CERVICAL CANCER

It is a malignant neoplasm of the cervix uteri or cervical area.

ETIOLOGY
Human papillomavirus is regarded as the vector that confers susceptibility to neoplastic conversion or that directly incites transmutation to a malignant phenotype in some infected epithelial cells.

RISK FACTORS
Becoming sexually active before age 18 Giving birth before age 16 If your mother took a drug called diethylstilbestrol (DES) during pregnancy Multiple sexual partners Persistent, high-risk HPV (genital warts) infection of the cervix Smoking Black, Hispanic, and Native American women have a two- to threefold elevation in risk Women of low socioeconomic status Dietary deficiency of ascorbic acid and carotene Lack of regular Pap screening Immunosuppressed patients

MANIFESTATIONS
Early stages: usually asymptomatic Abnormal bleeding from the vagina Bleeding or spotting between regular menstrual period Bleeding after sex Menstrual periods that last longer and are heavier than before Bleeding after menopause Leucorrhea

Late stages: a. Compression symptoms: Pain in the pelvis or lower back Pain during sexual intercourse b. Systematic symptoms:

Uremia Weight loss Anemia Fever Systematic failure Cachexia Lymph node metastasis

COMPLICATIONS
Local Disfigurement Nervous Lumbosacral Plexopathy Spinal Cord Compression Lymphatic Lymph Node Metastasis Urinary Alteration in Urinary Frequency Bladder Metastasis Reproductive Sterility Hematologic Anemia Psychiatric Psychosis Depression Latrogenic (Possible Complications of Surgery) Hemorrhage Infection Bladder Problems Damage to Surrounding Organs Blood Clots Anesthesia Pain

DIAGNOSTIC PROCEDURES
Screening test a. Papanicolaous test

The Pap test (sometimes called a Pap smear or cervical cytology) is a way to examine cells collected from the cervix. The main purpose of the Pap test is to detect cancer or abnormal cells that may lead to cancer. Initiation of Screening: Screening begins approximately 3 years after a woman begins having vaginal intercourse, but no later than age 21. It usually takes 3 to 5 years to develop these lesions after the first exposure to HPV infection. Screening Interval: For women Younger Than 30 Years- The American Cancer Society recommends that cervical screening be performed annually or every 2 years using liquidbased cytology after initiation of screening. For women Older than 30 Years - If the Pap test and the HPV DNA test are both negative in a woman at or after age 30, screening should be performed every 3 years. Discontinuing Screening: Current American Cancer Society guidelines recommend that women older than 70 years who have had three or more normal Pap tests and no abnormal Pap tests in the last 10 years may choose to stop Pap test screening. However, it is probably reasonable to screen women age 70 and older who have not been screened previously and have new sexual partners. Results: A doctor may simply describe Pap test results to a patient as normal or abnormal. Most laboratories use a standard set of terms, called the Bethesda System, to report Pap test results. Under the Bethesda System, samples that have no cell abnormalities are reported as negative for intraepithelial lesion or malignancy. Samples with cell abnormalities are divided into the following categories, ranging from the mildest to the most severe: Squamous cell abnormalities: ASCatypical squamous cells. This is subdivided into two groups: ASC-USatypical squamous cells of undetermined significance. The squamous cells do not appear completely normal, but doctors are uncertain about what the cell changes mean. ASC-Hatypical squamous cells, cannot exclude a high-grade squamous intraepithelial lesion. The cells do not appear normal, but doctors are uncertain about what the cell changes mean. LSILlow-grade squamous intraepithelial lesion. Low-grade means that there are early changes in the size and shape of cells. LSILs are sometimes referred to as mild dysplasia They may also be referred to as cervical intraepithelial neoplasia (CIN-1). HSILhigh-grade squamous intraepithelial lesion. High-grade means that there are more evident changes in the size and shape of the abnormal (precancerous) cells and that the cells look very different from normal cells. HSILs include lesions with moderate or severe dysplasia or carcinoma in situ. HSIL lesions are sometimes referred to as CIN-2, CIN-3,

or CIN-2/3, indicating that the abnormal cells occupy most of the layers of the lining of the cervix. Squamous cell carcinoma Glandular cell abnormalities: AGCatypical glandular cells. The glandular cells do not appear normal, but doctors are uncertain about what the cell changes mean. AISendocervical adenocarcinoma in situ. Precancerous cells are found in the glandular tissue. Adenocarcinoma. b. HPV DNA testing HPV DNA testing is now included in screening as an adjunct to the Pap test for women 30 years and older. The rationale for recommending HPV testing in women 30 years and older is based on the finding that the prevalence of high-risk HPV infection declines with age. Confirmatory Diagnostic procedure: a. Biopsy of the cervix, which often involves colposcopy, or a magnified visual inspection of the cervix aided by using an acetic acid solution to produce color changes in precancerous or cancerous areas. Colposcopy is a way for doctors to use a special magnifying device to look at the vulva, vagina, and cervix. For precancerous lesions: the CIN (cervical intraepithelial neoplasia) grading is used. It classifies mild dysplasia as CIN1, moderate dysplasia as CIN2, and severe dysplasia and CIS (carcinoma in situ) as CIN3. For severe dysplasia: Further diagnostic procedures are loop electrical excision procedure (LEEP) and conization. Results: Abnormal findings The vinegar or iodine shows areas of abnormal tissue. Sores or other problems, such as genital warts or an infection, are found in or around the vagina or cervix. A biopsy sample shows abnormal cells. This may mean cervical cancer is present or likely to develop. Diagnostic procedures for Staging: a. Loop electrical excision procedure (LEEP) uses a thin wire loop electrode which is attached to an electrosurgical generator. The generator transmits a painless electrical current that quickly cuts away the affected cervical tissue in the immediate area of the loop wire. This causes the abnormal cells to rapidly heat and burst, and separates the tissue as the loop wire moves through the cervix. This technique allows the physician to send the excised tissue to the lab for further evaluation which insures that the lesion was completely removed, as well as allowing for a more accurate assessment of the abnormal area. b. A cold knife cone biopsy (conization) is a procedure to get a sample of abnormal tissue from the cervix for further examination. A cold knife biopsy

may be done if a cervical biopsy using colposcopy cannot find the cause of an abnormal Pap smear. c. Endocervical curettage is done to examine the opening of the cervix. It is a procedure where a curette--a spoon-shaped instrument--is used to scrape the mucous membrane of the endocervical canal. This procedure obtains a small tissue sample, which is then sent to a pathology lab to be examined for abnormal cells. d. Hysteroscopy is done to inspect the uterine cavity by endoscopy with access through the cervix. This examines for metastasis. e. Cystoscopy is a procedure to see the inside of the bladder and urethra. It is done to examine metastasis of cancer on the bladder and urethra. f. Proctoscopy is done to examine the anal cavity, rectum or sigmoid colon. It is done to examine metastasis of cancer. g. Intravenous urography or intravenous pyelogram (IVP) is a special x-ray examination of the kidneys, bladder, and ureters. The test may reveal metastasis to the urinary system. h. X-ray examination of the lungs and skeleton to examine metastasis to the lungs and bones. STAGING for Cervical Cancer TNM staging system for cervical cancer is analogous to the FIGO stage. Stage 0 - full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ) Stage I - limited to the cervix o IA - diagnosed only by microscopy; no visible lesions IA1 - stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread IA2 - stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less o IB - visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm IB1 - visible lesion 4 cm or less in greatest dimension IB2 - visible lesion more than 4 cm Stage II - invades beyond cervix o IIA - without parametrial invasion, but involve upper 2/3 of vagina o IIB - with parametrial invasion Stage III - extends to pelvic wall or lower third of the vagina o IIIA - involves lower third of vagina o IIIB - extends to pelvic wall and/or causes hydronephrosis or nonfunctioning kidney Stage IV - extends outside the vagina o IVA - invades mucosa of bladder or rectum and/or extends beyond true pelvis o IVB - distant metastasis

MEDICAL MANAGEMENT
Treatment options depend on the following:

The stage of the cancer. The size of the tumor. The patient's desire to have children. The patients age.

Treatments used: Hysterectomy with lymph node biopsy for women with late-stage cancer or those with early-stage cancer who have completed childbearing Cone biopsy may remove enough of the dysplasia Ablation of the lesion with cryotherapy, which freezes the cells Trachelectomy Pelvic exenteration for recurrent cervical cancer in the pelvis Radiation therapy Chemotherapy: Cisplatin carboplatin paclitaxel cyclophosphamide ifosfamide 5-fluorouracil

NURSING MANAGEMENT
Assessment Subjective Data Postcoital bleeding (bleeding after intercourse) Spotting (between periods or after menopause) Foul-smelling vaginal discharge Increased or bloody discharge Weight loss Pain (radiates down the lower back and legs) Objective Data Presence and appearance of a vaginal discharge Cervix may appear eroded or raw and may bleed easily when touched with a cotton-tipped applicator or Pap scraper Necrotic tissue may be present and cause a foul odor Tissue samples obtained through colposcopic exam may show cellular changes Metastases are most likely to occur in the rectum, vagina, bladder, and pelvis

Nursing Diagnoses Preoperative Anxiety Knowledge Deficit Postoperative Impaired Skin Integrity Impaired Urinary Elimination, Bowel Incontinence, or Constipation Impaired Sexuality Patterns Planning The client will demonstrate measures to cope with anxiety. The client will demonstrate understanding of diagnosis and proposed therapeutic regimen. The clients skin integrity will be maintained. The client will have adequate bowel and bladder function during the postoperative period. The client will maintain satisfactory sexuality patterns postoperatively. Nursing Interventions Anxiety Encourage client to express her feelings and concerns to reduce her anxiety and to determine appropriate interventions. Assess the meaning of the diagnosis to the client, clarify misconceptions, and provide reliable, realistic information to enhance her understanding of her condition, subsequently reducing her anxiety. Assess clients psychological status to determine degree of emotional distress related to diagnosis and treatment options. Identify and address verbalized concerns, providing information about what to expect to decrease uncertainty about the unknown. Assess the clients use of coping mechanisms in the past and their effectiveness to faster use of positive strategies. Teach client about early signs of anxiety and her recognize them (e.g., fast heartbeat, sweating, or feeling flushed) to minimize escalation of anxiety. Provide positive reinforcement that the clients condition can be managed to relieve her anxiety. Knowledge Deficit Assess clients current knowledge about her diagnosis and proposed therapeutic regimen to establish a baseline from which to develop a teaching plan.

Review contributing factors associated with development of reproductive tract cancer, including lifestyle behaviours, to faster an understanding of the etiology of cervical cancer. Review information about treatments and procedures and recommendations for healthy lifestyle, obtaining feedback frequently to validate adequate understanding of instructions. Discuss strategies, including using condoms and limiting the number of sexual partners, to reduce the risk of transmission of STIs, including human papillomavirus (HPV), which is associated with cervical cancer. Encourage client to obtain prompt treatment of any vaginal or cervical infections to minimize the risk for cervical cancer. Urge the client to have an annual Pap smear to allow screening and early detection. Describe the treatment measures used to provide client with knowledge of what may be necessary. Provide written material with pictures to allow for client review and help her visualize what is occurring in her body. Inform client about available community resources and make appropriate referrals as needed to provide additional education and support. Document details of teaching and learning to allow for continuity of core and further education, if needed.

Impaired Skin Integrity Provide the client with proper skin-care instructions during and after radiation therapy that may include avoiding soaps, creams, powder, deodorants and other substances around the incision or that may irritate the skin. Teach client to look for signs of reaction to radiation therapy, such as tenderness, flushed color (may look like sunburn), delayed wound healing and itching. Perform daily cleansing of the incisional area with water only. If client is on CBR due to radium implant, provide complete bedbath as well as morning and bedtime care. Organize time near the clients bedside to brief periods to avoid overexposure to radiation. Wear rubber gloves when disposing of soiled materials. Put soiled dressings in a biohazard waste container and mark as radio-active. Impaired Urinary Elimination, Bowel Incontinence, or Constipation Explain dietary modifications designed to reduce residue. The diet should be limited in dairy products, raw fruits, grains and vegetables.

If client is no receiving radium implant, weigh client daily on the same time of the day, same clothes, and same weighing scale. Assess bowel sounds and abdominal distention at least every 4-8 hours. Carefully monitor the clients urinary pattern and maintain an accurate intake and output record. Observe urine and stool for color, consistency, amount, and presence of blood. Monitor for other GI problems, such as vomiting, nausea and tenesmus (spasmodic contraction of the anal or bladder sphincter causing pain and usual urge to empty the bowel or bladder.)

Ineffective Sexuality Patterns Assess clients use of self-criticism to determine clients current state of coping and adjustment. Provide opportunities for client to explore her feelings related to issues of sexuality to minimize feelings of guilt about her condition. Recommend the client to seek sexual counselling for both herself and her partner if she is unable to maintain normal sexuality patterns.