What is vaginal cancer?
It is an abnormal growth of malignant cells (neoplasm, tumor) in the vagina. The vagina itself, sometimes referred to as the “birth canal”, is a 3 - 4 inch hollow tube that runs from the vulva (outside genitalia) up to the cervix (the lower part of the uterus, or womb). The walls of the vagina are often in a “closed” or collapsed position, but are able to expand significantly during sexual activity or baby delivery.
What are the different types of vaginal cancer?
The vast majority of vaginal cancers (over 90%) are squamous cell carcinomas which grow in the “skin” (epithelial lining) of the vagina. They usually occur in the top part of the vagina near the cervix, and evolve over a period of many years from precancerous areas called vaginal intraepithelial neoplasia (VAIN).
A much smaller percentage of vaginal cancers (~5%) are adenocarcinomas. A subtype of these is clear cell adenocarcinoma, which occurs in young women whose mothers took an old hormonal medication called diethylstilbestrol (DES) while they were pregnant with them. Diethylstilbestrol was prescribed from the 1940s to early 1970s for prevention of miscarria ges.
Much rarer types of vaginal cancer are melanomas (2-3%), seen in the lower or outer portion of the vagina, and sarcomas (2-3%).
How common is vaginal cancer?
It is a rare cancer, representing only about 2% of all gynecologic tumors. There are about 2,000 new cases reported each year in the US.
Who gets vaginal cancer?
Typically this is a condition affecting older women, with a median age of 65 – 70 years old at diagnosis. The greatest number of cases are diagnosed in women over 70 years of age.
What are the risk factors for vaginal cancer?
Squamous cell cancer of the vagina is associated with increasing age and certain high-risk strains of the human papillomavirus (HPV). In fact, having a diagnosis of cervical cancer is itself a big risk factor for developing vaginal cancer. Chronic vaginal irritation has also been linked to some cases.
As mentioned earlier, clear cell adenocarcinoma of the vagina is associated with DES exposure in the womb.
What are the symptoms of vaginal cancer?
Painless vaginal bleeding, unrelated to menstrual periods, is the most common symptom. Vaginal bleeding in a postmenopausal woman is cancer until proven otherwise and should be promptly evaluated. Other symptoms can include vaginal discharge, painful or difficult urination, and painful sexual intercourse.
How is vaginal cancer diagnosed?
One of the most important steps in evaluating a patient with gynecologic complaint is a proper pelvic examination. The healthcare provider (HCP) should examine the uterus, ovaries, fallopian tubes, and vagina. Vaginal cancer is diagnosed and staged clinically, and so the bladder and rectum should also be evaluated (with cystoscopy and proctoscopy, if necessary) for any abnormalities.
CT and MRI scans of the upper abdomen and pelvis are not currently standard recommendations, but are often done to look for enlarged lymph nodes, kidney/bladder problems, and liver metastasis.
A Pap test should be performed, where the outside of the cervix and vagina are scraped and samples are submitted for microscopic analysis and HPV testing. Even if the suspected diagnosis is vaginal cancer, the Pap smear is especially important to rule out cervical cancer, which is much more common than vaginal cancer.
Colposcopy is where the HCP inserts a device with binocular magnifying lenses into the vagina to better visualize the cervix and the inside of the vagina. Any suspicious areas on the cervix and/or along the vaginal walls should be biopsied and sent for microscopic analysis.
Once it is diagnosed, how is vaginal cancer staged?
Both the American Joint Committee on Cancer stage (TNM model) and the Federation Internationale de Gynecologie et d’Obstetrique (FIGO) can be used.
Most gynecologists prefer the FIGO system, which has 5 stages, from stage 0 (earliest) to stage 4 (most advanced). They are defined as follows:
• Stage 0 - very earliest stage of vaginal cancer, also known as carcinoma in-situ (CIS), vaginal intraepithelial neoplasia (VAIN), or pre-cancer, because the cancer cells are trapped in the vaginal skin and have not yet grown into the deeper tissues or spread away from the vagina
• Stage 1 - cancer has started to grow into the deeper tissues of the vagina but has not spread beyond the vagina
• Stage 2 - cancer has started to spread outside the vagina into the surrounding tissues BUT has not reached the walls of the pelvis
• Stage 3 - cancer has spread outside the vagina and reached nearby lymph nodes or pelvic side walls
• Stage 4 - advanced vaginal cancer, with spread to other body organs outside the vagina
For further reference, the detailed TNM Categories/ FIGO Stages are shown below:
Primary tumor (T)
• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis/ 0: Carcinoma in situ
• T1/ I: Tumor confined to vagina
• T2/ II: Tumor invades paravaginal tissues but not to pelvic wall*
• T3/ III: Tumor extends to pelvic wall
• T4/ IVA: Tumor invades mucosa of the bladder or rectum and/or extends beyond the true pelvis
Regional Lymph Nodes (N)
• NX: Regional nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1/ IVB: Pelvic or inguinal lymph node metastasis
Distant metastasis (M)
• MX: Distant metastasis cannot be assessed
• M0: No distant metastasis
• M1/ IVB: Distant metastasis
Adapted from Vagina. In: American Joint Committee on Cancer: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 251-257.
How is vaginal cancer treated?
Surgery, radiation therapy and chemotherapy are the typical treatment options, and can be used as single modality therapies or in combination.
The optimal treatment regimen should ultimately be individualized as much as possible. It should take into account the patient’s stage of disease, other medical history, and personal preference, among other things.
Surgery can be done to remove either part or all of the vagina. Surgical methods include:
• laser surgery for very early stage disease, using a narrow beam of light to kill cancer cells
• wide local excision to excise the cancer and some surrounding tissue
• vaginectomy, where the surgeon removes the vagina and usually some pelvic lymph nodes
• radical hysterectomy if cancer has spread outside of the vagina, with removal of the uterus, ovaries and fallopian tubes, as well as lymph nodes
• pelvic exenteration for extremely advanced disease, especially if an abnormal connection (fistula) has formed between the vagina and the bladder or rectum
Radiation therapy uses high-energy rays to kill cancer cells. It is the treatment of choice for most patients with invasive vaginal cancer, especially stage 2 disease and higher. It can be delivered as external beam radiation (from an external machine), brachytherapy (using “seeds” of radioisotopes through thin plastic tubes directly into the cancerous area), or more often a combination of both.
Chemotherapy uses drugs to kill cancer cells. Given the relative rarity of this disease, there are no randomized data supporting the use of chemotherapy together with radiation for vaginal cancer. However, based on the multiple studies in cervical cancer showing better results with the combination compared to radiation alone, many HCPs recommend use of concurrent radiation and cisplatin-based chemotherapy for high-risk vaginal cancer patients. Chemotherapy can also be used to control (as opposed to cure) recurrent or widespread disease, but results have typically been poor.
What is the prognosis?
Squamous cell and adenocarcinoma
Stage 5-year survival rate

Stage 0 96%
Stage I 73%
Stage II 58%
Stage III/IV 36%
Adapted from American Cancer Society, www.cancer.org , revised 10-22-03