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Vulval cancer

Key points about vulval cancer

Vulval cancer describes any skin cancer that develops on the skin near the opening of your vagina.
It's rare in women under the age of 40 years.
You can lower your risk of developing this type of cancer by having the HPV vaccination.
If you notice a persistent lump, ulcer or bleeding from your vulva, see your healthcare provider straight away.

The most common cause of vulval cancer is infection with the Human Papilloma Virus (HPV). HPV is a common sexually transmitted infection that causes most cases of cervical cancer and is responsible for about 70% of vulval cancers.

Practising safe sex by using condoms can help prevent the spread of HPV. However, the best way to prevent HPV infection is to be immunised against it before you become sexually active. A vaccination is available in Aotearoa New Zealand for boys and girls free of charge. Read more about HPV and the HPV vaccination.

Risk factors for vulval cancer:

Age – your chance of developing vulval cancer increases as you get older.
Smoking weakens your immune system and increases the risk of many different cancers including vulval cancer.
Immune deficiency – your immune system is designed to prevent infection and stop cancer from growing. People who have a weak or deficient immune system are more likely to get vulval cancer. Some of the more common causes of immune deficiency are medical treatment with steroids, organ transplantation, or treatment for another type of cancer and HIV.
Lichen sclerosis is an autoimmune disorder (meaning your immune system is attacking healthy cells) that causes irritation, swelling and redness. It can occur in any area of skin but usually on the labia or vulva in women. The condition can usually be well controlled with steroid cream but it does increase your risk of vulval cancer – especially if it's not treated.

Image credit: Wikimedia Commons

Around 90% of vulval cancers are squamous cell carcinomas (SCC), which means the cancer starts from the surface layer of the skin. Melanoma is the next most common type (2-4%). Although melanoma is often caused by sun exposure, it can also develop in areas without sun exposure.

There are other rare types of vulval cancer, including basal cell carcinoma (BCC), adenocarcinoma, Bartholin gland carcinoma and Paget’s disease of the vulva.

The most common symptoms of vulval cancer are irritation, itch, skin changes or a lump.

Symptoms may include:

irritation or itchiness of the vulva
pain or tenderness of the vulva
thickened or discoloured patches of skin (usually red or white or dark)
a lump or an ulcer, which may bleed
burning pain when passing urine
a mole with swelling, changing shape or colour.

These symptoms can also be caused by other problems, eg, lichen sclerosis, recurrent thrush (candida) or herpes infection, but you should still see your healthcare provider to make sure. Even if the problem is not cancer, there are treatments for the other conditions that can improve your quality of life.

See your healthcare provider if you notice a lump that won’t go away, or an ulcer or unusual bleeding (eg, not your period) from your vulva. They will talk to you about your symptoms and will examine the area to decide if further investigations or a referral to a specialist is required.

The main way of diagnosing vulval cancer is by taking a tiny skin biopsy (small sample) of the affected area. This can be done under local anaesthetic (to numb the area and make the biopsy painless). The sample is sent to a laboratory where they will look at the cells under a microscope to see if there are any signs of cancer.

Scanning with computed tomography (CT scan) or multiple-resonance imaging (MRI scan) may also be recommended.

Treatment of vulval cancer will depend on what stage the cancer is. All cancers usually start in one small localised area of the body and then spread. Usually they spread first to the lymph glands nearby and then to parts of the body that are further away. The aim of any cancer treatment is to remove the cancer before it has spread.

Surgery

Most people with vulval cancer will require surgery, with the aim of removing all the abnormal cells.

Local excision: If the cancer is detected early, it's possible that only a small area including the affected skin is removed. The chance of a cure is very good.

Sentinel node biopsy: This is used to find out which lymph node the cancer drains to so that it can be removed to see if the cancer has spread. It involves injecting dye and/or a radioactive substance into the cancer and tracing which lymph nodes these substances go into.

Simple vulvectomy and lymph node dissection: If the cancer is more advanced, then more of the tissue in the vulva may have to be removed (vulvectomy) as well as the local lymph glands (lymph nose dissection or lymphadenectomy).

Radical vulvectomy: This treatment is for very advanced cancer and involves the removal of the skin around the vagina, the clitoris and the deeper tissues of the vulva as well as the lymph nodes in the groin area. It is specialised surgery that significantly affects a woman's ability to have sex. However, bladder and bowel function are generally not affected.

Radiotherapy

Radiation treatment may be recommended after surgery to improve the chance of cure, or decrease the chance of cancer coming back. This type of treatment is often referred to as adjuvant therapy, which means therapy in addition to surgery. Occasionally combined radiotherapy and chemotherapy is given before surgery so that the surgery is more likely to remove all of the tumour.

Chemotherapy

Chemotherapy is also used as an adjuvant therapy and is used more often in advanced cases of cancer. Chemotherapy often causes a number of side effects, eg, hair loss, gastrointestinal problems and a lowering (suppressing) of the immune system.

The emotional impact of living with vulval cancer and life after surgery for vulval cancer can be challenging. There's no easy answer for how to best cope with vulval cancer, but the following may help:

Ask lots of questions and learn as much as you can about vulval cancer and the treatment you require. This will help you to feel more involved in the decision-making process.
Talk to someone about your feelings. When you are ready, find a trusted person to talk to about your hopes and fears. This may be a support worker, counsellor, a close friend or a spiritual or cultural advisor.
Connect with other cancer survivors. Talking to other people who have been through the experience you are going through can be helpful. Ask your treatment team about support groups or online forums you can join.
Be kind to yourself. It's normal to feel anxious or self-conscious about having sex after treatment for vulval cancer. Try to talk to your partner about how you are feeling. You may also find it helpful to see a therapist. Remember there are many ways to be sexually intimate, such as touching, hugging, caressing and holding.