16 August 2026
Cervical and vaginal cancer are highly treatable but are still too often discovered late. Gynaecological oncologist Rawand Salihi on screening, specialised care and the underestimated impact of cancer treatment on quality of life.
Cervical cancer is probably the best-known cancer caused by HPV. In Belgium, around 610 new cases are diagnosed every year.[1] “We see a clear peak between the ages of 35 and 45,” says Dr Salihi. “But because older women can still develop cervical cancer too, the average age at diagnosis is higher, around 50.” Almost all cervical cancers are caused by a persistent infection with high-risk HPV.
Vaginal cancer is also often HPV-related: 70 to 75% of cases. The difference is that vaginal cancer is far less well known. With only 30 to 40 diagnoses a year, it is one of the rarest gynaecological cancers.[2] Most patients are diagnosed around the age of 70, although vaginal cancer can also occur in younger women.
Rawand Salihi is head of the gynaecological oncology clinic at UZ Gent and is affiliated with UGent, where he also teaches students and trainee residents. He is also a consultant at AZ Sint-Lucas Gent and chairs two working groups within the VVOG (the Flemish Society of Obstetrics and Gynaecology) focused on gynaecological oncology. He was closely involved in developing the new HPV screening guidelines on behalf of Flemish gynaecologists. His doctoral research focused on new treatments for cervical cancer.
“In its early stages, cervical cancer often causes no symptoms at all – which is exactly why screening matters. When symptoms do occur, they usually involve bleeding after intercourse or between periods. As the tumour grows, vaginal discharge, pain during intercourse and eventually bladder or bowel symptoms can also develop, such as a sensation similar to a urinary tract infection, without there actually being one, or a false urge to urinate.”
Vaginal cancer often causes similar symptoms but is sometimes recognised later because attention during a gynaecological exam is primarily directed at the cervix. “That’s why I teach my trainees to also take a good look at the vagina as they remove the speculum. It only takes five seconds, but that small extra step can reveal precancerous lesions (see box) or even tumours that would otherwise go unnoticed,” says Dr Salihi. “It has happened more than once that a woman had undergone one conisation after another without result, while the tumour was simply located in the vagina.”
Extra vigilance is also important for women who have previously had cervical cancer or a precancerous lesion, and for women with a weakened immune system. They face an increased risk of HPV-related vaginal cancer.
The most important warning sign in any case is bleeding at an unexpected time: between two periods, after intercourse, or after menopause. “Postmenopausal bleeding should always be investigated,” Dr Salihi stresses. “Nine times out of ten, it will turn out to be nothing serious, but that one time in ten is serious enough that it should never be ignored. So don’t put off seeking help. If you’ve had bleeding for several weeks, or vaginal discharge with an unusual colour or smell, pain, or other symptoms that won’t go away, get it checked out!”
VaIN: precancerous lesions of vaginal cancer
Vaginal cancer has precancerous lesions, just like cervical cancer (CIN). For vaginal cancer, these are called VaIN – vaginal intraepithelial neoplasia, which are abnormalities in the lining of the vagina, also known as dysplasia. They are classified into three grades based on the severity of the abnormalities:
The term precancerous lesion is only used for grade 2 and grade 3 lesions, VaIN2 and VaIN3. These lesions are usually treated to prevent them from developing into vaginal cancer. Less data is available on the likelihood of VaIN2 and VaIN3 resolving on their own compared with CIN, but that likelihood appears to be limited.
An abnormal smear test or symptoms? The next step is further investigation, including a biopsy and tissue analysis if needed . If cervical or vaginal cancer is diagnosed, additional tests follow to answer two questions: how far has the tumour spread, and are there any metastases?
The approach to further evaluating cervical and vaginal cancer is largely similar. An MRI scan provides information about the size of the tumour and how far it has grown into surrounding tissue or organs. CT or PET-CT scans check whether there are metastases in the lymph nodes or elsewhere in the body. This information is important for choosing and planning treatment.
For vaginal cancer, additional examination under anaesthesia may sometimes be needed to map out the exact extent of the tumour within the vagina.
“The approach to treating cervical cancer has become considerably more complex in recent years,” says Dr Salihi. “Which treatment is most suitable depends mainly on how advanced the tumour is, the patient’s general health, and whether she wishes to have children in the future. Put very simply: for early-stage cervical cancer, up to tumours of around 4 centimetres[3], we usually opt for surgery. For the smallest tumours, conisation is often enough. For tumours that can no longer be treated with conisation, a hysterectomy is needed (see below ). That procedure is usually combined with a sentinel node procedure to check whether cancer cells are present in the lymph nodes. For women who wish to have children, there are also alternatives, such as a trachelectomy, in which the cervix is removed but the uterus is preserved, so that pregnancy is still possible later.”
For larger or locally more advanced tumours[4], the standard treatment is chemoradiotherapy (a combination of chemotherapy and radiotherapy, in which the chemotherapy enhances the effect of the radiation), followed by brachytherapy – a form of internal radiotherapy. “If the pelvis needs to be irradiated, the ovaries are usually permanently damaged,” he says. “That’s why, with young women, we always discuss the option of freezing eggs or ovarian tissue. Sometimes we can move the ovaries outside the radiation field. The uterus, however, is usually rendered unsuitable for pregnancy by the radiation.”
Once the disease has spread, surgery is no longer an option. At that point, treating only locally has little benefit, and you need to switch to systemic treatments: treatments that act throughout the entire body. Because, unlike certain forms of breast cancer, cervical cancer is not hormone-sensitive, this treatment usually consists of chemotherapy, sometimes combined with immunotherapy or an angiogenesis inhibitor, a drug that slows the formation of new blood vessels feeding the tumour.
For vaginal cancer, the approach is largely determined by the location of the tumour, Dr Salihi explains. “Broadly speaking: if the tumour is close to the outside, treatment often resembles that for vulvar cancer. If it sits deeper in the vagina, the approach looks more like that for cervical cancer. Surgery is used less often, although small tumours high in the vagina can sometimes still be operated on. In practice, most patients receive chemoradiotherapy followed by brachytherapy. As with cervical cancer, this internal radiotherapy is crucial for gaining local control of the tumour.”
The final treatment decision is always discussed within a multidisciplinary team and tailored to the individual patient’s situation. In this context, Dr Salihi wants to correct a common misconception. “Patients think their prognosis is worse if they receive chemoradiotherapy instead of surgery. That’s not true. Chemoradiotherapy, often combined with brachytherapy, is a highly effective treatment for cervical cancer and offers just as good a chance of cure as surgery.”
“Even with locally advanced tumours, for example when the cancer has grown into the tissue around the cervix or into neighbouring organs, we can achieve excellent results with chemoradiotherapy. So, the choice between surgery and chemoradiotherapy isn’t primarily determined by the chance of cure, but by the question of which treatment offers the best balance between effectiveness and side effects in a given situation. If a tumour cannot be fully removed surgically, there’s little point in operating first and then still needing radiotherapy afterwards. In that case, we often choose chemoradiotherapy from the start.”
The most important factor determining prognosis is the stage at which the cancer is detected. If the disease is found at an early stage, the chances of cure (five-year survival) are often above 90%. With metastatic disease, however, the picture looks very different: five-year survival then drops to below 20%.
“That’s why early detection matters so much,” Dr Salihi stresses. “The problem is that cervical and vaginal cancer often cause no, few, or only vague symptoms. As a result, 60 to 70% of cases are only detected at a more advanced stage.”
Early menopause, sexual problems, fertility questions, or relationship difficulties – topics that have often received too little attention in the past. The message seemed to be: we’ve cured you, madam, you should be satisfied. But of course, it’s not that simple. Even once the cancer is gone, people can still struggle with the effects of treatment for years afterwards.
Dr Salihi remembers a patient who came in for a consultation years after being treated for cervical cancer. “She was around forty and had pretty much every menopausal symptom you can imagine. Her relationship was struggling, her sex life was non-existent, and psychologically she was in a bad place. She spent an hour telling me about everything that was going wrong.” He suggested trying hormone therapy. “Simply to bring her out of that early menopause. When she came back for a follow-up consultation sometime later, she said: doctor, you’ve cured me. I’ll never forget that. That woman had rediscovered her zest for life. Not because her cancer was gone – it had been gone for years already – but because she finally had her life back.”
These days, doctors take the long-term effects and side effects of treatment into account more than they used to. Even so, according to Dr Salihi, the impact of a gynaecological cancer on relationships and sexuality is still often underestimated. After surgery, sensation in and around the vagina can change, and radiotherapy can make the vagina drier, narrower and less elastic. Research shows that even after a relatively minor procedure, such as a conisation, some women experience difficulties with sexuality. “Not so much because of the procedure itself, but because something has happened to a deeply intimate part of their body,” he says. “I’ve seen women who were still completely preoccupied with what had happened, while their partner didn’t see the problem – the doctor helped you, right? That can put real strain on a relationship.”
Recovery isn’t only physical, but also has an emotional and psychological dimension. That’s why he finds it important for partners to be involved, both during diagnosis and treatment and in aftercare. When they understand what the other person is going through, it becomes easier to face it together. “And that’s also why I strongly believe in multidisciplinary care. Oncology nurses, sexologists, menopause counsellors and other care providers can all help patients with issues that often reach far beyond the cancer itself.”
Cervical cancer is one of the most preventable and treatable forms of cancer. Dr Salihi stresses that we need to keep investing in prevention and early detection. “There will probably never be a separate population-wide screening programme for vaginal cancer, the way we have for breast, bowel or cervical cancer. But a thorough examination of the vagina, and of the vulva for that matter, can easily be incorporated into existing cervical screening.”
The classic smear test, however, remains a barrier for too many women. Self-sampling tests could therefore be an important step forward. Still, in his view, self-sampling tests alone won’t solve the problem. “The women who participate least in screening today are often also the hardest to reach through other channels. I think that’s one of the biggest challenges for the coming years.”
On top of that, we need to keep working on further centralising care. “Thanks to vaccination and screening, cervical cancer and other HPV-related gynaecological cancers will become increasingly rare,” he explains. “That’s obviously a good thing, but it also means we will absolutely need to concentrate treatment of these cancers in centres that treat enough patients to maintain that expertise. These don’t necessarily have to be university centres, but they do need to have sufficient experience. Centralisation, by the way, isn’t only about treatment. It’s also about diagnosis – I’m thinking here of the tissue analysis that’s essential for an accurate diagnosis. That requires the expertise of experienced gynaecological pathologists, because some tumours can be difficult to distinguish from one another in a biopsy sample. Centralisation also makes it easier to surround patients with a multidisciplinary team of specialised care providers. In a hospital that only treats one or two patients a year, it’s hard to build up that kind of support structure. In specialised centres, that’s far more achievable.”
“We have the knowledge, the tests and the treatments. We’ll make the biggest gains if we also reach the groups who still too often fall through the cracks today, and if we can offer them good multidisciplinary support in specialised centres,” he concludes.
A great deal of progress has been made in treatment in recent years.
The SHAPE study showed that women with a small cervical tumour, up to 2 centimetres, can often be treated just as safely with a simple hysterectomy as with a radical hysterectomy, in which more surrounding tissue is removed in addition to the uterus and cervix. The less invasive procedure, the simple hysterectomy, was also associated with fewer urinary tract complications, better sexual function, and a better quality of life. “These results have helped change practice: for small tumours, a simple hysterectomy is now chosen more often, whereas in the past a radical procedure was more commonly performed,” says Dr Salihi.
The approach to the lymph nodes has also changed. “For cervical cancer, we used to often remove all the lymph nodes in a certain area, but nowadays it’s often enough to remove only the sentinel node – the first lymph node to which cancer cells are likely to spread. For vulvar cancer, we’ve been doing this for longer already.” This procedure gives comparable oncological results, but is associated with less lymphoedema. Today, it is also the standard approach for cervical cancer.
In addition, radiotherapy has evolved considerably. For cervical cancer, image-guided adaptive brachytherapy is now used. With the help of imaging, doctors can respond to changes in the tumour during treatment. This allows the radiation to be more precisely targeted at the tumour and less at the surrounding healthy tissue, reducing the risk of side effects.
And then there have been important advances in systemic treatments too. The INTERLACE study showed that induction chemotherapy – a short additional course of chemotherapy before standard chemoradiotherapy – improves survival in locally advanced cervical cancer. “In recent years, we’ve also seen an increasingly important role for immunotherapy,” says Dr Salihi. The KEYNOTE-A18 study showed that adding pembrolizumab to chemoradiotherapy can further improve outcomes in locally advanced cervical cancer. Pembrolizumab is a form of immunotherapy. For metastatic or recurrent disease, pembrolizumab can also be added to systemic treatment for patients with a PD-L1-positive tumour (a tumour that “expresses” the PD-L1 protein, a feature that can help predict whether this form of immunotherapy will be effective), as shown in the KEYNOTE-826 study.
There are also promising therapies in the pipeline. Clinical trials are currently underway into therapeutic HPV vaccines, designed to treat HPV infections, precancerous lesions and/or cancer. For recurrent cervical cancer, Dr Salihi also expects a lot from ADCs (antibody-drug conjugates), a form of targeted therapy in which an antibody delivers the cancer-killing agent mainly to the tumour cells. Compared with classic chemotherapy, this means more of the drug reaches the tumour and less ends up in healthy tissue.
“There’s certainly still a need for innovation,” he says, “but I don’t think the coming years should focus mainly on further improving survival. Results today are already very good, although of course we keep striving for every additional percentage point of progress. In my view, the biggest challenge will be further reducing the side effects of our treatments. Think of the impact of surgery, radiotherapy and chemoradiotherapy on patients’ quality of life, sexual function and fertility. We need to pay even more attention to that.”
[1] Belgian Cancer Registry, Cancer Fact Sheet 2023 Cervical Cancer
[2] Belgian Cancer Registry, Brussel, 2026 and Globocan 2022
[3] FIGO stage IA1 to IB2. FIGO is the international classification system doctors use to describe the stage of gynaecological cancers. Stage IA1 to IB2 covers early forms of cervical cancer that are confined to the cervix.
[4] +FIGO stage IB3 to IVA covers locally advanced cervical cancer: the tumour has grown larger or has spread beyond the cervix, but there are not yet any metastases to other organs.
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