Cervical cancer Cervical cancer is cancer that starts in the cervix, the lower part of the uterus (womb)

that opens at the top of the vagina. 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. Most cervical cancers are from squamous cells. Cervical cancer usually develops very slowly. It starts as a precancerous condition called dysplasia. This precancerous condition can be detected by a Pap smear and is 100% treatable. That is why it is so important for women to get regular Pap smears. Risk Factors Sexual risk factors y y y y y High number of sexual partners Partners with multiple sexual partners Early age at first sexual intercourse Multiple pregnancies History of sexual transmitted decease especially herper simplex virus II or human Papillomavirus (HPV)

Other risk factors y y y y Race. The incident of cervical is highest in native America, Africa-America and Hispanic-America women, double or more than double that for white women Long term cigarette smoking or exposure to passive cigarette smoke Nutritional deficiencies Rural or social economic factors that limit access to health care

Signs and symptoms y y y y y y y y y y Abnormal bleeding Prolonged menstrual period Bleeding following sexual intercourse Foul-smelling or serosanguineous vaginal discharge Pelvic lower back leg or groin pain Anorexia and weight loss Leakage of urine and feces from the vagina Dysuria Hematuria Cytological changes on Papanicolaous test

Complications

Serious short- and long-term complications can also occur and may vary depending on the specific agents used. They include the following:
y y

y y y y y y

Increased chance for infection from suppression of the immune system. Severe drops in white blood cells (neutropenia). Certain agents, such as taxanes, pose a higher risk for this than other chemotherapeutic drugs. White blood cell count may be improved with the addition of a drug called granulocyte colony-stimulating factor (either filgrastim and lenograstim). Liver and kidney damage. Abnormal blood clotting (thrombocytopenia). Allergic reaction, particularly to platinum-based agents. (A simple skin test in under investigation that may identify people with a potential allergic response.). Menstrual abnormalities are common and premature menopause occurs in about 30% of women, particularly in those over 40. Rarely, secondary cancers such as leukemia. Between a quarter and a third of women report problems in concentration, motor function, and memory, this may be long-term. This effect may be due to reductions in estrogen levels after treatments.

ASSESSMENT AND DIAGNOSTIC PROCEDURES: 1. Clinical examination : y Vaginal bleeding y Vaginal discharge for months before bleeding started y Lumbar pain that spread to the hip and later to the high on one side y Micturation occurred several times in a night a. Abdominal palpation y palpation of the iliac fossae may disclose the presence of a metastasic mass that usually arises laterally from behind Pouparts ligament. y If a mass is not present, this palpation may reveal tenderness on the side of greater extension of the tumor. y These also should include palpation of inguinal regions for adenopathy. b. Vaginal inspection y first, start with the speculum examination following a mere exploration of the vagina with the gloved finger of one hand. y Colposcope of Henselmann is used to diagnose early lesions of the cervix by direct examination. The instrument provides a magnified view of cervical lesions. y By painting the mucosa with an iodine solution, the normal mucosa becomes brown, whereas areas of abnormal epithelium remain uncolored. This procedure (Schillers test) is helpful in indicating the best place to take a biopsy in early cases of carcinoma and may indicate the extent of a carcinoma. c. Vaginal palpation

it furnishes information as to the consistency of the cervix, the depth of all vaginal fornices, the size, the position, and mobility of the uterus, and the possible extension of induration to the vaginal walls. It is done with two bimanual examinations, one with the right hand in the vagina and the left hand above the symphisis pubis, and the other with the hands in a reverse position. The index and middle fingers of one hand must reach far into the lateral fornix in order to feel the induration of the mucosa or the dimunition in depth of the fornix. When the tumor extends over the posterior of the fornix and wall, another type of bimanual examination is necessary. With the fingers of one hand placed in the vagina, palm facing down, and the index finger of the other hand introduced into the rectum, palm upward, the examiner will be able to establish whether the invasion of the mucosa is superficial or if the tumor has invaded the rectovaginal septum.

d. Rectal palpation y it establishes the extent of the parametrial infiltration. y The diminution in depth of a lateral fornix and los its elasticity and depressability as felt via the vagina can be taken as signs that the tumor has broken out of the cervix and extended into the aerolar tissue of the parametrium. y Palpation via rectum is limited to the use of either the index or the middle finger. The parametria are normally elastic and soft, but in some patients particularly with those history of pelvic inflammatory conditions, they may have become fibrotic and give a false impression of invasion by the tumor. 2. Cytoscopic examination y this exam reveals a deformity of the trigone area, small areas of echymossis and of cystitis may be observed, and there may be exaggeration of rugae of the floor of the bladder and linear edema. y It may be extended to include a study of ureteral meatus by means of an intravenously injected dye: the urine output may be diminished or abolished in case of ureteral compression. y A counterclockwise of the bladder may be seen that resullts from the development of cervical tumors with consequent change in position of ureteral meatuses. y Only the presence of bullous edema has been considered a significant cystoscopic finding 3. Exfoliative Cytology >Microscopic examination of vaginal smears is an essential procedure in the screening examination of women cancer. >The procedure is highly accurate, more so in the presence of carcinoma in than in large ulcerated and infected invasive carcinoma. >Positive cytology in a patient without symptoms or finding is only grounds for further investigation by biopsy or conization; no definitive treatment should be instituted on the basis of positive cytology done.

>PAP SMEAR or PAPANICOLAOU TEST is a screening test used to detect premalignant and malignant cell. In taking a Pap smear, a speculum is used to gather cells from the outer opening of the cervix of the uterus and the endocervix. The cells are examined under a microscope to look for abnormalities. The test aims to detect potentially pre-cancerous changes (called cervical intraepithelial neoplasia (CIN) or cervical dysplasia), which are usually caused by the sexually transmitted HPV's human papillomaviruses. The test remains an effective, widely used method for early detection of pre-cancer and cervical cancer. The test may also detect infections and abnormalities in the endocervix and endometrium.

4. Biopsy >removal of cells or tissues for examination to determine the presence of a disease. Biopsy of the cervix often done through Colposcopy. > COLPOSCOPY is a magnified visual inpection of the cervix aided by using a dilute acetic acid(vinegar) solution to highlight abnormal cells on the surface of the cervix. Other diagnostic test are CONIZATION and LOOP ELECTROCAUTERY EXCISION PROCEDURE(LEEP) >Conization is a procedure that may performed when colposcopic examination is not considered adequate and larger specimen is necessary.This procedure is particularly helpful if areas such as the endocervical glands are involved and are noy readily visualized. > Loop Electrocautery Excision procedure(LEEP) is performed to excise the cervical areas causing concern. Once the clinician identified the lesions with colposcopy, a paracervical nerve block is administered for anesthesia and the lesions are totally removed by a low voltage diathermy loop(an electrical current causing burning).There is less risk with this procedure because it is performed in the ambulatory setting without general anesthesia. 5. Laboratory Procedures >Enzymatic activity of tissues obtained for histopathologic diagnosis shows differentiating reactions for dysplasia,carcinoma in situ and invasive squamous cell carcinoma.Invasive carcinomas have marked increase of enzymatic activity when compared to normal epithelium. >Various enzymes: Pyruvate-kinase,moderately active in dyplasias and carcinoma in situ > A rise in activity is supposed to indicate the presence of invasive carcinoma elsewhere in the cervix. Medical Management Cryotherapy

Cryotherapy is the local or general use of low temperatures in medical therapy or the removal of heat from a body part. The term "cryotherapy" comes from the Greek cryo ( ) meaning cold and the word therapy ( ) meaning cure. Cryotherapy, also called cryosurgery, cryoablation or targeted cryoablation therapy, is a minimally invasive treatment that uses extreme cold to freeze and destroy diseased tissue, including cancer cells. Although cryotherapy and cryoablation can be used interchangeably, the term "cryosurgery" is reserved best for cryotherapy performed using an open, surgical approach. During cryotherapy, liquid nitrogen or argon gas is applied to diseased cells located outside or inside the body. Physicians use image-guidance techniques such as ultrasound,computed tomography (CT) or magnetic resonance (MR) to help guide these freezing substances to treatment sites located inside the body. Preparation for the procedure: Some physicians recommend taking ibuprofen (400 mg) a half-hour before this procedure to relieve minor discomfort; others give a dose of antibiotics before cryotherapy as a way to guard against infection. You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to local anesthetic medications,general anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or a blood thinner for a specified period of time before your procedure. Women should always inform their physician and x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. Equipments: In this procedure, ultrasound, computed tomography (CT) or magnetic resonance (MR) imaging, a cotton swab or spray device, cyroprobe and bronchoscope may be used. Procedures: Percutaneous image-guided procedures such as cryotherapy are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room. This procedure is often done on an outpatient basis. However, some procedures may require admission. Please consult with your physician.You will be positioned on the examining table. If topical cryotherapy is performed, your physician will apply liquid nitrogen to the area with a cotton swab or spray device.

For tumors deep inside the body that can be approached through the skin, your physician will perform a percutaneous procedure and insert thin, needle-size applicators or cryoprobes. You will be connected to monitors that track your heart rate, blood pressure and pulse during the procedure. A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. You may also receive general anesthesia. The area where the applicators or cryoprobe are to be inserted will be shaved, sterilized and covered with a sterile drape. A very small nick is made in the skin at the site. Using imaging guidance, the physician will insert one or more applicators or cryoprobes through the skin to the site of the diseased tissue. Once the applicators or cryoprobe(s) are in place, the liquid nitrogen or argon gas is delivered. Imaging is used to guide the placement of the applicators, and monitor the freezing process. At the end of the applicators, an "ice ball" forms and can be visualized using US, CT or MRI. Some tumors require multiple applicators to freeze completely. For prostate cancer, six to eight applicators are inserted through the perineum (the tissue between the rectum and the scrotum and penis) using ultrasound guidance. At the end of the procedure, the applicator(s) are removed and pressure will be applied to stop any bleeding. The opening in the skin is covered with a bandage. No sutures are needed. Your intravenous line will be removed. The entire procedure is usually completed within one to three hours. Cervical Cancer (Surgical Management) Surgery to remove cervical cancer may be an option when the cancer is confined to the cervix or uterus. The type of surgery performed depends on the location and extent of cervical cancer and your desire to be able to have children. Surgery Choices: >Surgery for very early stages of cervical cancer that preserves your ability to have children includes:
y y

A cone biopsy or loop electrosurgical excision procedure (LEEP), which removes a wedge of cervical tissue that contains the cancer. Radical trachelectomy to remove the cervix, part of the vagina, and the pelvic lymph nodes (lymph node dissection). But the uterus is left in place. >Surgery for most stages of cervical cancer does not preserve your ability to have children. Surgeries include:

y y

Hysterectomy with or without removal of the ovaries, to remove the cervix and related organs where recurrence would be most likely to occur. Modified radical hysterectomy with pelvic lymph node dissection. A radical hysterectomy usually includes removal of part of the vagina, the uterus, the ovaries, and the fallopian tubes. This removes the most likely sites of cancer and may reduce the risk of recurrence.

Surgery to remove the uterus and cervix (hysterectomy) may be done through an incision in the belly. For early-stage cervical cancer, laparoscopic surgery may be possible. This is done with several small incisions in the belly for a tiny camera and special instruments. Robotic-assisted laparoscopic surgery uses robotic arms that translate the surgeon's hand motions into finer and more precise movements. This surgery requires specially trained doctors. If surgery is part of your treatment, you also may be given radiation therapy, chemotherapy, or combination chemoradiation. These treatments may be given before or after surgery to try to destroy any cancer cells that may remain. Radiation, chemotherapy, or chemoradiation given before a surgery to help control or reduce the size of the tumor is called neoadjuvant therapy. Using these therapies after a surgery when only microscopic areas of cancer may still be present is calledadjuvant therapy. Compared with radiation alone, chemoradiation improves survival if it is used either before or after a hysterectomy. Side effects from surgery can include difficulty with urination or problems with bowel habits, such as constipation or diarrhea. Your ability to have or enjoy sexual intercourse may also be affected Alternative treatment for cervical Alternative cervical cancer treatment is used to ease stress, reduce side effects, and lessen symptoms. Patients who have cervical cancer may combine alternative treatments with the more standard treatment of cervical cancer (surgery, chemotherapy, and radiation therapy). Types of alternative cervical cancer treatment include:

Acupuncture Massage therapy Herbal products Vitamins or special diets Visualizatio, Meditation Spiritual healing.

Many patients claim that these alternative treatments help them feel better. It is important to note that some types of alternative treatment may interfere with standard treatment. In some cases, the combination of alternative treatment and standard treatment may even be harmful. NURSING DIAGNOSIS AND INTERVENTIONS: Nursing diagnosis: Anxiety r/t unknown outcome and possible treatments Interventions:

1. Be aware of the client/s emotional state throughout the course of care and use effective interpersonal communication to facilitate the clients acceptance of her condition and treatment. 2. Explain diagnostic tests and procedures to client to decrease her anxiety. 3. Provide therapeutic emotional support to client to help her cope with her feelings. Nursing diagnosis: Sexual dysfunction r/t vaginal bleeding, discomfort and procedures Interventions: 1. Inform client that she may experience dyspareunia r/t vaginal dryness after radiation therapy. 2. Listen to clients concerns. 3. Instruct client to use a H2o-soluble lubricant during intercourse or to use lubricated condoms to decrease irritation. Nursing diagnosis: Impaired urinary elimination r/t sensory motor impairment from radiation effects Interventions: Assess the function of the foley catheter to ensure patency and drainage. Provide catheter care. Record I&O including the color of the urine. Encourage the client to drink many fluids to flush the kidneys and decrease risk of UTI. 5. Promote urination when catheter is removed. Nursing diagnosis: Risk for loneliness Interventions: 1. Assess for indications of isolation and loneliness (e.g. absence of supportive significant others; uncommunicative and withdrawn; expression of feelings of rejection or being lonely; sad, dull affect). 2. Implement measures to decrease isolation and reduce the risk for loneliness. 3. Assist client to identify reasons for feeling isolated and alone; aid him/her in developing a plan of action to reduce these feelings. 4. Encourage significant others to visit. 5. Encourage client to maintain telephone contact with others. 6. Schedule time each day to sit and talk with client. 1. 2. 3. 4.

QUESTIONS
1.

A 40-year old woman is admitted to the hospital for a radiation implant therapy to treat recently diagnosed cervical cancer. The most important consideration when planning care is her a) level of anxiety b) loss of income due to inability to work c) support system d) energy level to perform ADL's ANSWER: A - anxiety is the usual response to a change in life situation like undergoing treatment for cancer.

2.

When the nurse is discussing risk factors for cervical cancer, which of these women would be at greatest risk? a) a 25-year old woman with family history of cancer and using birth control pills b) a 50-year old woman who has several exposures to radiation and has chronic anemia c) a 19-year old woman who initiated sexual intercourse early with multiple partners d) a 60-year old woman who had smoked cigarettes for 5 years and used diaphragm for birth control T ANSWER: C - early sexual intercourse and having multiple sexual partners pose highest risk to cervical cancer.

3.

he community nurse is conducting a health promotion program at a local school and is discussing the risk factors associated with cervical cancer. Which of the following, if identified by the client as a risk factor to cervical cancer, indicates a need for further teaching? a) smoking b) multiple sex partners c) first intercourse after age 20 d) annual gynecological examinations ANSWER : C

Risk factors for cervical cancer include human papillomavirus (HPV) infection, active and passive cigarette smoking, certain high-risk sexual activities (first intercourse before 17 years of age, multiple sex partners, or male partners with multiple sex partners). Screening via regular gynecological exams and Papanicolaou smear (Pap test) with treatment of precancerous abnormalities decrease the incidence and mortality of cervical cancer.
4.

A 40-year old woman is admitted to the hospital for a radiation implant therapy to treat recently diagnosed cervical cancer. The most important consideration when planning care is her a) level of anxiety b) loss of income due to inability to work c) support system d) energy level to perform ADL's

ANSWER: A - anxiety is the usual response to a change in life situation like undergoing treatment for cancer.

5.

When the nurse is discussing risk factors for cervical cancer, which of these women would be at greatest risk? a) a 25-year old woman with family history of cancer and using birth control pills b) a 50-year old woman who has several exposures to radiation and has chronic anemia c) a 19-year old woman who initiated sexual intercourse early with multiple partners d) a 60-year old woman who had smoked cigarettes for 5 years and used diaphragm for birth control

ANSWER : C - early sexual intercourse and having multiple sexual partners pose highest risk to cervical cancer.