Treating vulval cancer

Treatment for vulval cancer depends on factors such as how far the cancer has spread, your general health, andpersonal wishes.

The mainoptions are surgery, Radiotherapy and chemotherapy . Many women with vulval cancer have a combination of these treatments.

If your cancer is at an early stage, it's often possible to get rid of it completely.However, this may not be possible if the cancer has spread.

Even after successful treatment, there is up to a one in three chance of the cancer returning at some point later on, so you'll need regular follow-up appointments to check for this.

Your treatment plan

Most hospitals use multidisciplinary teams (MDTs) to treat vulval cancer. MDTs are teams of specialists that work together to make decisions about the best way to proceed with your treatment.

Members of your MDT will probably include a specialist surgeon, a specialist in the non-surgical treatment of cancer (clinical oncologist) and a specialist cancer nurse.

Deciding which treatment is best for you can often be confusing. Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions you would like to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.

Surgery to remove vulval cancer

In most cases, your treatment plan will involve some form of surgery. The type of surgery will depend on the stage of the cancer.

There are three surgical options to treat vulval cancer:

• radical wide local excision the cancerous tissue from your vulva is removed, as a well as a margin of healthy tissue, usually at least1cm wide, as a precaution
• radical partial vulvectomy a larger sectionofyour vulva is removed, such asone or both of the labia and the clitoris
• radical vulvectomy thewhole vulva is removed, including the inner and outer labia, and possibly the clitoris

The time it will take you to recover from surgery will depend on the type of surgery and how extensive it was. For extensive operations, such as a pelvic exenteration, it may be many weeks or monthsbefore you start tofeel better.

You surgeon will talk to you about the possible risks associated with the type of procedure you're having. Possible risks include infection, bleeding, blood clots , altered sensation in your vulva, and problems having sex.

Assessing and removing groin lymph nodes

An additional operation may also be required to assess whether the cancerous cells have spread into one or more lymph nodes in your groin, and remove these if they're found to contain cancer. This may involve one or more of the procedures outlined below.

Sentinel node biopsy

If the cancer has spread to nearby lymph nodes, it's sometimes possible to only remove certain lymph nodes, known assentinel nodes.

Sentinelnodes are identified by injecting a dye at the site of the tumour and studyingits flowto locate the nodes closest to the tumour. These are then removed and checked for cancerous cells.

Groin lymphadenectomy

In some cases, some or all of the nodes in your groinmay need to be surgically removed. This is called a groin oringuinofemoral lymphadenectomy. Further treatment with radiotherapy may also berecommended.

Removing cancerous lymph nodesreduces the risk of the cancer returning, but it can make you more vulnerable to infection and cause swelling in your legs from a build-up of lymphatic fluid (lymphoedema) .

Pelvic exenteration

In cases of advanced vulval cancer or where the cancer returns after previous treatment, an operation called a pelvic exenteration may be recommended. This involves removing your entire vulva as well as your bladder, womb and part of your bowel. This is a major operation and isn't carried out very often these days.

If a section of your bowel is removed, it will be necessary for your surgeon to divert your bowel throughan opening made in your tummy (a stoma). Stools then pass along this piece of bowel and into a bag you wear over the stoma. This is known asa colostomy .

If your bladder is removed, urine can be passed out of your body into a pouch via a stoma. This isknown as a urostomy. Alternatively,it may be possible to create a new bladder by removing a section of your bowel and using it to create a pouch to store urine in.

Reconstructive surgery

If only a small amount of tissue has been removed during surgery, the skin of the vulvacan often be neatly stitched together.

Otherwise, it may be necessary to reconstruct the vulva using askin graft,where a piece of skin is taken from your thigh ortummy and moved tothe wound in yourvulva. Another option is to have askin flap, whereanarea of skin near the vulva is used to create a flap andcover the wound.

These reconstructive procedures are usually carried out at the same time as the operation to remove the cancer.

Radiotherapy

Radiotherapy involves using high-energy radiation to destroy cancerous cells. There are several ways itcan be used to treat vulval cancer:

• before surgery totrytoshrink a large cancer this is tohelp make the operation possible without removing nearby organs
• after surgeryto destroy any cancerous cells that may be left for example, for cases where cancer cellshave spread to the lymph nodes in the groin
• as an alternative to surgery, if you're not well enough to have an operation
• to relieve symptoms in cases where a complete cure is not possible this is known as palliative radiotherapy

In most cases, you'll have external radiotherapy, where a machine directs beams of radiationon to the section of the body that contains the cancer.

Thisis normally given in daily sessions, five days a week, with each session lasting a few minutes.The whole course of treatment will usually last a few weeks.

Side effects

While radiation is effective in killing cancerous cells, it can also damage healthy tissues. This canlead to a number of side effects, such as:

• sore skin around the vulva area
• diarrhoea
• feeling tired all the time
• loss of pubic hair, which may be permanent
• swelling of the vulva
• narrowing of your vagina, which can make sex difficult
• inflammation of your bladder (cystitis)

In younger women, external radiotherapy can sometimes trigger an early menopause .This means theywill no longer be able to have any children.

It's usually given by injection.

It's usually used if vulval cancer comes back or to control symptoms when a cure is not possible. Sometimes it may be combined with radiotherapy.

Side effects

The medicines used in chemotherapy can sometimes damage healthy tissue, as well as the cancerous tissue. Side effects are common and include:

• tiredness
• feeling and beingsick
• hair thinning or hairloss
• sore mouth and mouth ulcers
• an increased risk of infections tell your care team if you develop any symptoms of an infection, and try to avoid close contact with people known to have an infection

These side effects should pass once treatment has finished.

Emotional support

The emotional impact of living with vulval cancer can be significant. Many people report experiencing a kind of rollercoaster effect. You may feel down at receiving a diagnosis, feel up when the cancer has been removed from your body, and then feel down again as you try to come to terms with the after-effects of surgery.

Some people experience feelings of depression . If you think you may be depressed, contact your GP or care team for advice. There are a range of treatments that can help.

You may also find it useful to contact one of the main cancer charities, such as:

• Macmillan Cancer Support the helplineis availableon 0808 808 00 00, Monday to Friday, 9am to 8pm
• Cancer Research UK a cancer nurse helpline is availableon 0808 800 4040, Monday to Friday, 9am to 5pm