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Causes and symptoms
Symptoms of invasive cervical cancer
- 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
The pap test
Diagnosing the stage
The figo system of staging
- 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
Treatment of precancer and carcinoma in situ
- cold knife cone biopsy
- 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)
- skin reaction in the area of treatment
- 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
- nausea and vomiting
- changes in appetite
- hair loss
- mouth or vaginal sores
- menstrual cycle changes
- premature menopause
- bleeding or anemia (low red blood cell count)
- 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
Diet and drugs
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 cancerOncology 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
- IVA–spread to bladder or rectum
- IVB–spread to distant organs, eg lungs
cervical cancerCancer 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.
|Mean LOS:||4.2 days|
|Description:||SURGICAL: Uterine and Adnexa Procedure for Non-Ovarian/Adnexal Malignancy With CC|
|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.
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.
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.
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.
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.
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.
|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
DiagnosisPain (acute) related to postprocedure swelling and nerve damage
OutcomesPain control; Pain: Disruptive effects; Well-being
InterventionsAnalgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application
Planning and implementation
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.
|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|
|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.
|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|
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.
- 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