Cervical Cancer

Introduction of Cervical Cancer

Malignant tumor of the cervix in women, the lower part of the uterus.

it is the third most common cancer worldwide in women.

Cervical cancer is a very slow-growing disease that begins with a precancerous condition called dysplasia. The dysplasia can be easily detected in a routine Pap smear and is completely treatable.

Sexually Transmitted Infections Different types of human papillomavirus (HPV) play a role in causing most cervical cancers.

Definition of Cervical Cancer

Cervical cancer is a type of cancer that occurs in the cells of the cervix — the lower part of the uterus that connects to the vagina.

Cervical cancer is a malignant tumor deriving from cells of the “cervix uteri”, which is the lower part, the “neck” of the womb, the female reproductive organ.

Cervical Cancer TERMINOLOGY

• Biopsy of cervical cancer – 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.
• Colposcopy-Diagnostic procedure using a hollow, lighted tube (colposcope) to look inside the cervix and uterus.
• Dysplasia –Abnormal cellular changes that may become cancerous.

Epidemiology

Worldwide about 500,000 women acquire the disease annually,

■ About 75-85% are from developing countries.

■ About 300,000 women die of the disease annually.

■ Incidence has fallen considerably in Europe and America.

• Improved public health measures – the screening procedures.
• Lifestyle modification.
• Pap smear screening.

Etiology

• Taking contraceptives for a long time
• Unhealthy lifestyle and diet
• Having several sexual relationships
• Other STIs
• Smoking
• HPV (Papilloma virus)
• Having sex at an early age (before 16)

Riskfactors

• Smoking
• Weakened immune system
• Several pregnancies
• Giving birth at a very young age
• Long-term use of the contraceptive pill
• Family history

Types of cervical cancer

1-ECTOCERVIX(SQUAMOUS CELL CARCINOMA)

This type of cervical cancer begins in the thin, flat cells (squamous cells) lining the outer part of the cervix, which projects into the vagina. Most cervical cancers are squamous cell carcinomas.

2-ENDOCERVIX(ADENOCARCINOMA)

This type of cervical cancer begins in the column-shaped glandular cells that line the cervical canal.

How does cervical cancer spread?

• Cervical cancer begins in cells on the surface of the cervix, Over time, the cervical cancer can invade more deeply into the cervix and nearby tissues.
• The cancer cells can spread by breaking away from the original (primary) tumor. They enter blood vessels or lymph vessels, which branch into all the tissues of the body.
• The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.
• The spread of cancer is called metastasis.

PATTERNS OF SPREAD

• Direct invasion: Cervical stroma, Vagina, and Parametrium.

• Lymphatic spread: Pelvic and then par aortic lymph nodes.
• Hematogenous spread: such as Lungs, Liver, and Bones.

CLINICAL MANIFESTATIONS

• Bleeding that occurs between regular menstrual periods.
• Bleeding after sexual intercourse, douching or a pelvic exam.
• Menstrual periods that last longer and are heavier than before.
• Bleeding after going through menopause.
• Increased vaginal discharge.
• Pelvic pain is a late symptom and is followed by wt. loss, anaemia and cachexia.
• Precancerous changes are asymptomatic.
• The peak incidence of non-invasive cervical cancer is in women in their early thirties.
• Early cervical cancer is generally asymptomatic, but leukorrhea and intermenstrual bleeding eventually occurs.
• The vaginal bleeding is initially only spotting. As the tumour enlarges, bleeding becomes heavier and more frequent.

STAGES OF CERVICAL CANCER

Stage I- Cancer is confined to the cervix.

Stage II- Cancer at this stage includes the cervix and uterus, but hasn’t spread to the pelvic wall or the lower portion of the vagina.

Stage III- Cancer at this stage has moved beyond the cervix and uterus to the pelvic wall or the lower portion of the vagina.

Stage IV- At this stage, cancer has spread to nearby organs, such as the bladder or rectum, or it has spread to other areas of the body, such as the lungs, liver or bones.

DIAGNOSIS

• History collection
• Physical examination
• PAP smear
• Blood test
• DNA testing (like the Pap test, the HPV DNA test involves collecting cells from the cervix for lab testing). 
• Biopsy 

PAP Smear Test of Cervical Cancer

It is a procedure in which a small brush is used to gently remove cells from the surface of the cervix and the area around it so they can be checked under a microscope for cervical cancer or cell changes that may lead to cervical cancer. 

A Pap smear may also help find other conditions, such as infections or inflammation. It is usually done at the same time as a pelvic exam and may also be done at the same time as a test for certain types of human papillomavirus (HPV).

• Colposcopy- A colposcopy is a test to take a closer look at your cervix. The cervix is the opening to your womb from your vagina. A colposcopy is often done if cervical screening finds changes to your cells that are caused by certain types of human papillomavirus (HPV). These changed cells can turn into cervical cancer cells.
• Cone biopsy- A cone biopsy (conization) is surgery to remove a sample of abnormal tissue from the cervix. The cervix is the lower part of the uterus (womb) that opens at the top of the vagina. Abnormal changes in the cells on the surface of the cervix is called cervical dysplasia.
• CT Scan
• MRI
• Pelvic ultrasound

MEDICAL MANAGEMENT OF CERVICAL CANCER

Chemotherapy for cervical cancer

Chemotherapy is the use of chemicals (medication) to destroy cancer cells. Cytotoxic medication prevents cancer cells from dividing and growing abnormally. Chemotherapy for cervical cancer, as well as most other cancers, is used to target cancer cells that surgery cannot or did not remove, or to help the symptoms of patients with advanced cancer. Cisplatin, a chemotherapy drug, is frequently used in combination with radiotherapy.

Side effects of Chemotherapy in cervical cancer:

• Hair loss
• Nausea 
• Vomiting 
• Mouth sores 
• Loss of appetite 
• Tiredness, easy bruising or bleeding and an increased chance of infection.

Target therapy-

Targeted therapies are drugs that interfere with one specific property or function of a cancer cell, rather than acting to kill all rapidly growing cells indiscriminately.

Radiation Therapy-

External Radiation Therapy:

A large machine directs radiation at your pelvis or other tissues where the cancer has spread. The treatment usually is given in a hospital or clinic. You may receive external radiation 5 days a week for several weeks. Each treatment takes only a few minutes. A thin tube is placed inside the vagina. A radioactive substance is loaded into the tube. You may need to stay in the hospital while the radioactive source is in place (up to 3 days). Or the treatment session may last a few minutes, and you can go home afterward.

Internal Radiation Therapy:

Once the radioactive substance is removed, no radioactivity is left in your body. Internal radiation may be repeated two or more times over several weeks.

Surgical Treatment of cervical cancer

Surgery to cut away the cancer only- For a very small cervical cancer, it might be possible to remove the cancer entirely with a cone biopsy. This procedure involves cutting away a cone-shaped piece of cervical tissue, but leaving the rest of the cervix intact. This option may make it possible for you to consider becoming pregnant in the future.

Surgery to remove the cervix (trachelectomy)- Early-stage cervical cancer might be treated with a radical trachelectomy procedure, which removes the cervix and some surrounding tissue. The uterus remains after this procedure, so it may be possible to become pregnant, if you choose.

Surgery to remove the cervix and uterus (hysterectomy)- Most early-stage cervical cancers are treated with a radical hysterectomy operation, which involves removing the cervix, uterus, part of the vagina and nearby lymph nodes. A hysterectomy can cure early-stage cervical cancer and prevent recurrence. But removing the uterus makes it impossible to become pregnant.

OTHER MANAGEMENTS

Cryosurgery: is the destruction of abnormal tissue using sub-zero temperatures. ( normal liver are frozen to – 190°C for 15 minutes).Cryosurgery is a new technique that can destroy tumors in a variety of sites (brain, breast, kidney, prostate, liver).

Palliative treatment: helps to improve people’s quality of life by reducing symptoms of cancer without trying to cure the disease. It is particularly important for people with secondary cancer. However, it is not just for end-of-life care and it can be used at different stages of cancer.

NURSING MANAGEMENT OF CERVICAL CANCER

Nursing Assessment

The patient with cervical cancer is usually asymptomatic in the early stages. 

• The history involves a thorough sexual history including first age of intercourse, postcoital bleeding, and if there is pain during intercourse.
• Other pertinent information to gather includes previous sexually transmitted infections, the number of lifetime partners, previous history of HPV infection, history of human immunodeficiency virus.
•  Use of tobacco, and whether the patient has had a previous vaccination against HPV.
• Menstrual patterns and any abnormal bleeding, persistent vaginal discharges, irritations, or known cervical lesions. 
• The physical exam must include a full evaluation of the external and internal genitalia.
• In women with cervical cancer, the exam findings might include a friable cervix, lesions, erosions, or bleeding with examination and fixed adnexa.

Nursing Diagnosis

• Pain related to cancer & treatment effect as evidenced by pain scale & facial expression.
• Imbalanced nutrition less than body requirement related to anorexia, vomiting as evidenced by weight loss.
• Impaired tissue integrity related to treatment as evidenced by mucositis.
• Anxiety related to diagnosis of cancer as evidenced by talking with family member.
• Risk for infection related to immune suppression.
• Impaired urinary elimination R/T surgical incision.

Nursing interventions

• For Pain:
• Determine pain history (location of pain, frequency, duration, and intensity using a numeric rating scale (0–10 scale), or verbal rating scale (“no pain” to “excruciating pain”) and relief measures used.
  (The information provides baseline data to evaluate the effectiveness of interventions. The pain of more than 6 months duration constitutes chronic pain, which may affect therapeutic choices).
• Evaluate and be aware of the painful effects of particular therapies (surgery, radiation, chemotherapy, biotherapy).
  (A wide range of discomforts is common (incisional pain, burning skin, low back pain, headaches), depending on the procedure and agent being used).
• Provide non-pharmacological comfort measures (massage, repositioning, backrub) and diversional activities (music, television).
  (Promotes relaxation and helps refocus attention).
• Provide cutaneous stimulation (heat or cold, massage).
  (May decrease inflammation, and muscle spasms, reducing associated pain).
• Evaluate pain relief and control at regular intervals. Adjust medication regimen as necessary.
  (The goal is maximum pain control with minimum interference with ADLs).
• For Imbalanced Nutrition:
• Monitor daily food intake; have the patient keep a food diary as indicated.
  (Identifies nutritional strengths and deficiencies).
• Measure height, weight (or other anthropometric measurements as appropriate). Ascertain the amount of recent weight loss. Weigh daily or as indicated.
  (If these measurements fall below minimum standards, the patient’s chief source of stored energy (fat tissue) is depleted).
• Assess skin and mucous membranes for pallor, delayed wound healing, and enlarged parotid glands.
• (Helps in the identification of protein-calorie malnutrition, especially when weight and anthropometric measurements are less than normal).
• Encourage the patient to eat a high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage the use of supplements and frequent or smaller meals spaced throughout the day.
  (Metabolic tissue needs are increased as well as fluids (to eliminate waste products). Supplements can play an important role in maintaining adequate caloric and protein intake).
• Encourage open communication regarding anorexia.
• (Often a source of emotional distress, especially for SO who wants to feed patients frequently).
• Adjust diet before and immediately after treatment (clear, cool liquids, light or bland foods, candied ginger, dry crackers, toast, and carbonated drinks). Give liquids 1 hr. before or 1 hr. after meals.
  (The effectiveness of diet adjustment is very individualized in the relief of posttherapy nausea).
• Encourage the use of relaxation techniques, visualization, guided imagery, and moderate exercise before meals.
• (May prevent the onset or reduce the severity of nausea, decrease anorexia, and enable the patient to increase oral intake).
• For Risk of Infection:
• Monitor temperature.
  Temperature elevation may occur (if not masked by corticosteroids or anti-inflammatory drugs) because of various factors (chemotherapy side effects, disease process, or infection).
•  Monitor CBC with differential WBC and granulocyte count, and platelets as indicated.
  (Bone marrow activity may be inhibited by the effects of chemotherapy, the disease state, or radiation therapy).
• Promote good handwashing procedures by staff and visitors. Screen and limit visitors who may have infections. Place in reverse isolation as indicated.
• (Protects patient from sources of infection, such as visitors and staff who may have an upper respiratory infection).
• Emphasize personal hygiene.
  (Limits potential sources of infection and secondary overgrowth).
• Promote adequate rest and exercise periods.
  (Limits fatigue, yet encourages sufficient movement to prevent stasis complications (pneumonia, decubitus, and thrombus formation)).
•  Stress the importance of good oral hygiene.
• (The development of stomatitis increases the risk of infection and secondary overgrowth).
• For Anxiety:
•  Review the patient’s and SO’s previous experience with cancer. Determine what the doctor has told the patient and what conclusion the patient has reached.
  (Clarifies patient’s perceptions; assists in the identification of fear(s) and misconceptions based on diagnosis and experience with cancer).
•  Encourage the patient to share thoughts and feelings.
  (Provides an opportunity to examine realistic fears and misconceptions about the diagnosis).
• Provide an open environment in which the patient feels safe to discuss feelings or refrain from talking.
• (Helps patients feel accepted in their present conditions without feeling judged, and promotes a sense of dignity and control).
• Provide an open environment in which the patient feels safe to discuss feelings or refrain from talking.
  (Helps patients feel accepted in their present conditions without feeling judged, and promotes a sense of dignity and control).
• Maintain frequent contact with the patient. Talk with and touch the patient as appropriate.
  (Provides assurance that patient is not alone or rejected; conveys respect for and acceptance of the person, fostering trust).
• Be aware of the effects of isolation on the patient when required by immunosuppression or radiation implant. Limit the use of isolation clothing and masks as possible.
  (Sensory deprivation may result when sufficient stimulation is not available and may intensify feelings of anxiety, fear, and alienation).

DIETARY MANAGEMENT

• Flavonoids are chemical compounds in fruits and vegetables that are thought to be a leading source protection against cancer. 
• The flavonoid-rich foods are Apples, Black beans, Broccoli, Brussels sprouts, Cabbage, Garlic, Onions, Soy, Spinach.
• Folate (a water-soluble B vitamin) reduce the risk of cervical cancer in people with HPV. Foods rich in folate include Avocados, breads, Lentils, Orange juice and Strawberries.
• Carotenoids, a source of vitamin A, are also helpful in preventing cervical cancer risk. Foods such as carrots, sweet potatoes and pumpkin are rich in vit. A.
• Safe sex
• Cervical screening
• Have few sexual partners
• Delay first sexual intercourse
• Don’t smoke

VACCINATION

• Three HPV vaccines (Gardasil, Gardasil 9, and Cervarix) reduce the risk of cancerous or precancerous changes of the cervix and perineum by about 93% and 62%, respectively.^[72] The vaccines are between 92% and 100% effective against HPV 16 and 18 up to at least 8 years.^[40]
• HPV vaccines are typically given to age 9 to 26, as the vaccine is most effective if given before infection occurs. The duration of effectiveness and whether a booster will be needed is unknown.