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Encouraging awareness of vulval cancer

Penny Ballinger
MA MBA BM BS BA RGN PG Dip HV Prof Dip Ed
Health Visitor
Forest of Dean

Public awareness of vulval cancer is low, and many women present late, resulting in late diagnosis, more invasive surgery and, potentially, a poor prognosis. Penny Ballinger argues the benefit of encouraging vulval self-examination and reducing the barriers to late presentation of embarrassing symptoms

Cancer of the vulva is an uncommon cancer, but its incidence has been steadily increasing in women over the age of 65. Among younger women there has been a significant increase in the rates of vulval cancer and its precancerous form, vulval intraepithelial neoplasia (VIN) also known as Bowen's disease.1

There are now approximately 1,000 new cases diagnosed each year in the UK, and the lifetime risk of developing vulval cancer has been estimated as one in 316.2 Age distribution shows bimodal peaks which relate to two different disease "aetiological types" affecting different age sectors.1

Cancer risk
In younger women vulval cancer is associated with human papilloma virus (HPV) exposure and there is some overlap with cervical cancer, as 23% of women with cervical cancer also have vulval cancer. Consequently, the UK HPV vaccination programme will confer a time-limited window of protection against vulval cancer associated with HPV strains 16 and 18, although this cancer has also been associated with strains 6,11,33, 35 and 54.

Both smoking and early sexual experience increase the relative risk of vulval cancer in younger women.3 However, the majority of vulval cancers occur in women over 50, and in this group they are associated with chronic vulval irritation such as lichen sclerosis and post menopausal vulval skin changes that have become malignant (see Boxes 1 and 2).4

[[Box 1 v cancer]]

Diagnosis and treatment
Vulval cancer comprises any malignancy arising from the skin, tissue or glands of the vulval area. As the vulva is richly supplied by the lymphatic system, it metastasises readily and quickly to the inguinal and femoral nodes, as well as spreading locally across the perineal and genital area.5

Consequently, it is very important for women to be comfortable examining themselves, developing awareness of what is normal, and what should prompt a consultation with a health professional (see Box 3).

[[Box 3 v cancer]]

It needs to be emphasised that the early symptoms are very general symptoms, and that biopsy is the only definitive method of diagnosis, so that a "suspicious" lesion, or one that has failed to respond to topical treatment, warrants a GP referral to a gynaecologist or gynaecological oncologist under the two-week rule.

Vulval cancer used to have 100% morbidity in the early half of the 20th century, but innovations such as laser and photodynamic therapy have established effective methods of tackling early disease, and even in advanced disease progress in surgical techniques has now led to a five-year postoperative survival rate of 74%.6

However, delays in diagnosis and treatment can produce long-term effects, such as the breakdown of groin tissue, haemorrhage, pubic bone damage and urinary tract infections and continence problems.

Summary
Five minutes' investment in advocating and talking through vulval self-examination as an adjunct to either a cervical smear consultation or advocacy for pelvic floor exercises, may sow the seeds of vulval awareness and the early presentation for diagnosis and treatment of symptoms which although potentially embarrassing, may avoid the need for potentially invasive and disfiguring surgery. 

References
1. Joura E. Trends in vulval neoplasia: Increasing incidence of vulval intraepithelial neoplasia and squamous cell carcinoma of the vulva in young women. Journal of Reproductive Medicine 2000;45(8):613-5.
2. Cancer Research UK. Vulval cancer - UK incidence statistics. Available from: http://info.cancerresearchuk.org/cancerstats/types/vulva/incidence
3. Hampl M, Deckers-Figiel S, Hampl J et al. New aspects of vulval cancer: changes in localization and age of onset. Gynaecological Oncology 2008;109(3):340-5.
4. Kumar S, Shah J, Bryant C et al. A comparison of younger vs. older women with vulval cancer in the United States. Am J Obstet Gynaecol 2009;200(5):
5. Sankaranarayanan R, Ferlay J. Worldwide burden of gynaecological cancer: the size of the problem. Best Pract Res Clin Obstet Gynaecol 2006;20(2):207-25.
6. Higgins R, Naumann R, Hall J. Surgical Treatment of Vulval Cancer, eMedicine Specialities. Available from: http://emedicine.medscape.com/article/268880-overview

Resources
Channel 4 Embarrassing Bodies website, including a vulval self-examination demonstration film
W: www.channel4embarrassingillnesses.com

Vulval Health Awareness Campaign
W: www.vhac.org

Vulva Awareness Campaign Organisation
W: www.vaco.co.uk

National Lichen Sclerosis Support Group
W: www.lichensclerosis.org

Vulval Pain Society
W: www.vulvalpainsociey.org