vaginal cancer

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vaginal cancer

Gynecology Any malignancy of the vagina, including nonepithelial lesions–eg, Sarcoma botryoides; vaginal adenoCA is linked to maternal use of DES during pregnancy. See Diethylstilbestrol.

Vaginal Cancer

DRG Category:	734
Mean LOS:	7.1 days
Description:	SURGICAL: Pelvic Evisceration, Radical Hysterectomy, and Radical Vulvectomy With CC or Major CC
DRG Category:	755
Mean LOS:	5 days
Description:	MEDICAL: Malignancy, Female Reproductive System With CC

Vaginal cancer (VC) is a neoplastic disease of cells within the vaginal canal. Because primary cancer of the vagina is rare, VC is usually secondary as a result of metastasis from choriocarcinoma (cancer of the cervix or adjacent organs). VC often extends to the bladder and rectum, which makes treatment difficult. Approximately 85% to 90% of vaginal cancers are squamous cell carcinomas, which begin in the epithelial lining in the upper areas of the vagina near the cervix. Less common are adenocarcinomas, which develop in women over age 50 who were exposed to diethylstilbestrol (DES) in utero; melanomas (14% of patients have a 5-year survival rate), which tend to affect the lower or outer portion of the vagina; or sarcomas that form in the deep wall of the vagina.

VC is rare and accounts for only 3% of all gynecologic malignancies. It is most commonly located in the upper one-third of the posterior vagina. The vagina has a thin wall and extensive lymphatic drainage; the severity of the cancer, therefore, varies depending on its location in relation to the lymphatic system and the thickness of the neoplastic involvement. Stage 0 VC is limited to epithelial tissue (96% of patients have a 5-year survival rate). Stage 1 VC is limited to the vaginal wall (73% of patients have a 5-year survival rate). Stage 2 VC involves the subvaginal tissue but not the pelvic wall (58% of patients have a 5-year survival rate). Stage 3 VC extends to the vaginal wall (36% of patients have a 5-year survival rate). Stage 4 VC extends beyond the pelvis or involves the bladder or rectum (36% of patients have a 5-year survival rate).

Low survival rates are caused by the advanced stage of the disease at the time of diagnosis, difficulty in treatment resulting from the proximity of important structures, and the rarity of the disease that makes it difficult to determine the best treatment.

Causes

The cause of VC is not known, although ingestion of DES, a drug given to women at one time to limit spontaneous abortion, has been identified as one possible cause. Risk factors include a previous malignancy of the vagina, vulva, or cervix and advancing age. Women who have had cervical cancer previously should be examined on a regular basis to assess for vaginal lesions. Other risk factors include exposure to DES in utero, the improper use of pessaries (infrequent cleaning, infrequent examination to ensure proper fit), exposure to radiation therapy, trauma, exposure to chemical carcinogens found in some sprays and douches, a history of human papillomavirus, and smoking. There may be some association with VC and late menarche. Many cases of VC are believed to start out as precancerous changes in the cells of the vagina, called vaginal intraepithelial neoplasia.

Genetic considerations

There are no known genetically inheritable patterns for vaginal cancer.

Gender, ethnic/racial, and life span considerations

VC occurs in menopausal and postmenopausal women, typically over age 50. VC is rare in African American and Jewish women.

Global health considerations

While VC occurs globally, no prevalence data are available.

Assessment

History

A complete reproductive history of the patient and the patient’s mother is important. Evaluate the patient for any risk factors. Ask if the patient’s mother was taking DES when pregnant with the patient. Determine a thorough history of the patient’s physical symptoms. One of the symptoms of VC is spontaneous vaginal bleeding after either intercourse or a pelvic examination. Vaginal discharge of a watery nature may also be present. Other symptoms include pain, urinary or rectal symptoms, pruritus, dyspareunia (pain during sexual intercourse), and groin masses.

Question the patient about any pain. Assess the use and effectiveness of any analgesics for pain. Document the location, onset, duration, and intensity of the pain. The patient may also describe urinary retention or urinary frequency if the lesion is near the bladder neck.

Physical examination

Painless vaginal bleeding is the most common symptom. Inspection of any bleeding or vaginal discharge, with particular attention to the characteristics and amount of bleeding, is imperative. Palpate the groin area to detect any masses. An internal pelvic examination may reveal an ulcerated vaginal lesion.

Psychosocial

A thorough assessment of each woman’s perception of the disease process and her coping mechanisms is required. Changes in sexual patterns and body image present stressors to patients. The family of the patient should also be included in the assessment to examine the extent of support they can provide. Her partner may experience anxiety over the potential loss of his mate or fear about altered patterns of sexuality.

Diagnostic highlights

General Comments: VC is often well advanced before diagnosis is made.

Test	Normal Result	Abnormality With Condition	Explanation
Lugol’s solution applied to vaginal areas	Normal tissue stains	Areas that do not stain indicate suspect areas	Identifies areas to be biopsied
Colposcopy	Normal structures visualized	Lesions noted	A magnifying lens is used to view the walls of the vagina to identify areas that should be biopsied
Biopsy	Benign	Malignant	Confirms the diagnosis

Other Tests: CA-125 blood test may be elevated with some cancer types. Other tests include Papanicolaou (Pap) test, barium enema, and imaging and endoscopic tests to check for metastasis.

Primary nursing diagnosis

Diagnosis

Altered sexuality patterns related to tissue damage, pain, and change in body structures

Outcomes

Sexual functioning; Anxiety control

Interventions

Sexual counseling; Coping enhancement

Planning and implementation

Collaborative

Most often, the treatment of choice for VC is radiation therapy delivered either by external beam or internally (brachytherapy). Treatment decisions are based on the extent of the lesion and the age and condition of the patient. Patients with early-stage disease are treated so that the malignant area is removed but the vagina is preserved. Laser surgery is often used during stages 0 and 1. Patients in the later stages of disease are treated with surgery or radiation. The type of surgery or radiation depends on the extent of the disease, the patient’s desire to preserve a functional vagina, and the location of the lesion. A radical hysterectomy may be done with removal of the upper vagina and dissection of the pelvic nodes. Most patients receive total external pelvic radiation therapy to shrink the tumor before surgery or before internal intracavity radiation. Internal radiation with radium or cesium into the vagina can be provided for 2 to 3 days. Current survival rates are similar for patients with VC whether they are treated with radiation or surgery.

Collaborative postoperative management includes analgesics for pain relief and careful assessment for signs of postoperative infection or poor wound healing. Before discharge, discuss with the physician the patient’s timetable for resumption of physical and sexual activity and be certain that the patient understands any limitations. For the management of patients with internal radiation, see Uterine Cancer, p. 1104.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Fluorouracil	Topical	Antineoplastic	Used topically in stages 0 and 1 (not as effective as radiation or surgery)
Acetaminophen, NSAIDs, opioids, combinations of opioids and NSAIDs	Depends on the drug and patient condition and tolerance	Analgesics	Choice of drug depends on the severity of pain

Independent

The nursing management of patients with VC is challenging because of the interaction between the patient’s physical and emotional needs. If the woman has pain from either the surgical procedure or the disease process, explore pain-control methods such as imagery and breathing techniques to manage discomfort. The woman may be depressed and angry. Allow the patient to express her anger and concerns without fear of being judged or discouraged. Provide a private place for her to discuss her concerns with the nurse or significant others. Provide a list of support groups for the patient and her partner.

Teach all female patients to be alert for signs of VC, particularly any unusual discharge or bleeding. Encourage all women over age 18 to seek annual checkups, including gynecological examination. Women should also be taught to perform a genital self-examination at the same time they perform breast self-examination. Teach them to use a mirror to inspect for any changes in the female anatomy and to report any lesions, sores, lumps, or the presence of a persistent itch.

Evidence-Based Practice and Health Policy

Mahdi, H., Kumar, S., Hanna, R.K., Munkarah, A.R., Lockhart, D., Morris, R.T., …Doherty, M. (2011). Disparities in treatment and survival between African American and White women with vaginal cancer. Gynecologic Oncology, 122(1), 38–41.

Investigators conducted a study among 2,675 patients diagnosed with invasive VC and found that 5-year survival rates were significantly lower among African American women compared to white women (38.6% versus 45%; p = 0.008). In this sample, 14.2% were African American and 85.8% were white.
African American women were also more likely to be diagnosed with advanced stage VC (III or IV) compared to white women (30.4% versus 23.1%; p = 0.019). In this sample, 24.2% of all patients presented with stage III or IV VC.
African American women were also more likely to be diagnosed at a younger age than white women (median age, 65 years versus 69 years; p < 0.001) and less likely to undergo surgery or radiotherapy (17.5% versus 27.7%; p < 0.001).

Documentation guidelines

Physical response: Amount and characteristics of any vaginal bleeding or discharge, vital signs, pain (location, onset, duration, intensity, response to interventions)
Emotional response: Support system, ability to deal with terminal diagnosis, emotional well-being; ability to cope with sexuality issues
Patient’s appetite, general appearance, and sleep patterns

Discharge and home healthcare guidelines

teaching.

Explain any procedures such as wound care or skin care that need to be continued at home. If the patient has had internal radiation therapy, teach her to use a stent or dilator to prevent vaginal stenosis; sexual intercourse also prevents vaginal stenosis. Teach the patient any limitations on the resumption of sexual activity or activity such as lifting or driving. Emphasize the importance of follow-up visits, which may include procedures such as x-rays, computed tomography scans, ultrasound, or magnetic resonance imaging. If the patient had vaginal reconstruction, teach her about the need for using a lubricant during sexual intercourse. Also inform her that, owing to neural pathways, she may feel as if her thigh is being stroked during intercourse.

complications.

Teach the woman with VC to report any further vaginal bleeding or signs of infection (fever, poor wound healing, fatigue, drainage with an odor).

coping.

Discuss helpful coping patterns with the patient if this was not done previously. Encourage her to be open about her concerns and needs with her family and friends. Provide her with a referral to the American Cancer Society if appropriate.

prevention.

Teach teenage and preteenage girls who have been exposed to DES to have examinations at least once annually beginning at menarche regardless of the absence of symptoms of VC. Practicing safe sex will reduce the likelihood of contracting human papillomavirus, which is a contributing factor to the development of VC.