Vaginal Cancer Treatment

Pelvic organ prolapse — or the intrusion of nearby organs into the vaginal canal — is a condition that occurs most often as a side effect of natural childbirth. 

But can pelvic organ prolapse ever be a sign of cancer? We checked in with O. Lenaine Westney, M.D., a reconstructive urologist who occasionally treats this condition. She specializes in managing urinary incontinence and structural genitourinary problems that occur during or after treatment for pelvic cancers. Here’s what she shared with us.

What is a prolapse?

A prolapse is a type of herniation, in which an organ bulges out of an opening that it normally wouldn’t — in this case, the vagina. Hernias are normally associated with the intestines, but prolapse is specific to the vagina. This means it could involve any of the structures that border it, including: 

• the bladder: known as a “cystocele”
• the rectum: known as a “rectocele”
• the small intestine: known as an “enterocele”
• the uterus: also called a “descensus” or “procidentia”

The term “prolapse” itself is very nonspecific, though, because it doesn’t tell you which organ is involved. And that depends on what’s on the other side of the weakened tissues. Still, a prolapse is only possible if you have a vaginal canal — because, by definition, whichever organ is involved will be pushing its way into that cavity. 

What’s the most common cause of pelvic organ prolapse?

It’s not a very common occurrence, but it happens most often in women who have given birth vaginally. It can also be a side effect of a hysterectomy, or the surgical removal of the uterus. 

Once the cervix is removed, the uppermost part of the vagina has to be reconnected to the ligaments and other structures that normally hold it in place. Otherwise, it becomes unstable inside the abdominal cavity and can kind of collapse on itself so that the top part of the vagina protrudes and becomes visible outside the body.

Is pelvic organ prolapse a symptom of cancer?

No. Pelvic organ prolapse is not related to the development of any particular type of cancer. 

However, it can occur because a large mass in the abdomen is creating abdominal pressure, or because a significant amount of fluid has accumulated in the pelvis. It may also occur after surgery for some cancers because it’s related to the removal of other structures.

Whenever a bladder is removed, for instance, some of the supporting tissue that lends thickness and muscularity to the vaginal wall gets removed, too. The same thing happens when surgery is performed on the rectum or cervix. Any time changes are made to the structures that normally support the vagina, they can weaken or destabilize its walls. And that, in turn, can lead to a secondary prolapse.

Can pelvic organ prolapse be treated?

Yes. But how it’s treated depends entirely on the severity of someone’s condition. Pelvic organ prolapse is graded on a scale of 1 to 4, with 1 being very mild and 4 being where the entire vagina is turned inside out.

One of the simplest and least invasive methods of treating mild pelvic organ prolapse is physical therapy. Patients are given various exercises to perform to increase the strength of their pelvic floor. They may also be prescribed stool softeners or other medications to reduce constipation and be given weight-lifting restrictions to reduce abdominal strain or pressure.

Another relatively non-invasive treatment is a pessary, in which a silicone or plastic object is placed in the vagina to keep the prolapse from bulging outside of it. Pessaries come in many shapes, depending on the type of prolapse, but the most common one is shaped like a doughnut.

Surgery is usually recommended for more advanced cases of pelvic organ prolapse. Doctors use a biological mesh to reinforce weakened areas and hold everything in place. They might also perform a sacral colpopexy. That’s where the top of the vaginal canal is connected to the sacrum, or tailbone, and mesh is used as a bridge to stabilize it.

Are there any other factors that make someone more likely to develop pelvic organ prolapse?

Again, it’s not a very common occurrence, but your risk does increase slightly with each additional vaginal delivery. Advanced age is also a risk factor, as ligaments and other support structures naturally weaken over time.

There are some exceptionally rare vascular disorders that can also prevent the development of good connective tissues and lead to prolapse, but those are highly unusual.

When should you see a doctor if you think you might have pelvic organ prolapse?

Call your doctor immediately if you see or feel something unusual protruding from your vagina when you bear down to urinate or defecate. But symptoms are not always so dramatic, so see a doctor, too, if you have difficulty emptying your bladder or having a bowel movement, especially if it doesn’t seem to improve on its own after a week or two.

Request an appointment at MD Anderson online or by calling 1-877-632-6789.

When I was first diagnosed with cervical cancer in March 2012, I got treated near my home in southern Louisiana. It wasn’t because I didn’t want to go to MD Anderson — I actually did. I even asked my gynecologist why she wasn’t sending me there. She said that because what I had wasn’t rare or weird, she felt confident we could handle it locally.

My kids were still really little back then — just 4 and 1. So, even though MD Anderson is just four hours away, sticking closer to home sounded great to me.

But when I had a second cervical cancer recurrence in 2016 — after chemotherapy, radiation, brachytherapy and a hysterectomy — I knew I wanted to be somewhere that focused exclusively on cancer. That’s why I finally went to MD Anderson.

MD Anderson’s cervical cancer expertise gave me confidence

My local gynecologic oncologist was recommending a fairly radical procedure called a total pelvic exenteration, which involves removing the vagina, rectum, anus and bladder. But he only did one or two of those procedures a year. I needed someone with more experience.

At MD Anderson, I met with Dr. Pedro Ramirez. He confirmed my diagnosis and made the same recommendation. That disappointed me a little bit at first. I’d been hoping for a less dramatic option. But then, Dr. Ramirez told me he did five or six total pelvic exenterations a year. That may not sound like a lot, but it’s three times as many — and way more — than my local doctor did. That gave me a lot more confidence.

Dr. Ramirez’s expertise also brought me comfort. I didn’t understand why I needed such an extreme procedure at first. The cervical cancer was so small this time, it didn’t even show up on any scans. The only reason we knew it was there was because every time I had another Pap test, the results came back positive.

Dr. Ramirez explained that the only way to make sure the cancer didn’t return yet again was by removing everything: a total pelvic exenteration. I didn’t like it, but I did understand it. And I wanted to live, so I decided to do it.

My life today, after a total pelvic exenteration

Dr. Ramirez performed my total pelvic exenteration at MD Anderson on March 23, 2016. The healing process took a long time. But I walked every day and continued to stay as physically active as I could.

I’m doing really great now, though I still have to do stretching exercises regularly, to keep my scar tissue from tightening up and hardening. But I’m back at work full-time as a certified public accountant, and I go to the gym four or five times a week. I even do one of the boot camp classes there, though I’ve had to modify a lot of the exercises.

I still have days occasionally when I mope around and feel sorry for myself. Usually those are the days when the seal on one of my bags isn’t perfect, and I show up at the office with a damp shirt and pants. But I’m still here four and half years later, I’m still able to work, and I’m still spending time with my kids and my husband. So, I try to remember that things like that are just small setbacks and not a big deal.

Life keeps getting better, even after a total pelvic exenteration

One really great thing I’ve discovered is that my recovery process is still ongoing. I used to have to carry a pillow around with me all the time, because sitting for long periods wasn’t comfortable. Then, about a year and a half ago, I had outpatient surgery to deal with some of my scar tissue, and I could finally give it up. It felt so great to hit another level of healing!

I still face challenges, and I do have setbacks every once in a while. But in most respects, my life has not really changed much at all. So, I feel very blessed.

Request an appointment at MD Anderson online or call 1-877-632-6789.

Like many women diagnosed with cervical cancer, Linda Ryan didn’t initially have any symptoms. So, she didn’t know she had the disease until a routine Pap test came back abnormal after a well-woman exam in 2004.

Unlike many women, though, Linda has also had six separate recurrences. And, no two back-to-back cervical cancer recurrences were caught in precisely the same way. 

With the first and third, Linda noticed swollen lymph nodes in her neck and/or groin. Another caused pelvic discomfort. Two more showed up on regular scans. And the latest caused alternating constipation and diarrhea because cancer had formed a tumor in her rectum.

“Having trouble going to the bathroom is such an unpleasant thing to talk about,” Linda notes. “But that was the truth of my experience. I’ve never had the bleeding that some people describe.”

Abnormal bleeding and other symptoms of cervical cancer

Cervical cancer in its earliest stages may not have any symptoms. But when women do have symptoms, abnormal vaginal bleeding is among the most common. 

That could mean anything from a faint tinge of pink in otherwise clear vaginal discharge to extremely heavy menstrual periods. It could also mean bleeding after sex, bleeding between periods, or even spontaneous vaginal bleeding after menopause. 

“I started having this watery discharge between my periods, and then really, really heavy menstrual cycles,” remembers Shalee Landry, who was 37 when she was diagnosed with cervical cancer in 2012. “I’d never had heavy periods like that before. I thought it was caused by stress.”

Other, less common symptoms of cervical cancer include:

• pelvic pain
• feeling bloated or full
• pain that radiates to the legs or back.

“It’s not unusual to experience irregularities in your cycle just before menopause,” notes Jolyn Sharpe Taylor, M.D., a surgeon specializing in gynecologic cancers. “And it’s important to talk to your doctor about those issues. But if you experience heavier than usual bleeding, bleeding in between your periods, bleeding after sex or bleeding after menopause, don't wait to contact your doctor.”

HPV increases the chances of a cervical cancer diagnosis

When watching for cervical cancer signs, your HPV status is another factor. The human papillomavirus (HPV) causes several types of cancer in both men and women — including cervical cancer.

A second positive HPV test is how Sylvia Zaro found out she had cervical cancer in 2016, at age 46. 

“I’d been having Pap tests and HPV tests done regularly for more than 20 years,” she explains. “I never had an abnormal result until 2015. So, I was surprised.”

Fortunately, none of the strains that can cause cancer were detected in Sylvia’s 2015 tissue sample. So, her doctor recommended waiting a year and then getting retested. 

In 2016, Sylvia tested positive for HPV again. But this time, it showed evidence of the strains that could cause cancer. Sylvia’s doctor performed a colposcopy to see if she’d already developed it. “To my surprise, those results came back positive, too,” Sylvia says.

That’s why it’s so important to stay current on your follow-ups if you have a positive HPV test or abnormal Pap test of any kind.

Get vaccinated against HPV, if eligible

Everyone ages 9-26 should get the HPV vaccine. In addition to preventing most cervical cancers, the vaccine prevents most anal, penile, vaginal and vulvar cancers, plus HPV-related throat cancers. 

If you are ages 27-45 and are unvaccinated, talk with your doctor about the possible benefits of getting the HPV vaccine. The vaccine is proven to be safe and effective at preventing infection from nine strains of HPV that are linked to cancer and genital warts. 

“The majority of cervical cancer cases are associated with HPV,” says Taylor. “So, prevention is the best way of avoiding HPV-related cervical cancer and its pre-cancerous relative, cervical dysplasia. Vaccinating boys and girls ages 11-12 is ideal, though as early as age 9 is reasonable, and even receiving the vaccine later can still protect young men and women from strains they might not have been exposed to yet.”

Request an appointment at MD Anderson online or by calling 1-877-632-6789.

In March 2019, Shelly Busby began experiencing unusual vaginal bleeding. Frightened and concerned, she went to her OB/GYN for an examination and biopsy.

“There was something there that didn’t belong,” says Shelly, 67, a retired schoolteacher. “There was a tumor, and before I knew it, I was having surgery to have it removed.”

She was diagnosed with stage III vaginal cancer, for which there is currently no approved therapy. After undergoing chemotherapy and radiation therapy, Shelly thought she was cancer-free for about a month. Her scans and tests looked promising at first, but she wasn’t out of the woods: the cancer had begun to metastasize to her retroperitoneum and her abdominal lymph nodes.

Shelly booked a flight from her home in Colorado to Texas to meet with gynecologic oncologist Karen Lu, M.D., at MD Anderson, who wanted to start her on another chemotherapy regimen in hopes that it would keep the cancer at bay. However, the drug wasn’t covered by Medicare so they had to come up with a plan B.

“Dr. Lu said, ‘I have somebody I want you to meet.’ That person was Dr. Yap,” Shelly recalls.

Genomic sequencing targets the Achilles’ heel of cancer cells

Lu ordered a molecular test and liquid biopsy in March 2020 to check if Shelly had any genetic mutations that might be driving her cancer. The results revealed that she had a DNA damage response mutation, also called DDR.

Thanks to advanced genomic sequencing of cancer, researchers have been able to identify tumor-specific genetic alterations and biological changes that drive cancer growth. This allows them to recognize and exploit weak links in cancer DNA to target tumors selectively. Timothy Yap, M.D., associate professor of Investigational Cancer Therapeutics and medical director of MD Anderson’s Institute for Applied Cancer Science, is doing this is by targeting cancer cells’ ability to repair its DNA, a process called DNA damage response.

Because cancer cells replicate uncontrollably and more rapidly, their DNA is more prone to damage than normal cells. Like an addiction, cancers with certain mutations become heavily dependent on these repair pathways to activate the DDR mechanism. Without it, the cancer cells would fall apart and die.

PARP is one of the repair proteins that initiates the DNA damage response process. PARP inhibitors, such as olaparib and niraparib, are a class of DDR inhibitor drugs that have already been approved by the Food and Drug Administration to treat certain types of BRCA-mutated cancers, including advanced ovarian, breast, prostate and pancreatic cancers.

However, targeting BRCA mutated tumors with PARP inhibitors are just the tip of the iceberg, Yap says. Researchers are discovering new targets and developing potent and effective therapies against these key cancer vulnerabilities. The ATR repair protein is one of the other major DNA repair pathways that has emerged as a promising target to develop drugs against.

This is the Achilles’ heel Yap is targeting.

He and his team have identified 10 to 15 mutations so far that will potentially respond to ATR inhibitors irrespective of the tumor type, and with minimal effects on normal healthy cells.

“This is precision medicine at its finest. We are going beyond tumor types and are focused on targeting different mutations with potent and selective drugs,” Yap says. “For example, we don't want to treat breast cancer all the same way. What we're trying to do is to find out what that underlying mutation is through a tumor biopsy or a liquid biopsy blood test, then match them with rational treatments.”

Vaginal treatment success for Shelly

Yap’s team identified that Shelly had a DDR mutation. That made her an ideal candidate for his clinical trial. Yap started her on an ATR inhibitor combined with immunotherapy in October 2020.

By that point, Shelly had already completed standard of care chemotherapies and participated in two other clinical trials to no avail. But she was determined to try again. Her trust in her doctors and gratitude for her care team never wavered.

“Dr. Yap has made such a positive difference in my life,” Shelly says. “I am living my life and doing my part to stay healthy while Dr. Yap is treating me”

In January 2021, a CT scan showed a 76% reduction in Shelly’s cancer lesions from her previous scans before starting the ATR inhibitor clinical trial therapy.

When Yap called Shelly to tell her the good news, she cried tears of joy.

“She had never received any good news from any of the scans she’d had,” Yap says. “She always progressed, but this was the first treatment that shrunk her cancer.”

A recent restaging CT scan showed the Shelly continued to do extremely well, with an 83% reduction of her cancer legions on the ART inhibitor clinical trial treatment, which she continues to tolerate very well with no side effects.

Clinical trials explore a growing list of mutations to target

Yap currently leads multiple clinical trials of drugs targeting DDR mutations, such as BRCA1, BRCA2, PALB2, ATM, RAD51C and RAD51D mutations. He is continuing to gather more data, and his list of mutations that he predicts may be responsive to such ATR and other DNA damage response mechanism inhibitors continues to be refined.

As this area of precision medicine becomes increasingly personalized, Yap encourages patients to ask their physicians for molecular testing of their tumor biopsies, as well as liquid biopsy of blood for circulating tumor DNA sequencing. This can help determine if patients may be a match for an approved drug or clinical trial therapy.

“If they have any of these mutations on the list, we want to know so that we can provide them with a rational option that makes sense and increases the chance of treatment success,” Yap says.

Shelly, an eternal optimist, is grateful she decided to participate in Yap’s clinical trial and hopes more patients will consider enrolling in one.

“You'll never know unless you take a chance,” Shelly says.

Request an appointment at MD Anderson online or by calling 1-877-632-6789.