Types of treatment for vulval cancer

The main treatments used for vulval cancer are surgery, radiotherapy and sometimes chemotherapy.

Your specialist may suggest a combination of treatments. So you may need to see a variety of doctors who specialise in different types of treatment. This might include a specialist surgeon called a gynaecologist, a cancer specialist (medical oncologist) and a radiotherapy specialist (clinical oncologist).

The treatment you need depends on the stage of the cancer when it is diagnosed.

If you have VIN, you are most likely to have surgery. Your surgeon will want to remove all the skin affected by VIN. Even if you have more than one area of VIN, this will usually be possible. The surgeon may cut out the affected area and stitch the healthy skin back together. Or the surgeon may use a laser to kill off the abnormal skin cells. You may have a combination of laser surgery and regular surgery.

If the VIN is very widespread, your surgeon may prefer to do an operation called a skinning vulvectomy. This means removing the skin over a large area. You may need a skin flap (or less often a skin graft) to repair the area, but your surgeon will avoid doing this if at all possible. A skin flap is an area of healthy skin with its blood supply, that is moved from close by to cover the area where skin has been removed.

With surgery for VIN, the most important thing is for the surgeon to make sure all the VIN is removed, along with a surrounding border of healthy skin. You may hear this called a healthy margin. As VIN can come back, your surgeon will try to remove a 1cm margin all round the area of VIN.

Stages 1 and 2 are regarded as early stage vulval cancer. You are most likely to have surgery. For stage 1A cancers, your surgeon will try to take away just the affected area, with a 2cm margin of healthy tissue around it. This operation is called a wide local excision. Your surgeon may also remove or biopsy nearby lymph nodes in the groin in case any cancer cells have spread there.

For most tumours of stage 1B or more, you will need to have part of the vulva removed (a partial vulvectomy) or the whole vulva removed (radical vulvectomy) to make sure all of the cancer is taken away. The surgeon aims to remove the cancer and a 2cm margin of healthy tissue around it. You will also have nearby lymph nodes in the groin removed. This is called groin lymphadenectomy or lymph node dissection. You might need nodes on one or both sides of your groin removed – this depends on exactly where the cancer is.

After your surgery, you may need to have radiotherapy to the lymph nodes in your groin if your doctor thinks any of them contain cancer cells. This is to help lower the risk of the cancer coming back later. Your specialist may also suggest radiotherapy if

• The healthy margin of tissue removed along with the cancer was less than 1cm wide
• The cancer was more than 5mm deep

If you are unable to have surgery for any reason, you are most likely to have radical radiotherapy treatment. Radical treatment means an intensive course of radiotherapy to try to cure your cancer. Your specialist may want you to have chemotherapy at the same time. This can help the radiotherapy to work.

Depending on where the cancer is, you may have to have quite a big operation for this stage of vulval cancer. This will include removing all the areas that contain cancer cells. Depending on where the cancer is, this could mean having surgery to remove your vagina, urethra or rectum as well as the vulva and the lymph nodes in the groin. This surgery is called radical vulvectomy with pelvic exenteration.

This type of surgery does have quite a few complications. If your urethra and bladder have to be removed, you would need to have a bag to collect your urine. If your rectum is removed, you will need to have a colostomy.

Your doctor may think it is better to do a smaller operation, even if this means it is not possible to remove a border of cancer free tissue. You may just have your vulva removed (vulvectomy) and then have a course of radiotherapy after surgery to try and kill off any cancer cells that have been left behind.

Doctors are very aware of the impact of major surgery on women with vulval cancer. They will try to do the smallest operation possible while trying to keep the risk of the cancer coming back as low as possible too. If you have a large cancer, your doctors may suggest radiotherapy before surgery, to try to shrink the cancer. If the cancer shrinks, you may then be able to have a smaller operation. This is called neoadjuvant radiotherapy. It is still an experimental treatment.

You may have chemotherapy at the same time as your radiotherapy. This is still under investigation, but doctors know that particular chemotherapy drugs can help radiotherapy to work. You may hear this treatment called concurrent chemoradiation. This just means chemo and radiotherapy at the same time. This type of treatment before surgery is called neoadjuvant concurrent chemoradiation.

If you have stage 3 or 4 vulval cancer, but are unable to have surgery, you may have radiotherapy with or without chemotherapy.

If cancer of the vulva spreads to another body organ, it is most likely to travel to the lungs. Your doctor may offer you chemotherapy to try to control the cancer and relieve any symptoms you may have. Doctors use a variety of drugs or combinations of drugs in this situation. So far, no one drug or combination of drugs has proved better than any other.

If your VIN or cancer comes back in the same area, you may just have more surgery. Your specialist may suggest chemoradiation before the surgery to shrink the cancer and to help lower the risk of it coming back again. There is ongoing research into treatments for VIN, and there is more about this in the vulval cancer research section.