Cervical cancer
• Cancer of the neck of the uterus
Risk Factors
• Sexual activity:
• Multiple sex partners
• Early age (younger than 20) at first coitus
(exposes the vulnerable young cervix to
potential carcinogens from a partner)
• Early childbearing
• Exposure to human papillomavirus
• HIV infection
• Smoking
• Exposure to diethylstilbestrol (DES) in utero
• Low socioeconomic status (may be related to
early marriage and early childbearing)
• Nutritional deficiencies (folate, beta-carotene,
and vitamin C levels are lower in women with
cervical cancer than in women without it)
• Chronic cervical infection
Preventive Measures
• Regular pelvic examinations and Pap tests for
all women, especially older women past
childbearing age (decreases the chance of
dying from cervical cancer from 1 in 250 to 1 in
2,000 women)
• Education related to reproductive health and
safer sex
• Smoking cessation
Clinical Manifestations
• Adenocarcinomas begin in mucus-producing
glands and are often due to HPV infection.
• Early cervical cancer rarely produces
symptoms. If symptoms are present, they may
go unnoticed as a thin watery vaginal
discharge often noticed after intercourse or
douching.
• When symptoms such as discharge, irregular
bleeding, or bleeding after sexual intercourse
occur, the disease may be advanced.
• Advanced disease should not occur if all
women have access to gynecologic care and
avail themselves of it. The nurse’s role in
access and utilization is crucial and may
prevent the delay of detection of cervical
cancer until the advanced stage.
• In advanced cervical cancer, the vaginal
discharge gradually increases and becomes
watery and, finally, dark and foul-smelling from
necrosis and infection of the tumor.
• The bleeding, which occurs at irregular
intervals between periods (metrorrhagia) or
after menopause, may be slight (just enough to
spot the undergarments) and occurs usually
after mild trauma or pressure (eg, intercourse,
douching, or bearing down during defecation).
• As the disease continues, the bleeding may
persist and increase. Leg pain, dysuria, rectal
bleeding, and edema of extremities signal
advanced disease.
• As the cancer advances, it may invade the
tissues outside the cervix, including the lymph
glands anterior to the sacrum.
• In one third of patients with invasive cervical
cancer, the disease involves the fundus. The
nerves in this region may be affected,
producing excruciating pain in the back and
the legs that is relieved only by large doses of
opioid analgesic agents. If the disease
progresses, it often produces extreme
emaciation and anemia, usually accompanied
by fever due to secondary infection and
abscesses in the ulcerating mass, and by
fistula formation.
Assessment and Diagnostic Findings
• Diagnosis may be made on the basis of
abnormal Pap smear results, followed by
biopsy results identifying severe dysplasia
(cervical intraepithelial neoplasia type III [CIN
III], high-grade squamous intraepithelial
lesions [HGSIL] [also referred to as HSIL], or
carcinoma in situ; see below).
• HPV infections are usually implicated in these
conditions. Biopsy results may indicate
carcinoma in situ. Carcinoma in situ is
technically classified as severe dysplasia and
is defined as cancer that has extended through
the full thickness of the epithelium of the
cervix, but not beyond. This is often referred to
as preinvasive cancer.
• In its very early stages, invasive cervical
cancer is found microscopically by Pap smear.
In later stages, pelvic examination may reveal
a large, reddish growth or a deep, ulcerating
lesion. The patient may report spotting or
bloody discharge.
• When the patient has been diagnosed with
invasive cervical cancer, clinical staging
estimates the extent of the disease so that
treatment can be planned more specifically
and prognosis reasonably predicted.
• Signs and symptoms are evaluated, and x-
rays, laboratory tests, and special
examinations, such as punch biopsy and
colposcopy, are performed.
• Depending on the stage of the cancer, other
tests and procedures may be performed to
 determine the extent of disease and
appropriate treatment. These tests include
dilation and curettage (D & C), computed
tomography (CT) scan, magnetic resonance
imaging (MRI), intravenous urography,
cystography, and barium x-ray studies.
Medical Management
PRECURSOR OR PREINVASIVE LESIONS
• When precursor lesions, such as low-grade
squamous intraepithelial lesion (LGSIL), which
is also referred to as LSIL (CIN I and II or mild
to moderate dysplasia), are found by
colposcopyand biopsy, careful monitoring by
frequent Pap smears or conservative treatment
is possible.
• Conservative treatment may consist of
monitoring, cryotherapy (freezing with nitrous
oxide), or laser therapy.
• A loop electrocautery excision procedure
(LEEP) may also be used to remove abnormal
cells. In this procedure, a thin wire loop with
laser is used to cut away a thin layer of
cervical tissue. LEEP is an outpatient
procedure usually performed in a
gynecologist’s office; it takes only a few
minutes. Analgesia is given before the
procedure, and a local anesthetic agent is
injected into the area. This procedure allows
the pathologist to examine the removed tissue
sample to determine if the borders of the tissue
are disease-free.
• Another procedure called a cone biopsy or
conization (removing a cone-shaped portion
of the cervix) is performed when biopsy
findings demonstrate CIN III or HGSIL,
equivalent to severe dysplasia and carcinoma
in situ.
• If preinvasive cervical cancer (carcinoma in
situ) occurs when a woman has completed
childbearing, a hysterectomy is usually
recommended.
• If a woman has not completed childbearing
and invasion is less than 1 mm, a cone biopsy
may be sufficient.
• A newly developed procedure called a radical
trachelectomy is an alternative to hysterectomy
in women with cervical cancer who are young
and want to have children. In this procedure
the cervix is gripped with retractors and pulled
into the vagina until it is visible.
• The affected tissue is excised while the rest of
the cervix and uterus remain intact. A
drawstring suture is placed to close the cervix.
INVASIVE CANCER
• Surgery and radiation treatment (intracavitary
and external) are most often used. When
tumor invasion is less than 3 mm, a
hysterectomy is often sufficient.
• Invasion exceeding 3 mm usually requires a
radical hysterectomy with pelvic node
dissection and aortic node assessment. Stage
1B1 tumors are treated with radical
hysterectomy and radiation. Stage 1B2 tumors
are treated individually because no single
correct course has been determined, and
many variable options may be seen clinically.
• Frequent follow-up after surgery by a
gynecologic oncologist is imperative because
the risk of recurrence is 35% after treatment
for invasive cervical cancer. Recurrence
usually occurs within the first 2 years.
Recurrences are often in the upper quarter of
the vagina, and ureteral obstruction may be a
sign. Weight loss, leg edema, and pelvic pain
may be signs of lymphatic obstruction and
metastasis.
• Radiation, which is often part of treatment to
reduce recurrent disease, may be delivered by
an external beam or by brachytherapy
(method by which the radiation source is
placed near the tumor) or both. The field to be
irradiated and dose of radiation are determined
by stage, volume of tumor, and lymph node
involvement.
• Treatment can be administered daily for 4 to 6
weeks followed by one or two treatments of
intracavitary radiation. Interstitial therapy may
be used when vaginal placement has become
impossible due to tumor or stricture.
• Platinum-based agents are being used to treat
advanced cervical cancer. They are often used
in combination with radiation therapy, surgery,
or both.
• Vaginal stenosis is a frequent side effect of
radiation. Sexual activity with lubrication is
preventive, as is use of a vaginal dilator to
avoid severe permanent vaginal stenosis.
• Some patients with recurrences of cervical
cancer are considered for pelvic
exenteration, in which a large portion of the
pelvic contents is removed. Unilateral leg
edema, sciatica, and ureteral obstruction
indicate likely disease progression.
• Patients with varicose veins or a history of
thromboembolic disease may be treated
prophylactically with heparin.
• Pneumatic compression stockings are
prescribed to reduce the risk for deep vein
thrombosis.
Surgical procedures that may be carried out to treat Involves lower third of vagina. One or both ureters
cervical cancer include the following: obstructed by the tumor on IV urogram
• Total hysterectomy—removal of the uterus,  Stage IIIa No extension onto the pelvic wall
cervix, and ovaries  Stage IIIb Extension onto the pelvic wall or
• Radical hysterectomy—removal of the uterus, hydronephrosis or nonfunctioning kidney,
ovaries, fallopian tubes, proximal vagina, and or both
bilateral lymph nodes through an abdominal • Stage IV Extension of carcinoma beyond
incision (Note: “radical” indicates that an the true pelvis
extensive area of the paravaginal, Clinical involvement of the mucosa of the bladder
paracervical, parametrial, and uterosacral or rectum
tissues is removed with the uterus.)  Stage IVa Spread of carcinoma to adjacent
• Radical vaginal hysterectomy—vaginal organs
removal of the uterus, ovaries, fallopian tubes,  Stage IVb Spread to distant organs
and proximal vagina
• Bilateral pelvic lymphadenectomy—removal of
the common iliac, external iliac, hypogastric,
and obturator lymphatic vessels and nodes
• Pelvic exenteration—removal of the pelvic
organs, including the bladder or rectum and
pelvic lymph nodes, and construction of
diversional conduit, colostomy, and vagina
• Radical trachelectomy—removal of the cervix
and selected nodes to preserve childbearing
capacity in a woman of reproductive age with
cervical cancer

International Classification of Carcinoma of the

Uterine Cervix
STAGE OF LESION SIZE AND DESCRIPTION
Preinvasive
• Stage 0 Carcinoma in situ; cancer limited to
epithelial layer; no evidence of invasion
Invasive
• Stage I Carcinoma strictly confined to
cervix
 Stage Ia Microinvasive; identified only
microscopically
 Stage Ia1 Invasion no greater than 3 mm in
depth and no wider than 7 mm
 Stage Ia2 Invasion > 3 mm and no greater
than 5 mm and no wider than 7 mm
 Stage Ib Clinical lesions confined to cervix
or preclinical lesions > stage Ia
 Stage Ib1 Clinical lesions no greater than 4
cm in size
 Stage Ib2 Clinical lesions > 4 cm in size
• Stage II Carcinoma extends beyond the
cervix but not onto thepelvic wall
 Stage IIa Vaginal extension only
 Stage IIb Paracervical extension with or
without vaginal involvement
• Stage III Carcinoma extends to one or both
pelvic walls