Vulvar Cancer is on the Rise in the UK, study shows

Relationship between vulvar symptoms and incidence of vulvar cancer in women referred to a rapid access clinic

Abstract

Objective
We performed a study to estimate incidence of vulvar cancer in women with vulvar symptoms (irritation, pain, bleeding +/− presence of lesion) referred to a secondary care, rapid‐access clinic.

Methods
Prospective data collection of all direct referrals from a primary to a secondary care gynecological oncology clinic from 2011 to 2016, for women with suspicious vulvar symptoms.

Results
32/393 (8.1%) women had vulvar cancer, and 24/393 (6.1%) had a premalignant lesion. Multivariate logistic regression showed that women referred without a specific lesion had considerably lower odds of a diagnosis of vulvar cancer than those with a lesion (OR=0.11, 95% CI: 0.03–0.49). In total, 30/234 (12.8%) women with a vulvar lesion (mass or ulcer), had vulvar cancer, compared with 2/159 (1.3%) of those referred without a lesion (these patients had vulvar irritation and bleeding but had a visible lesion on examination). None of the 140 women with irritation alone, in the absence of a visible lesion or bleeding, had pre‐invasive disease or cancer.

Conclusion
Presence of a vulvar lesion, especially if painful/bleeding, has a high positive predictive value for vulvar cancer and 12.8% of women presenting with any vulvar lesion to secondary care had cancer.

Discussion

Overall, 32/393 (8.1%) women referred with vulvar symptoms were diagnosed with a malignancy and a further 24/393 (6.1%) were diagnosed with a pre‐malignant lesion. The presence of a suspicious vulvar lesion, especially if symptomatic, was associated with a cancer diagnosis in 30/234 (12.8%) women. Unless the lesion is obviously benign (which in this series included: sebaceous inclusion cyst; urethral caruncle; inspissated sebaceous material trapped under the clitoral hood; and ecchymosis on a background of lichen sclerosus), a rapid‐access clinic referral is appropriate to exclude a malignancy in these women. A larger cohort would be required to stratify risk by age. However, as the incidence of vulvar cancer is increasing, especially in younger women, it would be important not to dismiss suspicious symptoms based on age alone.

Women without a visible lesion were extremely unlikely to have cancer, based on this cohort of patients (<1.3% depending on whether presence of lesion was defined by patient/primary care [0/159] vs secondary care (2/159). However, these findings would need to be applied to a larger population to test this hypothesis and with wider generalization to other healthcare populations. One strength of this dataset is that the population is well‐defined and relatively stable, so re‐referrals, subsequently diagnosed with a cancer, would have been referred back to the same clinic. In the present series, six women were re‐referred during the study period (one woman was seen three times and five women were seen twice). None of these women had a cancer diagnosis. Unfortunately, we were not able to define an average lead time from onset of symptoms to diagnosis from our data, since this was not reliably recorded.

Many women with symptoms of vulvar soreness and irritation, in the absence of a specific lesion, were diagnosed with an inflammatory condition; half had lichen sclerosus or lichen planus. Primary care physicians should be reassured that, in the absence of a suspicious lesion, a cancer diagnosis or a pre‐malignant condition was unlikely. As per dermatology guidelines, if there are classical signs of lichen sclerosis, a diagnostic biopsy is not needed if there is a response to high‐potency topical steroids. Women whose symptoms do not start to improve after 2–3 weeks of treatment, should be re‐assessed and referred if symptoms persist or a lesion develops.

The overall incidence of vulvar cancer in this series was slightly lower than in those in the literature. This is perhaps surprising, as the local population is relatively elderly; in the 2011 census 29.1% of West Somerset were aged 65 years or over compared with a UK average of 16.4%. However, this series is nearly 10‐fold larger than those previously published, so may reflect the increased statistical power of this study. It may also reflect a difference in local referral patterns and criteria, since women may be referred to a general gynecology clinic or a dermatologist in other areas. One study from an urban area in the South East of England looked at cancer diagnosis rates in women referred to a gynecologic fast‐track clinic. They included a total of 335 women referred to secondary care. Only 18 women had symptoms suggestive of vulvar cancer, of whom only two (11.1%) were diagnosed with vulvar cancer. A similar study, also from the South East of England, included only 13 women with vulvar symptoms and found a positive predictive value of a cancer diagnosis of 15.4% in this subset. A further series of women with suspected gynecologic malignancy, also from the South East of England, included 1105 women referred to secondary care. Forty‐four of these women were referred with suspected vulvo‐vaginal cancer and 13.6% were diagnosed with a malignancy.

These data help to differentiate between those who should be referred via a fast‐track clinic and those who could be treated more conservatively for vulvar symptoms, and could help to inform national guidance—including future updates of NICE guidelines. Further data would be required to determine whether these data had wider applicability in other, more diverse populations, and these data are limited by the secondary care focus of this study. It would be interesting to compare rates of women presenting with vulvar symptoms in a primary care population with secondary care referrals and cancer incidence in that population over the same time period to provide evidence for triage of those requiring rapid assessment. This is important in the face of the increasing incidence of vulvar cancer, due to changes in demographics and HPV prevalence.

Finally, many women delay presentation and may have significant symptoms for many months, due to fear, embarrassment or lack of awareness of vulvar conditions generally, and vulvar cancer in particular. Many women in our series had inappropriate treatment for vulvar skin conditions or suspicious lesions with low potency steroids, topical estrogens, anti‐fungal agents, antibiotics, or no treatment at all for prolonged periods. This may be due to ‘home remedy’ self‐treatment (possibly fueled by lack of knowledge and advertisements for ‘intimate itching’), avoidance of doctors, or reluctance to use adequate courses of high potency topical steroids, by both physicians and the women affected. Research is also needed to inform us about barriers to presentation, especially in older women, who are most at risk of vulvar cancers, and to improve health education for this under‐resourced area.
Feature image credit @DiggerGraham (see below).

Long Term Outcomes for Women treated for Cervical PreCancer

Possble risk of cervical or vaginal cancer higher in women previously treated for pre-cancerous cells on cervix

” Possble risk of cervical or vaginal cancer higher in women previously treated for pre-cancerous cells on cervix ” @DrAlisonHill

Long term outcomes for women treated for cervical precancer
British Medical Journal aims to lead the debate on health, and to engage doctors, researchers and health professionals to improve outcomes for patients. @bmj_latest

Although the risk of cervical cancer after treatment for screen detected cervical precancer is low compared with non-treated women, the incidence of invasive cervical cancer is still significantly higher than in the general population. These findings are confirmed by Strander and colleagues in a trend analysis that linked data from pathology, cancer, and cause of death registries that have covered the whole Swedish population for more than half a century. The authors report that the risk of developing or dying from cervical or vaginal cancer in women with a history of treatment for CIN3 (cervical intraepithelial neoplasia grade 3) is two to three times higher than in the general population. Furthermore the increase in risk among women treated for CIN3 rises significantly with older age and more recent year of treatment.

These results agree with previous data suggesting that the rates of residual or recurrent high grade CIN after treatment are higher for older than for younger women. Endocervical precancerous lesions, a predisposing factor for recurrence, are more common in older women than in younger ones. The lower recurrence rates in younger women that are independent of the completeness of excision suggest that age specific immunity may also contribute to the ultimate cure of cervical precancer.

It is worrying that Strander and colleagues found that women who received local treatment more recently were at greater risk of developing cervical and vaginal cancer. The authors suggest that the use of less aggressive treatments in the two most recent decades may have adversely affected oncological outcomes. The trend in treatment was driven by an increasing awareness that extensive procedures are associated with poor reproductive outcomes. Recent meta-analyses of reports published since the end of the 1970s and registry based cohort studies have shown that pregnant women with a history of excisional treatment of CIN have a greater risk of premature delivery, particularly if the excised cones were large. Researchers from Norway have also described a parallel trend between less aggressive treatment for cervical precancer and a lower risk of preterm delivery.

The study population comprising more than three million women years of follow-up after treatment gave the current trend analysis enough power to identify significant differences between different subgroups of women. (Nevertheless, an age-period interaction term was not included in the log-linear model and this could have informed readers about the age specificity of the period effect.) Further analysis of the Swedish data on compliance with follow-up could provide important information on the possible reasons for treatment failure. The suggestion of reduced therapeutic effectiveness over time might also be partly explained by the decreased use of hysterectomy over the past two decades. A separate analysis of cervical and vaginal cancer rates, adjusted for rates of hysterectomy and for trends in the dimensions of excised cones, would help interpret the observed period effect.

Research is needed to identify accurate biomarkers that predict a woman’s future risk of cancer. A recent review concluded that testing for DNA from human papilloma virus helps to identify early treatment failure (recurrence within two years of treatment for cervical precancer), with higher sensitivity and similar specificity to follow-up cytology or histological assessment of the section margins. However, longer term data are limited. A cohort study from the Netherlands assessed the predictive value of combined cytological and virological follow-up for 10 years after treatment for cervical precancer. The overall cumulative incidence of recurrent CIN2 or worse was 17%, and that for CIN3 or worse was 9%. In women with two negative tests (cytology and high risk human papillomavirus DNA) at six and 24 months post-treatment, the risk of these outcomes was similar to that in women who tested negative for cervical precancer at baseline screening. Further cohort studies with long term follow-up are needed to confirm these results and to generate more evidence on the safety of different follow-up protocols for women treated for cervical precancer.

Currently, colposcopists who treat women with high grade CIN lesions must choose between complete excision to obtain free margins or a more prudent approach, especially if a further pregnancy is desired. Published and aggregated data still leave considerable room for doubt about the magnitude of the association between the extent of treatment and risk of later preterm delivery. Divergent findings may be explained by variability in therapeutic practices, particularly the size of the cone excised. The COSPCC study—a meta-analysis of individual patient data—should allow more precise measurement of the obstetric and oncological safety associated with different treatment options, while accounting for patient and lesion characteristics. The study should also provide more detailed evidence on how to balance treatment decisions.

However, Strander and colleagues’ study makes it clear that women who have been treated for a high grade intraepithelial cervical lesion, particularly those aged 50 years or more, require careful surveillance, and that measures should be taken to assure full compliance with follow-up. The data also underline the need for better standardisation and quality assurance in colposcopic practice to achieve an optimal balance between risk of cancer and obstetric safety.

Sources: BMJ 2014;348:f7700 (Published 14 January 2014)
Tweeted by @DrAlisonHill

Vaginal Cancer Information Leaflet

If you have any concerns about vaginal cancer please speak to your G.P.

It’s a tough one. We talk about sexual health these days in such open terms, but I feel that people just aren’t yet ready to talk about gynaecological cancers.

Vaginal Cancer Information Leaflet
If you have any concerns about vaginal cancer please speak to your G.P.

Download The Eve Appeal Vaginal Cancer Information Leaflet.
By The Eve Appeal gynaecology cancer research fund, London UK – on Facebook and Twitter.

Watch the Diaporama, and the DES research photo set on flickr®  DES Diethylstilbestrol's photostream on Flickr

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Email your photos to des.daughter@gmail.com with a short description and title :-)

Our Posts about – Adenocarcinoma of the VaginaVaginal AdenosisVulvar cancer – Women’s Health.

DES Daughter: The Joyce Bichler Story

A True Story of Tragedy and Triumph

The Joyce Bichler Story, a True Story of Tragedy and Triumph
Read about first DES trial 35 years ago

The Joyce Bichler Story is a gripping memoir by a DES-victim daughter that interweaves her experiences of having treatment for vaginal cancer with the experiences of suing a drug company for exposing her to DES.

Joyce Bichler was the first DES daughter to sue and the first to win her law suit.

She tells of her testimony, of the court case and of the jury’s verdict.

Read book reviews on Amazon and GoodReads.

More DES DiEthylStilbestrol Resources

Vulvar Cancer: how I stayed Sane through my Medical Drama

The Cancer No One Talks About, by Darci Picoult

A New Lesson in Intimacy
Personal Stories

” …A day before the operation you will need to do a bowel cleanse…nothing to eat or drink after noon….after the operation, you will be in the hospital for a few days. Since a small piece of your urethra will be removed, you will have a catheter. Once you prove you can pee on your own, you will be sent home. You may be peeing on an angle for a while but that can be corrected.
No cardio exercise till you are healed.
…”

Continue reading: How I Stayed Sane Through My Medical Drama From the Author Who Had The Cancer No One Talks About
by Darci Picoult, journalist, DES daughter and author of My Virginia

About DES and Cancer:

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Vulvar Cancer: the Cancer no One talks about

A new Lesson in Intimacy on RedBookMag

A New Lesson in Intimacy
Personal Stories

” …It was five weeks after surgery to remove and reconstruct my vulva — and life in the Picoult-Ford household was back to normal except for one tiny fact. A large elephant had taken residency in our bed and was snoring loudly…”

Continue reading: A New Lesson in Intimacy From the Author Who Had The Cancer No One Talks About
by Darci Picoult, journalist, DES daughter and author of My Virginia

More DES DiEthylStilbestrol Resources

Vulvar Cancer: the Cancer no One talks about

Author Darci Picoult personal Essay

I Had the Cancer No One Talks About
Personal Stories

” …Sensation is returning! Slowly but surely my nerves are regenerating. A cause for celebration, the human body reviving itself. Some get a new heart and it beats, a new limb and it moves. In my case, a new vulva and it feels. Am I excited? You bet. My doctor? Ditto. And my husband, Larry? Did you hear trombones playing all the way from our house in Brooklyn?…”

Continue reading: An Exciting Update From the Author Who Had The Cancer No One Talks About
by Darci Picoult, journalist, DES daughter and author of My Virginia

More DES DiEthylStilbestrol Resources

Vulvar Cancer: the Cancer no One talks about

Author Darci Picoult personal Essay

I Had the Cancer No One Talks About
Personal Stories

” …So there I sit, watching a former stripper sing, moments before having my vulva removed. Thoughts boomerang inside me: Every story line on TV revolves around sex. But what about those of us who can’t make love? What if your sex drive is in reverse because in a place that should be divinely pleasurable, you feel pain? Isn’t there anything that defines intimacy beyond throbbing bodies? Everywhere I look makes me feel less like a woman. And yet. I know there is something bigger, something more. My “womanhood” has nothing to do with my vagina, it is in me…”

Continue reading: Vulvar Cancer Personal Essay, “I Had the Cancer No One Talks About“, by Darci Picoult, journalist, DES daughter and author of My Virginia.

DES DiEthylStilbestrol Resources

Vulvar Cancer: the Cancer no One talks about

Darci Picoult personal Essay

I Had the Cancer No One Talks About
Darci Picoult, journalist, DES daughter and author of My Virginia

After a devastating diagnosis and major gynecological surgery transformed author Darci Picoult’s body, she wondered whether anything — her marriage, her sex life, her relationship with her daughters — would ever be the same. It wasn’t. She came through stronger, more outspoken, and more intimately connected to the people she loves.

Read more: Vulvar Cancer Personal Essay, “I Had the Cancer No One Talks About
by Darci Picoult, journalist, DES daughter and author of My Virginia

About DES and Cancer:

More DES DiEthylStilbestrol Resources