MD Anderson Cancer Center
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Lisa Garvin: Welcome to Cancer Newsline, a weekly podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. We have two guests in our studio today Dr. Anuja Jhingran. She is a professor of Radiation Oncology at MD Anderson, and Dr. Charles Levenback, also a professor of Gynecologic Oncology in Reproductive Medicine. Our subject today is vaginal cancer. Dr. Levenback, pretty rare cancer.
Dr. Charles Levenback: Yes, very rare. A few thousand patients here in the country have--have this diagnosis and we see very few.
Lisa Garvin: Yeah, I think I saw from the American Cancer Society about 2000 a year. What is the typical age range of people with vaginal cancer?
Dr. Anuja Jhingran: So vaginal cancer is--the primary cause of vaginal cancer is HPV, and it is usually [inaudible]. So you're gonna see 'em in the 40s and 50s. It's probably the most common age range for vaginal cancer, but you can have patients coming in even in the 70s to have vaginal cancer.
Lisa Garvin: And when we're talking about the vagina, we're talking about what people may refer to as the birth canal, everything that's inside that leads from the uterus to the outside, correct?
Dr. Charles Levenback: Correct.
Lisa Garvin: And that's what about, a 4-inch--how long is it?
Dr. Charles Levenback: And, well, it's like a lot of things, a very wide anatomic range. So in young--younger sexually active women will be longer than that, but an elderly not sexually active patient population maybe with previous surgery will be much shorter.
Lisa Garvin: Where do you see most of the tumors? So do they--are they in a particular area of the vagina?
Dr. Anuja Jhingran: No, it varies. It can be at the top of the vagina. It can be any of the side walls. It can be distal. I have a--I had a 40-year-old patient to had it, I--one and a half cm lesion in the right lateral wall distal. And she had it for a year and a half and I treated her and she's--it's--and you know, it's a very curable cancer if it's caught early enough.
Lisa Garvin: But of course it's hidden from view, how--
Dr. Anuja Jhingran: So this is actually--the most common cancer that can be not seen because what happens is position--put a speculum in and if the lesion is anteriorly or posteriorly, the speculum will hide it. The only way that you can really find a vaginal cancer is by finger exam, and a good finger exam will help you identify any lesion in the vagina, and you really need to do that. The other thing we tell our residents and our fellows is as you're taking the speculum out in the vaginal vault, you rotate it and make sure you see every wall of the vagina.
Lisa Garvin: What sort of symptoms may women experience?
Dr. Charles Levenback: Yeah, I would say one of the most common symptoms with be post-coital spotting, so bleeding after intercourse, could be spontaneous bleeding. And pain is actually the symptom that occurs when a tumor is more advanced. So, early in the--in the disease cycle, I would say bleeding is a more prominent symptom. Foul smelling discharge is another one.
Lisa Garvin: What is the typical treatment? I guess it obviously--it always depends on the stage but is it a typically a surgical approach?
Dr. Charles Levenback: Well, there are some--some patients with very small early and superficial vaginal cancers are--it's amenable to surgery. And especially in a pre-menopausal patient, that would be our preference. However, the vast majority of patients we see, the tumor has advanced beyond that and radiotherapy is usually the treatment of choice.
Dr. Anuja Jhingran: But it also depends on the location too. If it's up in the top of the vagina, the apex of the vagina, then surgery may be an option because you don't--you can take out some of that and still live a good length of the vagina so the patient can be sexually active. So like if it's distal, you would have to take out quite a bit of the vagina to get a good margin and then it would interfere with her sexual activity or any other normal function that she may have. So it depends quite a lot on where that lesion is, whether you're gonna do surgery or radiation. Like this patient I just talked--we're talking about, she had a one and a half cm lesion, so it's a small lesion. But because it was distally, she was not a surgical candidate, so then we treated her with radiation. Majority of patients are really treated with surgery and radiation or radiation by itself.
Lisa Garvin: Because I guess you're trying to conserve the vaginal vault as much as possible.
Dr. Anuja Jhingran: Correct, 'cause there are younger patients. They're still sexually active and we like to try to preserve as much of their normal function as possible.
Lisa Garvin: So--and because a lot of these are kept--caught in the advanced stages of it, it--what's the typical survival rate for a vaginal cancer patient. I mean is it--is it less than say vulvar cancer or cervical cancer?
Dr. Anuja Jhingran: So, vaginal cancers are actually very curable because there're two types of radiation therapy that are needed to treat this. And because we use two different types of treatments, we can go to a much higher dose, so we can actually cure very large vaginal cancers. It's a combination of radiation from the outside, as well as some radiation from the inside.
Lisa Garvin: The brachytherapy.
Dr. Anuja Jhingran: With the brachytherapy. And there're two different types of brachytherapy too, so there's, you know, we could put needles in that can--will just treat the lesion without treating the normal tissue, so we can take that area to 90 gray. And so we can cure a very large vaginal lesion without causing a lot of toxicity. So, I would say for stage I and II, our cure rates, and we've looked at them, are over 80 percent. For stage III, it goes down to 70. Now that's for squamous cell. If it's an adenocarcinoma of the vagina, those are different. And those patients don't do as well because they do have a higher risk of distant metastasis and we have less local control rate. But for squamous cell, even at stage III we have over 70 percent cure rate.
Dr. Charles Levenback: You mentioned the ovarian cervix cancer. So this--the majority of patients with--at all three disease sites, cervix, vaginal and vulva are squamous carcinomas and the majority of those are related to the sexually transmitted virus human papilloma virus. And they well are generally radiation sensitive. So our--in our effort to preserve sexual function and body image in the case of vulvar cancer, you know, limited surgical approach is always a good option. However, for a lot of patients radiotherapy is really--is, is required. Unfortunately, this--particular tumor in most circumstances is radiosensitive and relatively limited regionally and therefore highly curable.
Lisa Garvin: What about fertility? I'm assuming that fertility would be impacted?
Dr. Anuja Jhingran: It is. In the old days when we saw--when--and we [inaudible]--actually when DES was still used and women that were exposed to DES, we would see clear cell of the vagina. Those patients didn't tend to go to the nodes so, a lot of those patients were actually treated with just interstitial brachytherapy alone and their fertility was preserved because [inaudible]. But nowadays we don't see those patients anymore, most of them still have a risk of having nodal metastasis, so we do effect. There are ways and we do affect their fertility.
Dr. Charles Levenback: A very common scenario in patients with vaginal cancer, they--that they've had a hysterectomy maybe years ago. And for example a woman has what we know now to be an HPV infection of the cervix and they have a premalignant abnormality cross [inaudible] of the cervix and have a hysterectomy. And now years later, sometimes they develop a vaginal cancer.
Dr. Anuja Jhingran: So, it is important to get Pap smears if you've had a hysterectomy for pre-cancerous reasons to make sure that you get regular Pap smears.
Lisa Garvin: And let's talk about that because there's been so much back and forth about if you have a hysterectomy, do you need a Pap, do you not? What's the current line?
Dr. Charles Levenback: Right, so there--this has been a bit of a moving target and as a general concept and as a--as a society, we probably have been doing too many Pap smears. And there's a lot of extra expense associated with that and a lot of extra worry associated with that. And there's been a recognition that there are certain patients in very low risk groups have probably--or have very, very low risk of having been infected with HPV or getting HPV in the future and the requirement for them to get Pap smears every year was probably too much. One group are patients who've had a hysterectomy where--and if their--their hysterectomy was for fibroids let's say and they never had an abnormal Pap smear and no history of HPV infection, the current guidelines would allow--that basically don't need Pap smears anymore. Now OB/GYN's would--would still advocate for a woman in that situation to get a Pap smear every--excuse me, a physical exam and a pelvic exam every year. And remember that OB/GYN's are frequently the primary care physician for women in this kind of transition between kind of reproductive years where maybe they're having babies and kind of a post menopausal older patient population where other medical problems like high blood pressure, diabetes, start to arise and in turn has become--are more likely to become the primary care physician. So OB/GYN's would still advocate to see a patient every year and do a pelvic exam every year and, you know, kind of keep reassessing the patient for what their risk factors might be. So if you had your hysterectomy 5 years ago and now something about your life circumstances has changed and your risk of HPV infection has changed even if you had--and had a Pap smear in 5 years, maybe now you should be getting a Pap smear.
Lisa Garvin: And a lot of people carry HPV and don't even realize it. Is that correct?
Dr. Charles Levenback: Correct.
Dr. Anuja Jhingran: Correct. But now the Pap smears are all detect--are looking for HPV. So the Pap smears will detect if you're HPV positive or not.
Lisa Garvin: Let's talk about the HPV vaccine that's been very successful in preventing the types of HPV that give rise to cervical cancer. Would those same benefits be conferred to women with vaginal cancer?
Dr. Anuja Jhingran: Correct. And also vulvar cancer as well as anal cancers, as well as some oral, head and neck cancers that are HPV correlated. In fact that is why one of the reasons boys are being recommended to have the HPV vaccine, one, they are the ones who give it to the girls. But the other thing is they will help prevent head and neck cancers for some of these boys.
Lisa Garvin: So, if a woman was considering getting an HPV vaccine for her daughter, would that be a good idea?
Dr. Anuja Jhingran: Definitely. And in fact, my daughter and my son both are HPV vaccinated. So my 14-year-old boy got his first dose and he will finish it and he didn't even ask 'cause he knew his mom was gonna make him do it. But I highly recommend it but we don't know how long it last. So we know for sure as probably going to the 30s but you probably need a booster after that but we don't know all the full data on that.
Dr. Charles Levenback: This--this topic of vaccinating children for a sexually transmitted disease have realized it's gotten a lot of--
Lisa Garvin: Very sensitive.
Dr. Charles Levenback: Attention in the press and very sensitive issue and I'm sure there are many opinions, you know, on--on all sides of the spectrum. But all I can say is that from what I observed that in among obstetrician/gynecologists, and I guess radiation oncologists, exactly what you heard from Dr. Jhingran which is that they got their own family--their own children vaccinated because the--the cost of a malignancy from one of these--one of these HPV infections is so high, so devastating and it's something that we see so often. And it's so rare for there to be a preventive strategy for a cancer. I mean the cervix, these cancers we are talking about, the idea that they might be sexually transmitted in that the consequences occur many, many years later in life. I mean the idea that you could prevent that is really revolutionary. And--so I--I understand the controversy but all I can say is that health care professionals involved with treating these cancers really embraced if for the--themselves and their families.
Lisa Garvin: So in closing, let's get kind of a--a wrap up message from both of you. Dr. Jhingran, what would you say to women about vaginal cancer?
Dr. Anuja Jhingran: So, vaginal cancer is a rare cancer but it's highly curable but it's so important to come to somebody who knows how to treat it. We see so many cases that are not treated correctly on the outside because it's such a rare tumor and they don't know how to treat it. So if you are diagnosed with vaginal cancer, I really suggest you get at least a second opinion, if not treatment, in this area where they see lots of vaginal cancers, like a big cancer center. Same with vulvar cancer, I think those two--any rare cancer you have, you really should go to a more specialized area.
Lisa Garvin: Dr. Levenback?
Dr. Charles Levenback: And I would extend that to cervix cancer because it's become, thankfully to the Pap smear screening and hopefully with the HPV vaccine, cervix cancer is becoming less rare and being treated in the high volume setting. I think it's a huge benefit to the patient. And the other thought I would just like to leave with is that, you know, just a--the importance of ongoing gynecologic care for all women. And it's really through all state phases of life and the life cycle. OB/GYN's want to be the primary care physician for patients that's very strongly held, that belief that doing an annual Pap--an annual physical exam, pelvic exam can detect a lot of pathology at an early state when it's easy to treat and is highly curable. And for these diseases that we disgressed--discussed most of the mortality and a lot of the morbidity to rise from patients who there's a delay in either detection or treatment.
Lisa Garvin: Alrightie, great. Thank you both. If you have questions about anything you've heard today on Cancer Newsline, contact askMDAnderson at 1-877-MDA-6789 or online at www.mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in next week for the next podcast in our series.
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