Vaginal Cancer: Radiation Therapy

What is radiation therapy?

Radiation therapy is a treatment for cancer that uses beams of energy, usually X-rays but stronger. Radiation therapy is also called radiotherapy. Its goal is to kill or shrink cancer cells.

There are two main types of radiation therapy:

• External radiation. The radiation comes from a large machine and is precisely aimed over the skin at the tumor. It's a lot like a dental X-ray or chest X-ray, but the radiation is stronger.

• Internal radiation (brachytherapy). Radioactive sources deliver temporary radiation inside the vagina, right near the tumor. This allows a large dose of radiation to go right to the tumor while minimizing damage to normal surrounding tissues.

When might radiation therapy be used?

In most cases, both external and internal radiation are used to treat vaginal cancer. Sometimes chemotherapy is given along with radiation to help it work better.

Radiation treatment might be suggested for any of these reasons:

• As part of the main treatment for vaginal cancer. It might be the only treatment needed for small tumors that haven't spread. It can also be used along with other treatments, like chemotherapy, to treat bigger tumors or ones that have spread to the lymph nodes.

• To try to kill any cancer cells left after surgery. Radiation can be used after surgery to treat nearby lymph nodes or kill any cancer cells that may not have been removed.

• To ease symptoms. Treating the vagina and pelvis can help reduce bleeding, pain, and other problems the tumor is causing.

Deciding on a radiation treatment plan

To plan your treatment, you'll meet with a team of cancer specialists. This might include a surgeon, radiation oncologist, and medical oncologist.

A radiation oncologist is a healthcare provider who specializes in both cancer and radiation. This healthcare provider works with you to decide the kind of radiation you need. They also determine the dose and how long treatment will last. During this visit, ask what you can expect during and after the treatment.

Internal radiation therapy

This type of radiation therapy is also called brachytherapy. It uses a radioactive source that travels to a cylinder-shaped tube. The cylinder-shaped tube is put in the vagina. The radiation doesn't go far, so it mostly affects the tissues near the tube.

There are two types of internal radiation therapy:

• LDR (low-dose radiation) brachytherapy. The tube with the radioactive source stays in for a day or two. Gauze packing is put in the vagina to hold the tube in place. You stay in bed in the hospital during treatment.

• HDR (high-dose radiation) brachytherapy.  Stronger radiation from the radioactive source in the tube means it doesn't have to stay in as long. Each treatment takes less than 20 minutes and is done as an outpatient.

Getting ready for internal radiation

Imaging tests, like a CT scan or MRI scan, will be done to see exactly where the tumor is. This helps your healthcare provider see your vagina and the nearby tissues so they can map out exactly where the radiation needs to be placed.

On the day you get radiation

You will be treated in a special room that keeps any radiation inside. You may be given medicines to make you sleepy and to help with pain control, and packing will be used to keep the tube in place.

Your healthcare provider will put the tube in place in your vagina. For LDR, the tube along with the radioactive material is left there for the duration of the treatment. How long it stays depends on where the cancer is and how big it is. You stay in the hospital during treatment.

For HDR, the procedure can be done as an outpatient or inpatient. In both cases, the radioactive material travels into the tube and sends bursts of radiation into the tube. For an outpatient procedure, the tube doesn't stay in very long, usually less than 20 minutes. The 4 or 5 follow-up treatments might be done a few weeks apart. For an inpatient procedure, you would have the tube remain in you for several days. You would be brought down to the machine that has the radioactive sources for 20 minutes at a time. During this time, the source would deliver the radiation into the cylinder tube in the vagina, and then the source would travel back out. This would usually occur over 3 days.

For both types of internal radiation, the radioactive material is taken out before you go home—none is left in your body. You are not radioactive, so you do not pose a risk to those around you.

External beam radiation

External radiation therapy is done in a hospital or a clinic. You receive treatment as an outpatient, which means you go in for treatment and then go home the same day. Treatment is usually done 5 days a week, Monday through Friday, for 5 weeks.

Getting ready for external radiation

Before your first treatment, you will have a planning appointment called a simulation. This is needed to find exactly where in your body the radiation beam needs to be directed. It may take up to 2 hours.

During this session, imaging tests such as CT scans or MRI scans may be done. These tests help your healthcare providers know the exact location of the tumor so they can aim the radiation directly at it. Also at this session, body molds might be made to put you in the exact same position for each treatment and help keep you from moving.

Then, you’ll lie still on a table while a radiation therapist uses the CT scan to define your treatment field. The field is the exact area on your body where the radiation will be aimed. Sometimes it’s called your port. The therapist may mark your skin with tiny dots of semi-permanent ink or tattoos. This is so the radiation will be aimed at the exact same place each time.

You can then go home, and the radiation oncologist and team will design your radiation plan. This can take up to two weeks.

On the days you get radiation

On the days you get treatment, you’ll lie on a table while the machine is placed over you. You may have to wear a hospital gown. Treatment is a lot like getting an X-ray, but it takes longer, up to 15 to 30 minutes. You should plan on being there for about an hour total.

At the start of the treatment session, a radiation therapist helps you get into position and may use blocks or special shields to protect other parts of your body from exposure to radiation. The therapist then lines up lights on the machine with the marks on your skin so the radiation is directed to the exact location. When you’re ready, the therapist leaves the room and turns the machine on. You may hear whirring or clicking noises as the machine moves during radiation. This may sound like a vacuum cleaner. When the machine sends radiation to your tumor, you'll need to be very still. You don't have to hold your breath. The machine won't touch you. During the session, you’ll be able to talk to and hear the therapist over an intercom. You can’t feel radiation, so the process will be painless. You will not be radioactive afterward.

What to expect after radiation

Because radiation affects normal cells as well as cancer cells, you may have some side effects. The side effects from radiation are normally limited to the area being treated. Some people have few or no side effects. If you do have them, your healthcare provider may change the dose of your radiation or how often you get treatment. Or treatment may be stopped until your side effects clear up. Tell your healthcare provider about any side effects you have right away. Often, they can be treated before they get worse.

Also talk to your healthcare provider about whether you can have sex during treatment and if there are any precautions you should take.

Possible side effects

Talk to your healthcare provider about what you might feel like during and after radiation. All cancer treatments can cause side effects. Radiation side effects often get worse as treatment goes on, but most can be treated and may also go away once the treatment is completed.

The side effects of radiation therapy include:

• Skin in the treated becomes irritated, sore, red, raw, and can peel like a sunburn. This can also happen inside your vagina.

• Hair loss in the area being treated (this can be permanent)

• Feeling very tired or weak

• Nausea or vomiting

• Diarrhea and bloody stool

• Bladder problems, and things like discomfort, burning, or urgency when passing urine

• Low blood counts

Most of these short-term side effects usually go away over time after you stop treatment. Still, if you have any of these side effects, talk with your healthcare provider about how to deal with them. Side effects tend to be worse if you get chemotherapy along with radiation.

Some long-term side effects of radiation may not show up for many years after you finish treatment. For instance, radiation can:

• Damage the ovaries and cause early menopause and infertility (inability to have children)

• Damage the bowels, which can cause blockages (bowel obstructions) and holes (called perforations)

• Cause vaginal dryness and pain during sex

• Weaken pelvis bones, so they might break more easily if you have an injury or fall

• Cause scar tissue in the vagina (called fibrosis) that can make it shorter or more narrow (called stenosis)

• Cause abnormal connections to form between organs in your pelvis, like the vagina, bladder, bowels, and uterus. These are called fistulas.

Talk to your healthcare provider about what side effects you can expect. Also talk about what can be done to prevent or ease them. Ask your healthcare provider what symptoms to watch out for. Know when you should call your healthcare team and how to get help after office hours and on weekends and holidays.