CERVICAL CANCER

I.   OBJECTIVES:

General Objective:

       To be able to know and learn more about the disease, cervical cancer,

    Specific Objectives:

1.           To render proper nursing care to the patient.

2.          To help patient as well as the family to know ways on how to handle situations pertaining to the disease.

3.          To be able to know how the disease occur.

4.          To know the pathophysiology of the disease.

5.          To be familiarized with the anatomy and physiology of the organ involved.

I.   MEDICAL DIAGNOSIS

Cervical cancer is malignant neoplasm of the cervix uteri or cervical area. It may present with vaginal bleeding, but symptoms may be absent until the cancer is in its advanced stages. Treatment consists of surgery (including local excision) in early stages and chemotherapy and radiotherapy in advanced stages of the disease.

Cervical cancer occurs when abnormal cells on the cervix grow out of control. The cervix is the lower part of the uterus that opens into the vagina. Cervical cancer can often be cured when it’s found early. It is usually found at a very early stage through a Pap test.

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. See the Staging section for information about cervical cancer that has spread.

Causes & Risk Factors

Cervical cancers start in the cells on the surface of the cervix. There are two types of cells on the cervix's surface: squamous and columnar. The majority of cervical cancers are from squamous cells.

The development of cervical cancer is usually very slow. It starts as a pre-cancerous condition called dysplasia.

Almost all cervical cancers are caused by HPV (human papilloma virus). HPV is a common virus that is spread through sexual intercourse. There are many different types of HPV, and many do not cause problems. However, only certain strains of HPV actually lead to cervical cancer. (Other strains may cause genital warts.)

Other risk factors for cervical cancer include:

• Having sex at an early age
• Multiple sexual partners
• Sexual partners who have multiple partners or who participate in high-risk sexual activities
• Women whose mothers took the drug DES (diethylstilbestrol) during pregnancy in the early 1960s to prevent miscarriage
• Weakened immune system
• Poor economic status (may not be able to afford regular Pap smears)
• Using birth control pills for more than 5 years. This may be related to infection with HPV.⁵
• Exposure to diethylstilbestrol (DES) before birth (prenatal exposure), though this is rare.
• Smoking or a history of smoking, and possibly exposure to secondhand smoke.

Symptoms

Most of the time, early cervical cancer has no symptoms. Symptoms that may occur can include:

• Continuous vaginal discharge, which may be pale, watery, pink, brown, bloody, or foul-smelling
• Abnormal vaginal bleeding between periods, after intercourse, or after menopause
• Periods become heavier and last longer than usual
• Any bleeding after menopause
• Bleeding when something comes in contact with the cervix, such as during sexual intercourse or when you insert a diaphragm.
• Pain during sexual intercourse.
• Abnormal vaginal discharge containing mucus that may be tinged with blood.

Symptoms of advanced cervical cancer may include:

• Loss of appetite
• Weight loss
• Fatigue
• Pelvic pain
• Back pain
• Leg pain
• Single swollen leg
• Heavy bleeding from the vagina
• Leaking of urine or feces from the vagina
• Bone fractures
• Anemia because of abnormal vaginal bleeding.
• Urinary problems because of blockage of a kidney or urether.
• Leakage of urine or fecal content into the vagina because an abnormal opening (fistula) has developed between the vagina and the bladder or rectum.

Staging

Cervical cancer is staged by the International Federation of Gynecology and Obstetrics (FIGO) staging system, which is based on clinical examination, rather than surgical findings. It allows only the following diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray

examination of the lungs and skeleton, and cervical conization.        

I.       ANATOMY AND PHYSIOLOGY

Female Reproductive System

The organs of the female reproductive system produce and sustain the female sex cells (egg cells or ova), transport these cells to a site where they may be fertilized by sperm, provide a favorable environment for the developing fetus, move the fetus to the outside at the end of the development period, and produce the female sex hormones. The female reproductive system includes the ovaries, Fallopian tubes, uterus, vagina, accessory glands, and external genital organs.

The organs of the female reproductive system produce and sustain the female sex cells (egg cells or ova), transport these cells to a site where they may be fertilized by sperm, provide a favorable environment for the developing fetus, move the fetus to the outside at the end of the development period, and produce the female sex hormones. The female reproductive system includes the ovaries, Fallopian tubes, uterus, vagina, accessory glands, and external genital organs.

external female genitalia

Part of the female reproductive system. The external genitalia are the accessory structures of the female reproductive system that are external to the vagina. They are also referred to as the vulva or pudendum. The external genitalia include the labia majora, mons pubis, labia minora, clitoris, and glands within the vestibule.

The clitoris is an erectile organ, similar to the male penis, that responds to sexual stimulation. Posterior to the clitoris, the urethra, vagina, paraurethral glands and greater vestibular glands open into the vestibule.

cervix

A small, cylindrical organ, several centimeters long and less than 2.5cm (1 inch) in diameter, which comprises the lower part and neck of the uterus. The cervix separates the body and cavity of the uterus from the vagina. Running through the cervix is a canal, through which sperm can pass from the vagina into the uterus and through which blood passes during menstruation. The cervical canal, which forms part of the birth canal during childbirth, dilates (expands) widely to allow passage of a baby.

The bulk of the cervix consists if fibrous tissue with some smooth muscle. This tissue makes the cervix into a form of sphincter (circular muscle) and allows for the great adaptability in its size and shape required during pregnancy and childbirth.

I.       MEDICAL MANAGEMENT

Surgical management of cervical cancer

Choice of the appropriate surgical procedure depends on the stage and the site of the cervical cancer. The diverse surgeries and forms of treatments used are:

1. Conization: This procedure involves the removal of a cone shaped piece of the cervical tissue for examination and investigation. This procedure is done if PAP tests reveal the presence of precancerous cells.
2. Hystrectomy: A procedure which entails the removal of the cervix and the uterus. There are further sub types – a vaginal hysterectomy (extraction of the uterus and the cervix through the vagina), a total abdominal hysterectomy (removal of the uterus and the cervix through a large abdominal incision), and a laproscopic hysterectomy (removal of the uterus and the cervix through a small incision in the abdomen and using a laproscope). More about Hystrectomy Surgery Abroad
3. Bilateral salpingo-oophorectomy: A surgery that entails the removal of the fallopian tubes and the ovaries (components of the female reproductive system).
4. Radical hysterectomy: This surgical procedure, removes the uterus, cervix, and a part of the vagina. Furthermore, the lymph nodes in the pelvic region are also dissected. The ovaries are spared.
5. Pelvic exentration: This procedure calls for the removal of the cervix, uterus, vagina, ovaries, lymph nodes, lower colon, rectum, and bladder. Artificial openings are made for the elimination of urine and feces in to a collection bag. Plastic surgery can be resorted to for the reconstruction of an artificial vagina. More about total pelvic exenteration abroad.
6. Cryosurgery: An advanced procedure, it involves the freezing and destruction of the cancerous tissue. It is advocated in the management of pre-invasive cancers.
7. Laser surgery: A laser beam is used as a knife to make blood-less incisions to excise smaller abnormal tissues.
8. Loop electro-surgical excision procedure (LEEP): An electrical current passes through a thin wire loop that acts as a knife to excise out abnormal tissue.
9. Radiotherapy: In cases, where the carcinoma has spread beyond the cervix and surgical intervention alone cannot suffice, radiotherapy becomes necessary. Radiotherapy also promises a prevention of recurrence. Both internal and external radiotherapy are utilized. The therapy cycles are 5 days a week for a period of 6 weeks. Certain side effects of the treatment are hair loss, fatigue, nausea, diarrhea, and dysuria. Stages 1B and 2A show 85 to 90 % 5 year cure rates, 2B shows 60 to 65 %, stage 3 shows 25 to 40 % cure rates, and 4 shows 15 to 20 % cure rates.
10. Chemotherapy: Chemotherapy is used to destroy cancer cells remaining after surgery. Chemotherapy may be given before the therapy, and then after the therapy to ensure that no cancer cells are left behind. The drugs are given through a series of injections. Side effects of the therapy are loss of appetite, nausea, vomiting, diarrhea, fatigue, headaches, and dysuria. More about chemotherapy abroad.

DISCHARGE PLANNING:

1.     Educate the patient and the family about the proper medications the patient should take to help manage the disease.

2.    Instruct the patient the types of work she is allowed to do and the activities she is prohibited to do.

3.    Advise the patient to go to the hospital for follow up checkups.

4.    Instructed the patient to eat nutritious and healthy foods.

5.    Advise the patient not to work to hard so as not to abuse herself.

6.    Advised the patient not to stop taking the medications prescribed to her.