Treatment Option Overview for Vaginal Cancer

Because vaginal cancer is rare, studies are limited to retrospective case series, usually from single-referral institutions.[Level of evidence C2] During the long span of time covered by these case series, available staging tests and radiation techniques often changed, including the shift to high-energy accelerators and conformal and intensity-modulated radiation therapy.[1,2] Comparing treatment approaches is further complicated by the frequent failure of investigators to provide precise staging criteria (particularly for stage I vs. stage II disease) or criteria for the choice of treatment modality. This has led to a broad range of reported disease control and survival rates for any given stage and treatment modality.[3]

The following factors should be considered when planning treatment for vaginal cancer:

Radiation-induced damage to nearby organs may include:[1,2]

Management of the extremely rare vaginal clear cell carcinoma is similar to the management of squamous cell carcinoma. However, techniques that preserve vaginal and ovarian function should be strongly considered during treatment planning, given the young age of the patients at diagnosis.[4]

For patients with early-stage vaginal carcinoma, radiation therapy, surgery, or a combination of these treatments are standard. Data from randomized trials are lacking, and the choice of therapy is generally determined by institutional experience and the factors listed above.[3]

For patients with stages III and IVa disease, radiation therapy is standard and includes external-beam radiation therapy (EBRT), alone or with brachytherapy. Regional lymph nodes are included in the radiation portal. When used alone, EBRT involves a tumor dose of 65 Gy to 70 Gy, using shrinking fields, delivered within 6 to 7 weeks. Intracavitary brachytherapy provides insufficient dose penetration for locally advanced tumors, so interstitial brachytherapy is used if brachytherapy is given.[3,5]

For patients with stage IVb or recurrent disease that cannot be managed with local treatments, current therapy is inadequate. No established anticancer drugs have demonstrated proven clinical benefit, although patients are often treated with regimens used to treat cervical cancer. Concurrent chemotherapy, using fluorouracil or cisplatin-based therapy, and radiation are sometimes advocated, based solely on extrapolation from cervical cancer management strategies.[6-8] Evidence is limited to small case series and the incremental impact on survival and local control is not well defined.[Level of evidence C3]

Local control is a problem with bulky tumors. Some investigators have also used concurrent chemotherapy with agents such as cisplatin, bleomycin, mitomycin, floxuridine, and vincristine without improved outcomes.[1] It is an extrapolation from treatment approaches used in cervical cancer, based on shared etiologic and risk factors.

Because vaginal cancer is rare, these patients are candidates for clinical trials of anticancer drugs and/or radiosensitizers to attempt to improve survival or local control. Discussion of clinical trials should be considered with eligible patients. Information about ongoing clinical trials is available from the NCI website.