cervical cancer

Cervical Cancer

 

Definition

Cervical cancer is a disease in which the cells of the cervix become abnormal and start to grow uncontrollably, forming tumors.

Description

In the United States, cervical cancer is the fifth most common cancer among women aged 35-54, and the third most common cancer of the female reproductive tract. In some developing countries, it is the most common type of cancer. It generally begins as an abnormality in the cells on the outside of the cervix. The cervix is the lower part or neck of the uterus (womb). It connects the body of the uterus to the vagina (birth canal).

Approximately 90% of cervical cancers are squamous cell carcinomas. This type of cancer originates in the thin, flat, squamous cells on the surface of the ectocervix, the part of the cervix that is next to the vagina. (Squamous cells are the thin, flat cells of the surfaces of the skin and cervix and linings of various organs.) Another 10% of cervical cancers are of the adenocarcinoma type. This cancer originates in the mucus-producing cells of the inner or endocervix, near the body of the uterus. Occasionally, the cancer may have characteristics of both types and is called adenosquamous carcinoma or mixed carcinoma.

The initial changes that may occur in some cervical cells are not cancerous. However, these precancerous cells form a lesion called dysplasia or a squamous intraepithelial lesion (SIL), since it occurs within the epithelial or outer layer of cells. These abnormal cells can also be described as cervical intraepithelial neoplasia (CIN). Moderate to severe dysplasia may be called carcinoma in situ or non-invasive cervical cancer.

Dysplasia is a common condition and the abnormal cells often disappear without treatment. However, these precancerous cells can become cancerous. This may take years, although it can happen in less than a year. Eventually, the abnormal cells start to grow uncontrollably into the deeper layers of the cervix, becoming an invasive cervical cancer.

Although cervical cancer used to be one of the most common causes of cancer death among American women, in the past 40 years there has been a 75% decrease in mortality. This is primarily due to routine screening with Pap tests (Pap smear), to identify precancerous and early-invasive stages of cervical cancer. With treatment, these conditions have a cure rate of nearly 100%.

Worldwide, there are more than 400,000 new cases of cervical cancer diagnosed each year. The American Cancer Society (ACS) estimated 13,000 new cases of invasive cervical cancer diagnosed in the United States in 2002. More than one million women were diagnosed with a precancerous lesion or non-invasive cancer of the cervix in 2001.

Older women are at the highest risk for cervical cancer. Although girls under the age of 15 rarely develop this cancer, the risk factor begins to increase in the late teens. Rates for carcinoma in situ peak between the ages of 20 and 30. In the United States, the incidence of invasive cervical cancer increases rapidly with age for African-American women over the age of 25. The incidence rises more slowly for Caucasian women. However, women over age 65 account for more than 25% of all cases of invasive cervical cancer.

The incidence of cervical cancer is highest among poor women and among women in developing countries. In the United States, the death rates from cervical cancer are higher among Hispanic, Native American, and African-American women than among Caucasian women. These groups of women are much less likely to receive regular Pap tests. Therefore, their cervical cancers usually are diagnosed at a much later stage, after the cancer has spread to other parts of the body.

Causes and symptoms

Human papillomavirus

Infection with the common human papillomavirus (HPV) is a cause of approximately 90% of all cervical cancers. There are more than 80 types of HPV. About 30 of these types can be transmitted sexually, including those that cause genital warts (papillomas). About half of the sexually transmitted HPVs are associated with cervical cancer. These "high-risk" HPVs produce a protein that can cause cervical epithelial cells to grow uncontrollably. The virus makes a second protein that interferes with tumor suppressors that are produced by the human immune system. The HPV-16 strain is thought to be a cause of about 50% of cervical cancers.

More than six million women in the United States have persistent HPV infections, for which there are no cure. Nevertheless, most women with HPV do not develop cervical cancer.

Symptoms of invasive cervical cancer

Most women do not have symptoms of cervical cancer until it has become invasive. At that point, the symptoms may include:

• unusual vaginal discharge
• light vaginal bleeding or spots of blood outside of normal menstruation
• pain or vaginal bleeding with sexual intercourse
• post-menopausal vaginal bleeding

Once the cancer has invaded the tissue surrounding the cervix, a woman may experience pain in the pelvic region and heavy bleeding from the vagina.

Diagnosis

The pap test

Most often, cervical cancer is first detected with a Pap test that is performed as part of a regular pelvic examination. The vagina is spread with a metal or plastic instrument called a speculum. A swab is used to remove mucus and cells from the cervix. This sample is sent to a laboratory for microscopic examination.

The Pap test is a screening tool rather than a diagnostic tool. It is very efficient at detecting cervical abnormalities. The Bethesda System commonly is used to report Pap test results. A negative test means that no abnormalities are present in the cervical tissue. A positive Pap test describes abnormal cervical cells as low-grade or high-grade SIL, depending on the extent of dysplasia. About 5-10% of Pap tests show at least mild abnormalities. However, a number of factors other than cervical cancer can cause abnormalities, including inflammation from bacteria or yeast infections. A few months after the infection is treated, the Pap test is repeated.

Biopsy

Following an abnormal Pap test, a colposcopy is usually performed. The physician uses a magnifying scope to view the surface of the cervix. The cervix may be coated with an iodine solution that causes normal cells to turn brown and abnormal cells to turn white or yellow. This is called a Schiller test. If any abnormal areas are observed, a colposcopic biopsy may be performed. A biopsy is the removal of a small piece of tissue for microscopic examination by a pathologist.

Other types of cervical biopsies may be performed. An endocervical curettage is a biopsy in which a narrow instrument called a curette is used to scrape tissue from inside the opening of the cervix. A cone biopsy, or conization, is used to remove a cone-shaped piece of tissue from the cervix. In a cold knife cone biopsy, a surgical scalpel or laser is used to remove the tissue. A loop electrosurgical excision procedure (LEEP) is a cone biopsy using a wire that is heated by an electrical current. Cone biopsies can be used to determine whether abnormal cells have invaded below the surface of the cervix. They also can be used to treat many precancers and very early cancers. Biopsies may be performed with a local or general anesthetic. They may cause cramping and bleeding.

Diagnosing the stage

Following a diagnosis of cervical cancer, various procedures may be used to stage the disease (determine how far the cancer has spread). For example, additional pelvic exams may be performed under anesthesia.

There are several procedures for determining if cervical cancer has invaded the urinary tract. With cystoscopy, a lighted tube with a lens is inserted through the urethra (the urine tube from the bladder to the exterior) and into the bladder to examine these organs for cancerous cells. Tissue samples may be removed for microscopic examination by a pathologist. Intravenous urography (intravenous pyelogram or IVP) is an x ray of the urinary system, following the injection of special dye. The kidneys remove the dye from the bloodstream and the dye passes into the ureters (the tubes from the kidneys to the bladder) and bladder. IVP can detect a blocked ureter, caused by the spread of cancer to the pelvic lymph nodes (small glands that are part of the immune system).

A procedure called proctoscopy or sigmoidoscopy is similar to cystoscopy. It is used to determine whether the cancer has spread to the rectum or lower large intestine.

Computed tomography (CT) scans, ultrasound, or other imaging techniques may be used to determine the spread of cancer to various parts of the body. With a CT scan, an x-ray beam rotates around the body, taking images from various angles. It is used to determine if the cancer has spread to the lymph nodes. Magnetic resonance imaging (MRI), which uses a magnetic field to image the body, sometimes is used for evaluating the spread of cervical cancer. Chest x rays may be used to detect cervical cancer that has spread to the lungs.

Treatment

Following a diagnosis of cervical cancer, the physician takes a medical history and performs a complete physical examination. This includes an evaluation of symptoms and risk factors for cervical cancer. The lymph nodes are examined for evidence that the cancer has spread from the cervix. The choice of treatment depends on the clinical stage of the disease.

The figo system of staging

The International Federation of Gynecologists and Obstetricians (FIGO) system usually is used to stage cervical cancer:

• Stage 0: Carcinoma in situ; non-invasive cancer that is confined to the layer of cells lining the cervix
• Stage I: Cancer that has spread into the connective tissue of the cervix but is confined to the uterus
• Stage IA: Very small cancerous area that is visible only with a microscope
• Stage IA1: Invasion area is less than 3 mm (0.13 in) deep and 7 mm (0.33 in) wide
• Stage IA2: Invasion area is 3-5 mm (0.13-0.2 in) deep and less than 7 mm (0.33 in) wide
• Stage IB: Cancer can be seen without a microscope or is deeper than 5 mm (0.2 in) or wider than 7 mm (0.33 in)
• Stage IB1: Cancer is no larger than 4 cm (1.6 in)
• Stage IB2: Stage IB cancer is larger than 4 cm (1.6 in)
• Stage II: Cancer has spread from the cervix but is confined to the pelvic region
• Stage IIA: Cancer has spread to the upper region of the vagina, but not to the lower one-third of the vagina
• Stage IIB: Cancer has spread to the parametrial tissue adjacent to the cervix
• Stage III: Cancer has spread to the lower one-third of the vagina or to the wall of the pelvis and may be blocking the ureters
• Stage IIIA: Cancer has spread to the lower vagina but not to the pelvic wall
• Stage IIIB: Cancer has spread to the pelvic wall and/or is blocking the flow of urine through the ureters to the bladder
• Stage IV: Cancer has spread to other parts of the body
• Stage IVA: Cancer has spread to the bladder or rectum
• Stage IVB: Cancer has spread to distant organs such as the lungs
• Recurrent: Following treatment, cancer has returned to the cervix or some other part of the body

In addition to the stage of the cancer, factors such as a woman's age, general health, and preferences may influence the choice of treatment. The exact location of the cancer within the cervix and the type of cervical cancer also are important considerations.

Treatment of precancer and carcinoma in situ

Most low-grade SILs that are detected with Pap tests revert to normal without treatment. Most high-grade SILs require treatment. Treatments to remove precancerous cells include:

• cold knife cone biopsy
• LEEP
• cryosurgery (freezing the cells with a metal probe)
• cauterization or diathermy (burning off the cells)
• laser surgery (burning off the cells with a laser beam)

These methods also may be used to treat cancer that is confined to the surface of the cervix (stage 0) and other early-stage cervical cancers in women who may want to become pregnant. They may be used in conjunction with other treatments. These procedures may cause bleeding or cramping. All of these treatments require close follow-up to detect any recurrence of the cancer.

Surgery

A simple hysterectomy is used to treat some stages 0 and IA cervical cancers. Usually only the uterus is removed, although occasionally the fallopian tubes and ovaries are removed as well. The tissues adjoining the uterus, including the vagina, remain intact. The uterus may be removed either through the abdomen or the vagina.

In a radical hysterectomy, the uterus and adjoining tissues, including the ovaries, the upper region (1 in) of the vagina near the cervix, and the pelvic lymph nodes, are all removed. A radical hysterectomy usually involves abdominal surgery. However, it can be performed vaginally, in combination with a laparoscopic pelvic lymph node dissection. With laparoscopy, a tube is inserted through a very small surgical incision for the removal of the lymph nodes. These operations are used to treat stages IA2, IB, and IIA cervical cancers, particularly in young women. Following a hysterectomy, the tissue is examined to see if the cancer has spread and requires additional radiation treatment. Women who have had hysterectomies cannot become pregnant, but complications from a hysterectomy are rare.

If cervical cancer recurs following treatment, a pelvic exenteration (extensive surgery) may be performed. This includes a radical hysterectomy, with the additional removal of the bladder, rectum, part of the colon, and/or all of the vagina. Such operations require the creation of new openings for the urine and feces. A new vagina may be created surgically. Often the clitoris and other outer genitals are left intact.

Recovery from a pelvic exenteration may take six months to two years. This treatment is successful with 40-50% of recurrent cervical cancers that are confined to the pelvis. If the recurrent cancer has spread to other organs, radiation or chemotherapy may be used to alleviate some of the symptoms.

Radiation

Radiation therapy, which involves the use of high-dosage x rays or other high-energy waves to kill cancer cells, often is used for treating stages IB, IIA, and IIB cervical cancers, or in combination with surgery. With external-beam radiation therapy, the rays are focused on the pelvic area from a source outside the body. With implant or internal radiation therapy, a pellet of radioactive material is placed internally, near the tumor. Alternatively, thin needles may be used to insert the radioactive material directly into the tumor.

Radiation therapy to the pelvic region can have many side effects:

• skin reaction in the area of treatment
• fatigue
• upset stomach and loose bowels
• vaginal stenosis (narrowing of the vagina due to build-up of scar tissue) leading to painful sexual intercourse
• premature menopause in young women
• problems with urination

Chemotherapy

Chemotherapy, the use of one or more drugs to kill cancer cells, is used to treat disease that has spread beyond the cervix. Most often it is used following surgery or radiation treatment. Stages IIB, III, IV, and recurrent cervical cancers usually are treated with a combination of external and internal radiation and chemotherapy. The common drugs used for cervical cancer are cisplatin, ifosfamide, and fluorouracil. These may be injected or taken by mouth. The National Cancer Institute recommends that chemotherapy with cisplatin be considered for all women receiving radiation therapy for cervical cancer.

The side effects of chemotherapy depend on a number of factors, including the type of drug, the dosage, and the length of the treatment. Side effects may include:

• nausea and vomiting
• fatigue
• changes in appetite
• hair loss
• mouth or vaginal sores
• infections
• menstrual cycle changes
• premature menopause
• infertility
• bleeding or anemia (low red blood cell count)

With the exception of menopause and infertility, most of the side effects are temporary.

Alternative treatment

Biological therapy sometimes is used to treat cervical cancer, either alone or in combination with chemotherapy. Treatment with the immune-system protein interferon is used to boost the immune response. Biological therapy can cause temporary flu-like symptoms and other side effects.

Some research suggests that vitamin A (carotene) may help to prevent or stop cancerous changes in cells such as those on the surface of the cervix. Other studies suggest that vitamins C and E may reduce the risk of cervical cancer.

Prognosis

For cervical cancers that are diagnosed in the preinvasive stage, the five-year-survival rate is almost 100%. When cervical cancer is detected in the early invasive stages, approximately 91% of women survive five years or more. Stage IVB cervical cancer is not considered to be curable. The five-year-survival rate for all cervical cancers combined is about 70%. The death rate from cervical cancer continues to decline by about 2% each year. Women over age 65 account for 40-50% of all deaths from cervical cancer. About 4,100 women died of the disease in the United States in 2002.

Prevention

Viral infections

Most cervical cancers are preventable. More than 90% of women with cervical cancer are infected with HPV. HPV infection is the single most important risk factor. This is particularly true for young women because the cells lining the cervix do not fully mature until age 18. These immature cells are more susceptible to cancer-causing agents and viruses.

Since HPV is a sexually-transmitted infection, sexual behaviors can put women at risk for HPV infection and cervical cancer. These behaviors include:

• sexual intercourse at age 16 or younger
• partners who began having intercourse at a young age
• multiple sexual partners
• sexual partners who have had multiple partners ("high-risk males")
• a partner who has had a previous sexual partner with cervical cancer

HPV infection may not produce any symptoms, so sexual partners may not know that they are infected. In 2003, a new DNA screening test was approved by the FDA to test for HPV at the same time as the Pap test. Condoms do not necessarily prevent HPV infection. However, in 2003, a preliminary study demonstrated that a vaccine against the type of HPV that causes the most cervical cancers showed promise in preventing HPV infection. Scientists predict having FDA approval of an HPV vaccine by about 2008 or 2010.

Infection with the human immunodeficiency virus (HIV) that causes acquired immunodeficiency syndrome (AIDS) is a risk factor for cervical cancer. Women who test positive for HIV may have impaired immune systems that cannot correct precancerous conditions. Furthermore, sexual behavior that puts women at risk for HIV infection, also puts them at risk for HPV infection. There is some evidence suggesting that another sexually transmitted virus, the genital herpes virus, also may be involved in cervical cancer.

Smoking

Smoking may double the risk of cervical cancer. In fact, studies suggest that nearly 50% of women diagnosed with cervical cancer smoke. Chemicals produced by tobacco smoke can damage the DNA of cervical cells. The risk increases with the number of years a woman smokes and the amount she smokes. A 2003 study also linked smoking to poorer outcomes and survivals in cervical cancer patients.

Diet and drugs

Diets that are low in fruits and vegetables increase the risk of cervical cancer. A 2003 study also linked obesity to increased risk for cervical adenocarcinoma. Even women who were overweight had a higher incidence of the disease. The link appears to be increase levels of estrogen. Excessive fat tissue influences levels of estrogen and other sex hormones. Women also have an increased risk of cervical cancer if their mothers took the drug diethylstilbestrol (DES) while they were pregnant. This drug was given to women between 1940 and 1971 to prevent miscarriages. Some statistical studies have suggested that the long-term use of oral contraceptives may slightly increase the risk of cervical cancer.

Pap tests

Most cases of cervical cancers are preventable, since they start with easily detectable precancerous changes. Therefore, the best prevention for cervical cancer is a regular Pap test. The ACS revised its guidelines for regular screening in late 2002. In brief, women should begin having Pap tests about three years after having sexual intercourse, but no later than 21 years of age. Women should continue screening every year with regular Pap tests until age 30. Once a woman has had three normal results in a row, she may get screened every two to three years. A doctor may suggest more frequent screening if a woman has certain risk factors for cervical cancer. Women who have had total hysterectomies including the removal of the cervix and those over age 70 who have had three normal results generally do not need to continue having Pap tests under the new guidelines.

The National Breast and Cervical Cancer Early Detection Program provides free or low-cost Pap tests and treatment for women without health insurance, for older women, and for members of racial and ethnic minorities. The program is administered through individual states, under the direction of the Centers for Disease Control and Prevention.

Special concerns

If a woman is diagnosed with very early-stage (IA) cervical cancer while pregnant, the physician usually will recommend a hysterectomy after the baby is born. For later-stage cancers, the pregnancy is terminated or the baby is removed by cesarean section as soon as it can survive outside the womb. This is followed by a hysterectomy and/or radiation treatment. For the most advanced stages of cervical cancer, treatment is initiated despite the pregnancy.

Many women with cervical cancer have hysterectomies, which are major surgeries. Although normal activities, including sexual intercourse, can be resumed in four to eight weeks, a woman may have emotional problems following a hysterectomy. A strong support system can help with these difficulties.

Key terms

Adenocarcinoma — Cervical cancer that originates in the mucus-producing cells of the inner or endocervix.

Biopsy — Removal of a small sample of tissue for examination under a microscope; used for the diagnosis and treatment of cervical cancer and precancerous conditions.

Carcinoma in situ — Cancer that is confined to the cells in which it originated and has not spread to other tissues.

Cervical intraepithelial neoplasia (CIN) — Abnormal cell growth on the surface of the cervix.

Cervix — Narrow, lower end of the uterus forming the opening to the vagina.

Colposcopy — Diagnostic procedure using a hollow, lighted tube (colposcope) to look inside the cervix and uterus.

Conization — Cone biopsy; removal of a cone-shaped section of tissue from the cervix for diagnosis or treatment.

Dysplasia — Abnormal cellular changes that may become cancerous.

Endocervical curettage — Biopsy performed with a curette to scrape the mucous membrane of the cervical canal.

Human papillomavirus (HPV) — Virus that causes abnormal cell growth (warts or papillomas); some types can cause cervical cancer.

Hysterectomy — Removal of the uterus.

Interferon — Potent immune-defense protein produced by viral-infected cells; used as an anti-cancer and anti-viral drug.

Laparoscopy — Laparoscopic pelvic lymph node dissection; insertion of a tube through a very small surgical incision to remove lymph nodes.

Loop electrosurgical excision procedure (LEEP) — Cone biopsy performed with a wire that is heated by electrical current.

Lymph nodes — Small round glands, located throughout the body, that filter the lymphatic fluid; part of the body's immune defense.

Pap test — Pap smear; removal of cervical cells to screen for cancer.

Pelvic exenteration — Extensive surgery to remove the uterus, ovaries, pelvic lymph nodes, part or all of the vagina, and the bladder, rectum, and/or part of the colon.

Squamous cells — Thin, flat cells on the surfaces of the skin and cervix and linings of various organs.

Squamous intraepithelial lesion (SIL) — Abnormal growth of squamous cells on the surface of the cervix.

Vaginal stenosis — Narrowing of the vagina due to a build-up of scar tissue.

Resources

Books

Holland, Jimmie C., and Sheldon Lewis. The Human Side of Cancer: Living with Hope, Coping with Uncertainty. New York: HarperCollins, 2000.

Runowicz, Carolyn D., Jeanne A. Petrek, and Ted S. Gansler. Women and Cancer: A Thorough and Compassionate Resource for Patients and their Families. New York: Villard Books, 1999.

Periodicals

"American Cancer Society Issues New Early Detection Guidelines." Women's Health Weekly December 19, 2002: 12.

"Get Ready to Take Cervical Cancer Screening to the Next Level: Newly Approved Human Papillomavirus Test Offers 2-in-1 Package." Contraceptive Technology Update June 2003: 61-64.

"Obesity Linked to Cervical Adenocarcinoma, a Hormone-Dependent Cancer." Cancer Weekly July 29, 2003: 59.

"Study: HPV Test Is more Effective than Pap Smear for Cervical Cancer Screening." Biotech Week December 31, 2003: 143.

Van Kessel, Katherine, Koutsky, and Laura. "The HPV Vaccine: Will it One Day Wipe Out Cervical Cancer?" Contemporary OB/GYN November 2003: 71-75.

Walgate, Robert. "Vaccine Against Cervical Cancer Passes Proof of Principle." Bulletin of the World Health Organization January-February 2003: 73-81.

Worcester, Sharon."Smoking Tied to Poorer Outcomes in Cervical Ca: Locally Advanced Disease." Family Practice News May 15, 2003: 29-31.

Organizations

Eyes On The Prize. Org. 446 S. Anaheim Hills Road, #108, Anaheim Hills, CA 92807. http://www.eyesontheprize.org. On-line information and emotional support for women with gynecologic cancer.

Other

"Cancer of the Cervix." CancerNet. 12 Dec. 2000. National Cancer Institute. NIH Publication No. 95-2047. April 3, 2001. http://cancernet.nci.nih.gov/wyntk_pubs/cervix.htm#2.

"Cervical Cancer." Cancer Resource Center. American Cancer Society. Mar 16, 2000. [cited April 3, 2001]. 〈http://www3.cancer.org/cancerinfo/load_cont.asp?ct=8&doc=25&Language=English〉.

cervical

 [ser´vĭ-k'l]

1. pertaining to the neck.

2. pertaining to the neck or cervix of any organ or structure.

cervical cancer cancer of the cervix uteri, the third most common cause of cancer deaths in American women (after lung cancer and breast cancer). Its victims are usually women over 40. One of the first warning signs of cervical cancer is vaginal bleeding between menstrual periods, after coitus, or after menopause is established. There may also be increased vaginal discharge. The papanicolaou test should be done routinely every year in women over 40 to rule out the possibility of cervical malignancy. This test identifies cancer in its earliest stages while the malignancy can still be eradicated with relative ease.

Traditionally, a positive finding of abnormal cells from the cervix was an indication for cervical biopsy, which, if positive for malignancy, was an indication for total hysterectomy. Currently, this sequence is giving way to more selective methods of diagnosis and treatment. Special stains and colposcopy are used to define more clearly the nature and extent of abnormal changes in cervical cells. These techniques have permitted a greater use of localized excision of cervical tissues (conization) and cryosurgery of early cancer zones, thereby avoiding total removal of the uterus.

cervical mucus method a type of natural family planning; see contraception.

cervical rib syndrome pain over the shoulder, often extending down the upper limb or radiating up the back of the neck, due to compression of the nerves and vessels between a cervical rib and the anterior scalene muscle.

cervical cancer

Oncology Invasive malignancy of the uterine cervix Epidemiology Incidence is 2.5-fold > in black ♀ Prevention Regular pelvic exams, pap smears Clinical Abnormal bleeding Pathology SCC–85%, adenoCA–10% Management Cryosurgery, cauterization, laser surgery Prognosis Poor if advanced; CC-related deaths are ugly; death is accompanied by uremia, and a typical 'funky' urinary odor. See Conization, LEEP. Cf Cervical intraepithelial neoplasia.

Cervical cancer staging

Stage I

No spread to nearby tissues

• IA–minimal microscopic CA found in deep cervical tissues
• IB–larger amount of CA found in deep cervical tissues

Stage II

Extension of tumor, but confined to pelvis

• IIA–spread beyond cervix to upper two thirds of the vagina
• IIB–spread to pericervical tissue

Stage III

Spread throughout pelvic area, eg to lower vagina, blockage of ureters

Stage IV

Metastases

• IVA–spread to bladder or rectum
• IVB–spread to distant organs, eg lungs

.

cervical cancer

Cancer of the cervix of the womb (uterus). This cancer is the second highest cause of cancer deaths in women worldwide with half a million new cases each year. It is usually associated with the human papillomavirus (HPV) and the strain HPV-16 is present is almost half of all cases of this cancer. Several trials of vaccines against this strain of HPV have shown that vaccination can significantly reduce the risk of developing cervical cancer.

Cervical Cancer

DRG Category:	740
Mean LOS:	4.2 days
Description:	SURGICAL: Uterine and Adnexa Procedure for Non-Ovarian/Adnexal Malignancy With CC
DRG Category:	755
Mean LOS:	5 days
Description:	MEDICAL: Malignancy, Female Reproductive System With CC

Cancer of the cervix is one type of primary uterine cancer (the other being uterine-endometrial cancer) and is predominately epidermoid. Invasive cervical cancer is the third-most common female pelvic cancer. Based on estimates from 2012, experts report that approximately 12,000 cases of invasive cervical cancer are diagnosed in the United States each year and four times that number of noninvasive cervical cancer cases (carcinoma in situ [CIS]) occur. As of 2012, approximately 4,000 women die from cervical cancer in the United States each year.

Cervical cancer involves two types of cancer: squamous carcinoma (about 85% of the cases) and adenocarcinoma (about 10% to 15% of the cases). There are also precancerous or pre-invasive types of cervical disease, such as cervical dysplasia, when the lower third of the epithelium contains abnormal cells with early, premalignant changes, and CIS, which is carcinoma confined to the epithelium. The full thickness of the epithelium contains abnormally proliferating cells. Both dysplasia and CIS are considered preinvasive cancers and, with early detection, have a 5-year survival rate of 73% to 92%.

Invasive carcinoma occurs when cancer cells penetrate the basement membrane. Metastasis occurs through local invasion and by way of the lymphatic ducts. As many as 10 years can elapse between the preinvasive and the invasive stages. A further 5 years can be added if one considers the precancerous changes that occur in atypical cells and dysplasia as the first step of malignancy.

Causes

Worldwide epidemiological studies suggest that sexually transmitted human papillomaviruses (HPVs) are the primary cause of cervical cancer. HPV viral DNA has been detected in more than 90% of squamous intraepithelial lesions (SILs) and invasive cervical cancers. HPV infection occurs in a large percentage of sexually active women. However, most HPV infections clear spontaneously within months or a year, and only a small proportion progress to cancer. Thus, other factors influence the progression of low-grade SILs to high-grade SILs, such as the type and duration of viral infection; compromised immunity such as multiparity or poor nutritional status; and factors such as smoking, oral contraceptive use, vitamin deficiencies, age of menarche, age of first intercourse, and number of sexual partners. Other risk factors include early first pregnancy, postnatal lacerations, grand multiparity, sexual partners with a history of penile or prostatic cancer or those uncircumcised, exposure to diethylstilbestrol (DES) in utero, and a history of cervicitis.

Genetic considerations

While most risk factors for cervical cancer are environmental, some studies have found that the daughters or sisters of cervical cancer patients are more likely to get the disease. The increased incidence in families may be due to an inherited vulnerability to HPV infection.

Gender, ethnic/racial, and life span considerations

Although cervical cancer can occur from the late teens to old age, it occurs most commonly in women 35 to 55 years of age. Preinvasive cancer of the cervix is most commonly seen in 25- to 40-year-old women, whereas invasive cancer of the cervix is more common in 40- to 60-year-olds. Latina and black/African American women and women from lower socioeconomic groups are the highest risk groups for cervical cancer.

Global health considerations

A significant health disparity exists for women in developed versus developing countries with respect to cervical cancer. It is the second leading cause of cancer-related death for women in developing countries and tenth leading cancer-related death for women in developed countries. With routine Papanicolaou (Pap) smears, the incidence of invasive cervical cancer has declined over the past few decades in North America and Western Europe. Globally, 500,000 new cases are diagnosed each year.

Assessment

History

Establish a thorough history with particular attention to the presence of the risk factors and the woman’s menstrual history. Establish a history of later symptoms of cervical cancer, including abnormal bleeding or spotting (between periods or after menopause); metrorrhagia (bleeding between normal menstrual periods) or menorrhagia (increased amount and duration of menstrual bleeding); dyspareunia and postcoital bleeding; leukorrhea in increasing amounts and changing over time from watery to dark and foul; and a history of chronic cervical infections. Determine if the patient has experienced weight gain or loss; abdominal or pelvic pain, often unilateral, radiating to the buttocks and legs; or other symptoms associated with neoplasms, such as fatigue.

Physical examination

Early cervical cancer is usually asymptomatic. The first symptom that occurs is usually abnormal vaginal bleeding. Conduct a pelvic examination. Observe the patient’s external genitalia for signs of inflammation, bleeding, discharge, or local skin or epithelial changes. Observe the internal genitalia. The normal cervix is pink and nontender, has no lesions, and has a closed os. Cervical tissue with cervical cancer appears as a large reddish growth or deep ulcerating crater before any symptoms are experienced; lesions are firm and friable. The Pap smear is done before the bimanual examination. Palpate for motion tenderness of the cervix (Chandelier’s sign); a positive Chandelier’s sign (pain on movement) usually indicates an infection. Also examine the size, consistency (hardness may reflect invasion by neoplasm), shape, mobility (cervix should be freely movable), tenderness, and presence of masses of the uterus and adnexa. Conduct a rectal examination; palpate for abnormalities of contour, motility, and the placement of adjacent structures. Nodular thickenings of the uterosacral and cardinal ligaments may be felt.

Psychosocial

Uneasiness, embarrassment about a pelvic examination, or fear of the unknown may be issues for the patient. Determine the patient’s level of knowledge about a pelvic examination and what she expects. Determine her recommended Pap test screening schedule as well as how she obtains the results and their meaning.

If the patient requires follow-up to a positive Pap smear, assess her anxiety and coping mechanisms. Stressors may be fear of the unknown, of sexual dysfunction, of cancer, or of death, or she may have self-concept disturbances.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Pap smear	No abnormality or atypical cells noted	High-class/high-grade cytological results	Initial screening; indicates a need for further testing
Colposcopy followed by punch biopsy or cone biopsy (via the loop electrosurgical excision procedure [LEEP])	Benign results	Malignant cells	Vaginal vault and cul-de-sac are visualized; malignant diagnosis can be confirmed

Other Tests: Chest x-ray, cystoscopy, proctosigmoidoscopy, intravenous pyelogram, barium studies of lower bowel, ultrasound, computed tomography, magnetic resonance imaging, and lymphangiography. Visual inspection with acetic acid (vinegar) is being used to identify HPV-positive women in developing countries where a Pap smear is not available.

Primary nursing diagnosis

Diagnosis

Pain (acute) related to postprocedure swelling and nerve damage

Outcomes

Pain control; Pain: Disruptive effects; Well-being

Interventions

Analgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application

Planning and implementation

Collaborative

Treatment depends on the stage of the cancer, the woman’s age, and concern for future childbearing. Preinvasive lesions (CIS) can be treated by cervical conization, cryosurgery, laser surgery, or simple hysterectomy (if the patient’s reproductive capacity is not an issue). All conservative treatments require frequent follow-up by Pap tests and colposcopy because a greater level of risk is always present for the woman who has had CIS. A cone-shaped piece of tissue is removed from the cervix after epithelial involvement is clearly outlined as described with the cone biopsy. The cone includes all the abnormal and some normal tissue. Following this procedure, the woman can still have children. The major complication is postoperative bleeding.

cryosurgery.

Cryosurgery is performed 1 week after the patient’s last menstrual period (thereby avoiding treatment in early pregnancy). The surgeon uses a probe to freeze abnormal tissue and a small amount of normal tissue.

laser surgery.

For laser surgery, a carbon dioxide laser is used. Healing takes place in 3 to 6 weeks, and recurrence rates are lower than with cryosurgery.

hysterectomy.

A hysterectomy, removal of the cervix and uterus, is the definitive therapy for CIS. The risks of general anesthesia and abdominal surgery are present. Major risks are infection and hemorrhage.

invasive cancer.

Invasive cancer (stages I to IV) can be treated with surgery, radiotherapy, or a combination of both (Table 1). Pelvic exenteration can be done for recurrence and/or for advanced stage III or IV. Total exenteration entails the removal of the pelvic viscera, including the bladder, rectosigmoid, and all the reproductive organs. Irradiation of metastatic areas is done to provide local control and decrease symptoms. Treatment Alternatives for Invasive Cervical Cancer

Table 1. Treatment Alternatives for Invasive Cervical Cancer

STAGE	TREATMENT ALTERNATIVE
I	May be managed conservatively (conization), with simple hysterectomy and close follow-up, or may be treated as stage II
II	Surgery (total abdominal hysterectomy [TAH] or radical hysterectomy with bilateral pelvic lymphadenopathy) and radiotherapy are treatments of choice; positive pelvic nodes usually receive full pelvic radiation postoperatively
III	Radiation alone
IV	Radiation alone or systemic or regional chemotherapy

radiation therapy.

Radiation therapy may be internal (radium applications to the cervix), external, and interstitial (by the use of cesium). Radiation cystitis, proctitis, and fistula formation (vesicovaginal) are major complications. Radiation sickness (nausea, vomiting, diarrhea, malaise, fever) may be a result of a systemic reaction to the breakdown and reabsorption of cell proteins. Internal radiation results in some cramping because of dilation of the cervix and in a foul-smelling vaginal discharge because of cell destruction. The patient who receives intracavity radiation (brachytherapy) is placed on bedrest and is able only to roll from side to side so as not to dislodge the implant. Vaginal packing, a urinary catheter, and pretreatment enemas plus a low-residue diet are designed to keep healthy tissue from the implant. Smoking increases the side effects from radiation, and patients who smoke are encouraged to stop smoking.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Cisplatin; Paclitaxel; Ifosfamide; Hydroxyurea; Fluorouracil; Irinotecan	Depends on the patient condition, progress of the disease, and if other chemotherapeutic agents are given	Antineoplastic	Used to treat or stabilize the disease; 38% response rate documented; can also be used in combination with other chemotherapeutic agents
Acetaminophen; NSAIDs; opioids; combinations of opioid/NSAIDs	Depends on the drug and the patient’s condition and tolerance	Analgesics	Analgesic chosen is determined by the severity of the patient’s pain

Independent

Teaching about and providing access to regular Pap screening tests for high-risk and other women are the most important preventive interventions. The importance of regular Pap smears cannot be understated because cervical CIS is 100% curable. Embarrassment, modesty, and cultural values may make seeking a gynecological examination more difficult for some women. Provide clear explanations and respect the patient’s modesty.

When a patient requires surgery, prepare her mentally and physically for the surgery and the postoperative period. Be certain to teach the patient about vaginal discharges that may follow a surgical procedure. Teach the patient that she will probably have to refrain from douching, using tampons, and coitus until healing occurs. Discuss any changes that may affect the patient’s sexual function or elimination mechanisms. Explain to the patient that she will feel fatigued and that she should gradually increase activity but should not do heavy lifting or strenuous or rough activity or sit for long periods. Encourage the patient to explore her feelings and concerns about the experience and its implications for her life and lifestyle. Provide the patient who has undergone a hysterectomy with information about what to expect.

If internal radiation (brachytherapy) is the treatment, the primary focus of the nursing interventions is to prepare the patient for the treatment, to promote her comfort, and to lessen her sense of isolation during the treatment. Explain to the patient and significant others the reason for the time-restricted visits while the insert is in place. Nursing care is of shorter duration and of essential nature only during this time; therefore, ensure that before the insertion of the implant, the patient has a bath and clean bed linen. Decrease the patient’s feelings of isolation by providing diversionary activities and frequent interaction from a safe distance. If the patient has external radiation, teach her about how the treatment is given, how the skin is prepared, and how blood tests to monitor white blood cell count are done. Explain that her immunity to common colds and other illnesses is lessened, and teach the patient the proper use of anti-emetics and antidiarrheals.

Evidence-Based Practice and Health Policy

Kepka, D., Berkowitz, Z., Yabroff, K.R., Roland, K., & Saraiya, M. (2012). Human papillomavirus vaccine practices in the USA: Do primary care providers use sexual history and cervical cancer screening results to make HPV vaccine recommendations? Sexually Transmitted Infections, 88(6), 433–435.

• The American Cancer Association, along with the Advisory Committee on Immunization Practices, recommends that all girls and young women between the ages of 11 to 18 receive the HPV vaccine as part of cervical cancer prevention efforts. However, guidelines include recommendations that Pap testing and sexual practices not be used to determine vaccine appropriateness.
• A review of the 2007 Cervical Cancer Screening Supplement, in which 407 primary care providers reported their vaccination recommendations, 90% recommended the HPV vaccine to their patients, among which 41% recommended it to girls ages 9 to 12, 80% to girls and women ages 13 to 26, and 21% to women over age 27.
• However, only 53% reported making recommendations that were consistent with national guidelines (95% CI, 42% to 63%). Among providers who recommended the HPV vaccine, 31% used the number of sexual partners (95% CI, 21% to 43%), 22% used an HPV test (95% CI, 14% to 33%), and 18% performed a Pap test (95% CI, 10% to 30%) to determine who should receive the vaccine.

Documentation guidelines

• Physical findings: Pain and discomfort; type, color, and amount of vaginal discharge; appearance of wounds or ulcers; urinary elimination; bowel movement
• Emotional response: Coping, fears, body image, response to examination, strategies to support modesty; partner’s response to illness
• Response to treatment: Conization, cryosurgery, laser surgery, hysterectomy; presence of complications

Discharge and home healthcare guidelines

medications.

Be sure the patient and family understand any pain medication prescribed, including dosage, route, action, and side effects.

follow-up.

Make sure the patient knows all the postprocedure complications. Provide a phone number to call if any complications occur. Ensure that the patient understands the need for ongoing Pap smears if appropriate. Vaginal cytological studies are recommended at 4-month intervals for 2 years, every 6 months for 3 years, and then annually.