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Parkway Cancer Centre’s Dr See Hui Ti explains how vaginal cancer can still occur after a hysterectomy. “Doctor, you must have made a mistake! How can I still be suffering from vaginal cancer? “I had my uterus and ovaries removed 10 years ago due to uterine fibroids. You must have seen wrongly. Please take another look – 15 years ago, my gynaecologist told me that I don’t have to come for follow-up anymore after undergoing hysterectomy. Now you’re saying that I have vaginal cancer?” Madam Yang, 63 years old, was wiping away her tears as she spoke to me. I can empathise with her sense of betrayal. It is true that normally, women who have their ovaries and uterus entirely removed due to benign issues do not require any follow-up. Yet, she has now been diagnosed with vaginal cancer. Luckily, Madam Yang sought medical help early due to vaginal itchiness and persistent vaginal discharge. That was how we discovered that she was suffering from squamous cell carcinoma vaginal cancer early. Because she came to us early, there is a very good chance of making a complete recovery after radiotherapy.

Why is it still possible to suffer from vaginal cancer after hysterectomy?

The female reproductive organs consist of the uterus and cervix, ovaries, vagina and vulva. They are different organs subjected to different cancers. For example, a high risk factor of ovarian cancer is family history while the high risk factors of uterus cancer are obesity and diabetes. On the other hand, the high risk factor of cervical and vaginal cancer is infection by the human papillomavirus (HPV). In recent years, the incidence of cervical cancer has decreased greatly due to Pap smears being more widely used; it now ranks as the 10th most common cancer among Singaporean women. Vaginal cancer is not very common. The incidence rate of vaginal cancer is low and it can be considered a rare cancer, with the majority of those afflicted being women above the age of 60.

What are the symptoms of vaginal cancer and how can it be treated?

Vaginal cancer is similar to cervical cancer in many ways. In the early stages, both have no symptoms. Most cases of vaginal cancer can be divided into two types: squamous cell carcinoma and adenocarcinoma.

1. Squamous cell carcinoma vaginal cancer: Risk factor is the same as that of cervical cancer, i.e., long-term infection of the cells in the vagina by the HPV, resulting in pathological changes and developing into Vaginal in-situ neoplasm (VAIN).
2. VAIN can be classified into severe (VAIN III), moderate (VAIN II), and mild (VAIN I).

If left undetected, VAIN may develop into invasive cancer. By then, the patient may experience abnormal vaginal discharge. Late stage vaginal cancer can result in symptoms such as pain in the lower abdomen and vagina. If the cancer spreads to the lymph nodes, the patient may discover lumps in the groin. VAIN I is very slow growth and does not spread, therefore there is no need for the patient to receive treatment, and follow-ups are for monitoring and observation only. The best treatment method for VAIN II and VAIN III is having an operation to remove the entire uterus and ovaries. If the patient already had a hysterectomy, vaginal excision would have to be carried out. If the patient cannot be operated on (for example, because of age), targeted chemotherapy or laser treatment can be used. The best form of treatment for invasive vaginal cancer is a combination of electrotherapy and chemotherapy. Early stage vaginal cancer is similar to cervical cancer – the earlier it is detected, the better the odds of making a full recovery.

Vaginal cancer may be rare, but is there any way to screen for it or prevent it?

All women who have had sexual intercourse can undergo a Pap smear periodically to screen for early stage cervical and vaginal neoplasm. Those who have never been infected by the HPV are very unlikely to suffer from vaginal cancer. Early detection means that treatment efficiency is higher, and the chances of making a complete recovery are also higher. As a Pap smear test is highly efficient and inexpensive, it is actively promoted by the Ministry of Health. However, a Pap smear test needs to be administered at least once every three years but most women fail to do so. To prevent viral infection, the only way to do so at present is to receive a HPV vaccination when young. In recent years, the United States Department of Health recommends HPV testing:

1. The test is most suitable for women above the age of 30 who have had sexual intercourse.
2. The doctor sends the cervical and vaginal fluid obtained during a Pap smear for laboratory testing to find out if a woman is infected by high risk HPV.
3. If there are no signs of the virus, the test only has to be conducted once every five years. If there are signs of the virus, further testing is done.

Compared to a Pap smear, this test is even more efficient, as it only has to be conducted once every five years. The test has been available in Singapore for a number of years but because it is more suitable for women above the age of 30, it has not been able to completely replace Pap smears. The best weapon that a woman has at her disposal to protect herself is to understand the pathological changes of cancer cells in order to select the best screening.

Human papillomavirus (HPV) testing

• Most suitable for women above the age of 30 who have had sexual intercourse.
• Cervical and vaginal fluid obtained during a Pap smear is sent for laboratory testing to find out if a woman is infected by high risk HPV.
• Conducted only once every five years if there are no signs of the virus. Further testing is done if there are signs of the virus.