the symptoms and their symptoms are monitored. This does require good communication between patient and GP. A GP should arrange for follow-up of the patient, or clearly advise the patient if their symptoms do not clear up with the prescribed treatment, that the patient should return to the surgery. The patient needs to be motivated to go back to the GP to report ongoing symptoms.
If symptoms of itching and soreness return, or the Dermovate ceases to be as effective as it was previously, and if patients develop any lumps, ulcers or bleeding from the vulval skin then these may be symptoms of a vulval cancer. If a patient is under GP and/or hospital care for follow-up and monitoring, and the patient is educated in the symptoms about which they should be aware, then this should lead to an early referral back to a specialist vulval service.
The aim of early referral to diagnose the vulval cancer at a smaller size is to provide more treatment options for the patient. In addition, if the tumour is smaller in volume, the risk of it spreading to surrounding lymph nodes (where it can then get to other parts of the body) is reduced.
If a postmenopausal woman presents with vulval irritation or soreness does not respond completely to antifungal or antibiotic treatment then examination of the vulva is required. It may be substandard care for a GP not to examine a lady. These days, chaperoning is arranged in the GP surgery to safeguard patients during such examinations. If any abnormality is found, onward referral to a specialist would be the usual reasonable standard of care.
In other cases, if a lady really does not wish to be examined by a GP, perhaps because only a male GP is available, then other arrangements have to be made for follow-up and consideration should be given to referring the lady to a female GP at the same GP practice, or to a gynaecologist or dermatologist at a local hospital to enable an examination.
How is a vulval cancer diagnosed?
Once a suspicion of the vulval cancer, it will be necessary to take a biopsy from the suspicious area. An actual lesion has to be present on the vulva for a clinician to become suspicious that cancer is present and perform a biopsy. There may be an area of soreness with bleeding, there may simply be an ulcer, there may be a lump.
How is vulval cancer treated?
It is necessary to have surgery to remove the cancer in the vulva. This can be followed by radiotherapy to the groin. In addition, chemotherapy is available to treat vulval cancer. Caught in the early stages, this will usually cure the cancer. However, regular follow-up is needed after this because there is a chance of the cancer coming back. Statistically, there is up to a 1 in 3 chance of the cancer re-occurring in the future.
The extent of the surgery depends upon when the cancer is caught.
- Radical wide local excision – the cancerous tissue is removed, as well as usually at least 1 cm of healthy tissue around the cancerous tissue, as a precaution. It is usually possible to stitch the skin of the vulva neatly back together.
- Radical partial vulvectomy – this is a larger removal of tissue, usually one or both of the labia and clitoris. Reconstruction may be carried out at the same time, if necessary, where a piece of skin is taken from your thigh or tummy and moved to the wound in your vulva.
- Radical vulvectomy – the whole vulva is removed, inner and outer labia and possibly the clitoris. Again, necessary reconstructive surgery is done at the same time.
- Removal of groin lymph nodes – an additional surgery may be required to assess whether there has been spread into any of the lymph nodes in your groin.
- Pelvic extenteration – this is only required in advance vulval cancer or it may also be recommended where cancer has come back. This involves removing the entire vulva, bladder, womb and part of the bowel. This is a major operation and isn’t one that is carried out very often.
This is high-energy radiation that destroys cancer cells. This is sometimes done before surgery to try and shrink a large cancer, to make surgery easier and less extensive. It may also be carried out after surgery, to destroy any cancer cells that may be left, for example, if there has been spread to the lymph nodes in the groin. It can be a replacement the surgery, if a patient isn’t well enough for surgery. It can also relieve symptoms where a complete cure is just not possible.
Usually, you have to have daily sessions, 5 days a week but the sessions only last a few minutes and the whole course of treatment is over a few weeks. They can be side effects radiotherapy because as well as killing cancer cells it can also damage healthy tissues. Patients are advised about all of the side effects when consenting to the treatment.
Chemotherapy is given through injection and kills cancer cells. Often this will be given in vulval cancer if cancer has come back or to control symptoms of the cure is just not possible, and it may be combined with radiotherapy. Again, there are side effects about which patients are advised when consenting to the treatment.