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Vulvar Precancer Cases Increase More Than Fourfold: Ob-Gyns Issue Treatment Recommendations

October 20, 2011

Washington, DC -- Women diagnosed with vulvar intraepithelial neoplasia (VIN) should be treated with surgery, laser ablation, or medical therapy, according to a new Committee Opinion issued jointly today by The American College of Obstetricians and Gynecologists (The College) and The American Society for Colposcopy and Cervical Pathology (ASCCP). The College and ASCCP issued the recommendations in light of the rising incidence of VIN among US women, particularly those in their 40s.

Surveillance data show that the incidence of VIN increased more than fourfold between 1973 and 2000. Certain characteristics of VIN are similar to cervical dysplasia, a precancerous condition. VIN is subdivided into two main groups: usual-type VIN and differentiated VIN. Usual-type VIN is often associated with the cancer-causing strains of human papillomavirus (HPV) and risk factors such as cigarette smoking and compromised immune systems. Differentiated VIN is more often linked to dermatologic conditions of the vulva, such as lichen sclerosus. Most women with VIN have visible lesions that are raised, and the lesions vary in color from white to gray, or red, brown, or black.

"Most women with VIN will not notice any symptoms, but some may have bleeding, discharge, or itching," said Gerald F. Joseph, Jr, MD, The College's Vice President for Practice Activities. "It would be sensible," he said, "for women to periodically examine their vulvar area for any unusual spots or lesions, and if they find something, make an appointment with their ob-gyn."

"Although VIN appears to be increasing in the US, the risk of vulvar cancer is small when compared with cervical, ovarian, and uterine cancers," said L. Stewart Massad, MD, a member of The College's Committee on Gynecologic Practice. "VIN is similar to precancerous cervical lesions in that they are both generally slow-growing." The quadrivalent HPV vaccine that helps prevent cervical cancer and genital warts has also been shown to decrease the risk of VIN.

There is no screening recommendation for preventing vulvar cancer. Currently, the only way to diagnose VIN is by visually examining the lesions. Most lesions will need to be biopsied, an in-office procedure performed with local anesthesia, said Dr. Massad. If cancer is suspected, then surgical excision of the lesion(s) is the preferred treatment. If a VIN lesion appears precancerous, then laser ablation is an acceptable treatment. Low-grade lesions can be simply monitored to see if they spontaneously resolve, as some do, or can be treated like genital HPV warts with the off-label use of topical imiquimod 5% cream for 12-20 weeks.

Regardless of treatment method, the recurrence rate of VIN is high, and women remain at risk for recurrent VIN and vulvar cancer throughout their lives. "Because the recurrence rate exceeds 30-50%, women diagnosed with VIN must be vigilant and report any vulvar changes to their gynecologist," said Dr. Joseph. The College and ASCCP recommend that women have follow-up visits with their ob-gyn at six months and 12 months after treatment, and then should be monitored annually.

Committee Opinion #509 "Management of Vulvar Intraepithelial Neoplasia" is published in the November 2011 issue of Obstetrics & Gynecology.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation's leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of approximately 55,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women's health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org


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