CERVICAL CANCER

Cervical intraepithelial neoplasia (CIN) is a premalignant condition of the cervix. It is usually asymptomatic and is detected by routine cytological screening. It is a common gynecologic malignancy. Major risk factors include early sexual activity, multiple sexual partners, and history of sexually transmitted diseases especially human papilloma virus and herpes simplex virus. Cervical cancer may involve the bladder, rectum, and may metastasize to the lungs, mediastinum, bones, and liver. Types of cervical cancer includes: Dysplasia atypical cells with some degree of surface maturation. Carcinoma in Situ (CIS) which is confined to the cervical epithelium. Invasive carcinomas the stroma is involved, 90% are of the squamous cell type. Invasive cancer spreads by local invasion and lymphatics to the vagina and beyond.

Risk Factors: Behavioral: Early Coitarche Multiple Sexual Partners Male partner who has multiple sexual partner Human Papilloma Virus (HPV) Smoking Immunosuppression Dietary Deficiencies Oral Contraceptives Poor uptake of screening programs Indirect Risk Factors: High parity Low socioeconomic status Ethnicity: Black Races

Pathophysiology
The ectocervix is covered by stratified squamous epithelium The canal of the cervix if lines by columnar epithelium the point where these two epithelia meet is called the squamocolumnar junction.

It lies just at the external os. But as the cervix increases in the volume during puberty and also pregnancy, the SCJ is said to roll out he ectocervix He delicate columnar epithelium exposed to the acid environment of the vagina undergoes a process of mtaplasia whereby it becomes squamous epithelium. Thetransformation zone is that part of the cervix that extends from the widest part of the skin that was originally columnar epithelium into the current SCJ. Dysplasia occurs in the stratified squamous epithelium leading to disordered squamous epithelium. HPV is a factor in the dysplastic changes Smoking and immune suppression appear to be additional factors. Dysplastic epithelium lacks the normal maturation of the cells. Dysplasias are now usually referred to as cervical intraepithelial neoplasia (CIN).

Clinical Manifestation
Signs: General: Cachexia in advance cases Ureamia if the ureter is compressed Leg edema suggest lymphatic/ vascular obstruction from tumor Abdominal: Kidneys may be enlarged if hyronephrosis occurred. Pelvioabdominal mass may be felt in case of pyometria with tender uterus and high fever. If the disease involves the liver, hepatomegaly may develop. Symptoms Clinically, the first symptom is abdominal vaginal bleeding, usually postcoital. Vaginal discomfort , malodorous discharge, and dysuria are common. Tumor growth: Constipation, fistula and urethral obstruction frequency, dysuria and hematuria, leg edema, pain and hydronephrosis, back aches Somatic pain deeply seated pelvic pain, loin pain Pelviabdominal mass Clinical Vaginal: o Inpatients with early-stage cervical cancer, physical examination findings can be relatively normal. o As the disease progresses, the cervix may become abnormal in appearance, withgross erosion, ulcer or mass. These abnormalities can external to the vagina.

o Rectal examination may reveal an xternal mass or gross blood from tumor erosion. o Bimanual examination findings often reveal pelvic metastasis.

Laboratory and Diagnostic Examination

Precancerous changes of the cervix and cervical cancer cannot be seen with the naked eye. Special tests and tools are needed to spot such conditions. Pap smears screen for precancers and cancer, but do not make a final diagnosis. If abnormal changes are found, the cervix is usually examined under magnification. This procedure is called colposcopy. Pieces of tissue are surgically removed (biopsied) during this procedure. The tissue is sent to a laboratory for examination. A procedure called cone biopsy may also be done. If cervical cancer is diagnosed, the health care provider will order more tests. These help determine how far the cancer has spread. This is called staging. Tests may include: Chest x-ray CT scan of the pelvis Cystoscopy Intravenous pyelogram (IVP) MRI of the pelvis

Medical Management
Treatment of cervical cancer depends on: The stage of the cancer The size and shape of the tumor The woman's age and general health Her desire to have children in the future Early cervical cancer can be cured by removing or destroying the precancerous or cancerous tissue. There are various surgical ways to do this without removing the uterus or damaging the cervix, so that a woman can still have children in the future. Types of surgery for early cervical cancer include: Loop electrosurgical excision procedure (LEEP) -- uses electricity to remove abnormal tissue Cryotherapy -- freezes abnormal cells Laser therapy -- uses light to burn abnormal tissue

A hysterectomy (surgery to remove the uterus but not the ovaries) is not often done for cervical cancer that has not spread. It may be done in women who have repeated LEEP procedures. Treatment for more advanced cervical cancer may include: Radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina. Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed. Radiation may be used to treat cancer that has spread beyond the cervix or cancer that has returned. One type of radiation therapy uses a device filled with radioactive material. The device is placed inside the vagina next to the cervical cancer. The device is removed before the patient goes home. Another type of radiation beams radiation from a large machine onto the body where the cancer is located. It is similar to an x-ray. Chemotherapy uses drugs to kill cancer. Some of the drugs used for cervical cancer chemotherapy include 5-FU, cisplatin, carboplatin, ifosfamide, paclitaxel, and cyclophosphamide. Sometimes radiation and chemotherapy are used before or after surgery. Support Groups You can ease the stress of illness by joining a cancer support group. Sharing with others who have common experiences and problems can help you not feel alone. Outlook (Prognosis) How well the patient does depends on many things, including: Type of cervical cancer--some types do not respond well to treatment Stage of cancer Age and general health If the cancer comes back after treatment Precancerous conditions can be completely cured when followed up and treated properly. Most women are alive in 5 years (5-year survival rate) for cancer that has spread to the inside of the cervix walls but not outside the cervix area. The 5-year survival rate falls as the cancer spreads outside the walls of the cervix into other areas. Prevention Cervical cancer can be prevented by doing the following: Get the HPV vaccine. Two types of vaccines are approved, Gardasil and Cervarix. They prevent against most types of HPV infection that cause cervical cancer. Your health care provider can tell you if the vaccine is right for you.

Practice safer sex. Using condoms during sex reduces the risk of HPV and other sexually transmitted infections (STIs). Limit the number of sexual partners you have. Avoid partners who are active in high-risk sex. Get regular Pap smears as often as your health care provider recommends. Pap smears can help detect early changes, which can be treated before they turn into cervical cancer. If you smoke, quit. Smoking increases your chance of getting cervical cancer.

Nursing Management
Assessment Develop a rapport with patient; ascertain her health habits and receptivity for learning. Give preoperative preparation and psychological encouragement. Nursing Diagnoses

Anxiety related to diagnosis and surgery Impaired skin integrity related to wound and drainage Acute pain related to surgical incision and subsequent wound care Sexual dysfunction related to change in body part Self-care deficit related to lack of understanding of perineal care and general health status.

Collaborative Problems/Potential Complications

Wound infection and sepsis Deep vein thrombosis Hemorrhage

Planning and Goals Goals for the patient may include acceptance of and preparation for surgical intervention, recovery of optimal sexual function, ability to perform adequate and appropriate self-care, and absence of complications.

Nursing Interventions: Preoperative RELIEVING ANXIETY Allow patient time to talk and ask questions. Advise patient that the possibility of having sexual relations is good and that pregnancy is possible after a wide excision. Reinforce information about the surgery, and address patient's questions and concerns. Nursing Interventions: Postoperative RELIEVING PAIN AND DISCOMFORT Administer analgesic agents prophylactically. Position patient to relieve tension on incision (pillow under knees or low Fowler's position), and give soothing back rubs. IMPROVING SKIN INTEGRITY Provide pressure-reducing mattress. Install over-bed trapeze. Protect intact skin from drainage and moisture. Monitor for accumulation of purulent material (suppuration) under graft. Assist patient to keep perineal area clean and dry (warm saline or antiseptic irrigation). Assess and document surgical site characteristics and drainage. SUPPORTING POSITIVE SEXUALITY AND SEXUAL FUNCTION Establish a trusting relationship with patient. Encourage patient to share and discuss concerns with sexual partner. Consult with surgeon to clarify expected changes. Refer patient and partner to a sex counselor, as indicated. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Monitor closely for local and systemic signs and symptoms of infection: purulent drainage, redness, increased pain, fever, increased white blood cell count. Assist in obtaining tissue specimens for culture. Administer antibiotics as prescribed. Avoid cross-contamination; carefully handle catheters, drains, and dressings; handwashing is crucial.

Provide a low-residue diet to prevent straining on defecation and wound contamination. Discourage sitz baths because of risk for infection. Assess for signs and symptoms of deep vein thrombosis and pulmonary embolism; apply elastic compression stockings; encourage ankle exercises. Encourage and assist in frequent position changes, avoiding pressure behind the knees. Monitor closely for signs of hemorrhage and hypovolemic shock.

Promoting Home and Community-Based Care TEACHING PATIENTS SELF-CARE Encourage patient to share concerns as she recovers. Encourage participation in dressing changes and self-care. Give complete instructions to family member or other who will provide posthospital care regarding wound care, urinary catheterization, and possible complications. CONTINUING CARE Encourage communication with home care nurse to ensure continuity of care. Reinforce teaching with follow-up call between home visits. Evaluation EXPECTED PATIENT OUTCOMES Adjusts to the trauma of the surgical experience Obtains pain relief Maintains skin integrity Exhibits positive outlook about sexuality and sexual functioning Increases participation in self-care activities Experiences no complications