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Cervical cancer:prevention,diagnosis,
treatment and nursing care
NS483 Hughes C (2009) Cervical cancer: prevention, diagnosis, treatment and nursing care.
Nursing Standard. 23, 27, 48-56. Date of acceptance: November 25 2008.
Introduction
Summary
The application of cervical screening
This article provides an update on cervical cancer, broadly covering
programmes in developed countries has reduced
aspects of the disease ranging from epidemiology to aetiology and
the incidence of cervical cancer. Although the
prevention to treatment.
number of women diagnosed with the disease in
Author the UK has fallen by about 44% since 1975
Cathy Hughes is cancer lead, National Patient Safety Agency, (Cancer Research UK (CRUK) 2008), awareness
London. Email: cathy.hughes@npsa.nhs.uk and prevention of cervical cancer remain
important issues for women and healthcare
Keywords professionals. All women in the UK over the age
Cervical cancer; Human papillomavirus; Prevention; Screening of 25 years will have been routinely invited, at
some point, to attend cervical screening. With the
These keywords are based on the subject headings from the British introduction of the HPV vaccination programme,
Nursing Index. This article has been subject to double-blind review. girls over the age of 12 years are now being made
For author and research article guidelines visit the Nursing Standard aware of the disease and the effect it could have
home page at nursingstandard.rcnpublishing.co.uk. For related on their lives.
articles visit our online archive and search using the keywords.
Incidence
Globally, cervical cancer is the second most
common cancer in women after breast cancer.
Aims and intended learning outcomes
Around half a million women are diagnosed with,
This article aims to provide an update on and one quarter of a million women die from,
cervical cancer, including the incidence, the disease each year – the vast majority
aetiology, diagnosis, treatment and prevention of whom live in the developing world (World
of the disease. The role of the nurse is also Health Organization (WHO) 2008). Cervical
considered. After reading this article you should screening has significantly reduced the number of
be able to: women who develop or die from the disease but
only in countries where there is easy access to
Describe the risk factors associated with
cervical cytology or an organised cervical
cervical cancer.
screening programme.
Outline the developments in the human In the UK, more than 2,800 women were
papillomavirus (HPV) vaccination. diagnosed with cervical cancer and around 1,000
died from the disease in 2005 (CRUK 2008).
Detail the aims and main components of
The highest number of cases of cervical cancer
the NHS cervical screening programme.
occurred in women aged between 30 and 34 years
Identify the treatment options available and around 70% of cases occurred in women
for women with cervical cancer. under the age of 60 years (CRUK 2008) (Figure 1).
FIGURE 1
Incidence of cervical cancer in the UK in 2005 (adapted from Cancer Research UK 2008)
400
368 364
350 329
300
Number of cases
45-49
40-44
70-74
65-69
50-54
55-59
60-64
80-84
85+
15-19
30-34
75-79
2
2 Prevention
Health protection messages relating to cervical
cancer are controversial. The link between
cervical cancer and sexual behaviour has led to
stigmatisation and accusations of promiscuity
3 1 despite the common prevalence of HPV. HPV is
3
spread by skin contact and can be found all round
The cervical epithelium is made At puberty the junction of these the genital area, so penetrative intercourse is not
up of multilayered squamous two types of epithelium lies at the required to transmit the virus, although condoms
epithelium on the ectocervix and external os. have been shown to reduce the rates of infection
thinner columnar epithelium in by up to 70% (Winer et al 2006).
the endocervix. The identification of HPV in almost all cases
of cervical cancer has led to the development of
2 prophylactic vaccines. Two products are now
licensed and available for use. Gardasil® and
Cervarix® target the two most common high-risk
HPV types 16 and 18, found in 70% of cervical
cancers (WHO and Institut Català d’Oncologia
Information Centre on HPV and Cervical Cancer
5 2007). Gardasil® also targets HPV types 6 and
4 11, which cause most cases of genital warts.
6 5
Short-term data suggests that the vaccines offer
Lateral view of the cervix – the numbers relate to: protection against the development of cervical
1. Squamous epithelium. 4. Everted columnar epithelium. intraepithelial neoplasia and few side effects have
been observed (WHO 2007).
2. Columnar epithelium. 5. Transformation zone. In October 2007, the UK government
3. Squamocolumnar junction. 6. Glands opening in the announced the introduction of an HPV
transformation zone. immunisation programme for females aged
12-13 years, to commence in September 2008.
(Diagram courtesy of the British Society for Clinical Cytology)
A ‘catch up’ programme was also announced for
Time out 3
for Colposcopy and Cervical Pathology (BSCCP)
sets standards for colposcopy and colposcopists In the UK, more than
(NHS Cancer Screening Programmes 2004). 4.5 million women are offered
Current recommendations insist that unsupervised cervical screening each year
colposcopy should only be performed by those (NHS Cancer Screening Programmes
accredited by the BSCCP, whatever their clinical 2008, Cervical Screening Wales 2009,
background or expertise. Nurses can become NHS National Services Scotland 2009 and
accredited alongside medical colleagues if they NI Cancer Screening Programmes 2009).
complete the training and maintain practice as Think about the value of screening and the
stipulated by the BSCCP (2009). According to the physical, financial, social and psychological
BSCCP (2009) there are now more than 100 implications for the individuals. List the
trained nurse colposcopists who are registered potential advantages and disadvantages of
members and this number is increasing. cervical screening.
In England, 3.4 million women were screened
in 2007/08. Around 6.6% of the target group had Implications Cervical screening may affect
an abnormal result, with 122,000 being referred individuals in a number of ways. In relation to
to colposcopy and 16% of those having severe Time out 3 you should have considered:
dyskaryosis or worse(NHS Information Centre
The overall financial cost of all aspects of
2008). The cervical screening programme in
screening, which would include the
England costs about £157million (NHS Cancer administration of services, laboratory staff,
Screening Programmes 2008) but it is thought to counselling services, clinical staff, out of hours
be directly responsible for the 42% drop in services or time off work and the management
cervical cancer incidence in England and Wales of treatment complications.
observed between 1988 and 1997. This equates
to a saving of around 1,300 lives per year The medicalisation of women’s health, which
(Sasieni and Adams 1999). refers to the way in which patriarchal systems
Given the rising rates of sexually transmitted control women’s bodies.
infections, it is now estimated that the cervical The anxiety associated with having a medical
screening programmes in the UK are preventing investigation, waiting for a result and the
about 5,000 deaths per year (Peto et al 2004). significance of an inconclusive or abnormal
Screening coverage (the percentage of eligible result.
women screened in the defined time) has fallen The number of women who worry about an
steadily in England, from 82.5%in 1998 to abnormal result without ever having cancer,
79.2% in 2008, but this decline has been more or ever going on to develop cancer.
marked in the 25-29 years age group where
five-year coverage fell from 78.8% to 66.2% and The number of women who are treated
the three or 3.5-year coverage fell from 66.4% to unnecessarily, by having CIN removed that
58.6% in the same ten-year period (NHS would never have developed into cervical cancer.
Information Centre 2008). It is not clear why The physical and psychological risks and
some younger women are no longer attending benefits associated with treatment of CIN.
cervical screening appointments, but falling
The number and type of women who do not
mortality rates may have reduced general
attend for cervical screening and how they are
awareness of the condition.
disadvantaged or ignored.
Cervical cancer incidence in the UK may
increase in the future because of this fall in The number of women whose lives have been
screening attendance and also because of the saved, and the families that will benefit from this.
increase in eastern European immigration where
there are cohorts of women who have never been Time out 4
screened. Women should be encouraged to
participate in the screening programme at the Consider how you would
appropriate age and frequency by all healthcare encourage women to participate
professionals (DH 2007b). in the cervical screening
It takes many years for cervical cancer to develop programme and the advice you
following HPV infection. Therefore, it will take would offer to patients, friends and
many years before the introduction of a vaccine has family members who are anxious about
any major effect on the number of cases of cervical undergoing cervical screening.
In 1995 a Europe-wide study showed that the UK Stage IVb – spread to distant organs.
lagged behind comparable European countries in (Benedet et al 2000)
the successful treatment of people with cancer
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