UNIVERSITY OF THE EAST

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER

#64 Barangay Doña Imelda Aurora Boulevard Quezon City 1113
Telephone No. 713-33-09 ; 715-08-61 local 289

COLLEGE OF NURSING

MEDICAL SURGICAL NURSING

NCM 112

CERVICAL CANCER

Submitted by:
Jabian, Patricia Jeanne M.
Lachica, Oshelley Q.
Lautchang, Anne Beatrice P.

N3B
 Incidence and Epidemiology

Cervical cancer is the second most common female malignant tumor globally which seriously
threatens female’s health. Persistent infection of high-risk human papillomavirus (HPV) has been clarified
to be the necessary cause of cervical cancer. Over the past 30 years, young women who were affected
by cervical cancer have increased with a proportion range of 10% to 40%. In 2018, it was estimated that
there were 570,000 cases and 311,000 deaths of cervical cancer worldwide, and was ranked as the fourth
most frequently diagnosed cancer and the fourth leading cancer death in women. Approximately 85% of
the worldwide deaths from cervical cancer are from underdeveloped or developing countries, and the
death rate is 18 times higher in low-income and middle-income countries compared to wealthier countries.

Source: https://gco.iarc.fr/today/data/factsheets/populations/608-philippines-fact-sheets.pdf

In the Philippines, cervical cancer is the 2nd most frequent cancer among Filipino women
between 15 and 44 years of age. According to the 2015 Philippine Cancer Facts and Estimates, there is
an annual age standardized incidence of cervical cancer of 16/100,000 and mortality rate of 7.5 per
100,000. In Filipino women with cervical cancer, high-risk human papillomavirus (HPV) types such as 16
and 18 are consistently identified. Factors such as; young age at first intercourse, low socioeconomic
status, high parity, smoking, use of oral contraception and risky sexual behaviors were identified to cause
the increase in the likelihood of HPV infection and subsequent development of cervical cancer.
Consequently, certain cancer screening programs were developed in the Philippines such as Pap smears,
single visit approach utilizing visual inspection with acetic acid followed by cryotherapy, as well as
colposcopy. However, due to lack of basic knowledge, women cannot view these screening programs as
an important measure in preventing cervical cancer that’s why there is still a low number of them adhering
to such prevention activity.
 Types and Classification

The types of cervical cancer named after the type of cell where the cancer started. The types of cervical
cancer are:
1. Squamous cell cancer
● About 80-90% of cervical cancers are squamous cell cancer.
● These are flat, skin-like cells that cover the ectocervix. They mostly begin in the
transformation zone where the squamocolumnar junction resides.

2. Adenocarcinoma
● This type of cancer develops from the glandular cells, that produces mucus, of the
endocervix

3. Adenosquamous carcinoma or Mixed Carcinomas

● These are when cervical cancer cells can feature characteristics of both squamous cell
carcinoma and adenocarcinoma. They are mostly caused by HPV-16 infection.

4. Small Cell Carcinoma

● They are a very rare type of cervical cancer. This type of carcinoma grows quickly and is
more likely to spread to other lymph nodes. They are mostly caused by HPV-18 infection.

5. Melanoma, Sarcoma, and Lymphoma

● They are the other types of cervical cancer which can very rarely occur in the cervix and
are treated differently compared to the other types of cervical cancer.

STAGES OF CERVICAL CANCER

International Classification Of Carcinoma Of The Uterine Cervix

Stage of Lesion Size and Description

Pre-Invasive

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 the pelvic wall

Stage IIa Vaginal extension only

Stage IIb Paracervical extension with or without vaginal involvement

Carcinoma extends to one or both pelvic walls. Involves the lower third of
Stage III vagina. One or both ureters obstructed by the tumor on IV urogram

Stage IIIa No extension onto the pelvic wall

Stage IIIb Extension onto the pelvic wall or hydronephrosis or non functioning kidney, or
both

Extension of carcinoma beyond the true pelvis Clinical involvement of the

Stage IV mucosa of the bladder or rectum

Stage IVa Spread of carcinoma to adjacent organs

Stage IVb Spread to distant organs

Risk Factors

Modifiable Non-modifiable

● Exposure to human papillomavirus ● HIV infection

● Sexual activity: ● Chronic cervical infection
○ Multiple sex partners ● Low socioeconomic status
○ Early age (younger than 20) at first coitus (may be related to early
(exposes the vulnerable young cervix to marriage and early
potential carcinogens from a partner) childbearing)
● Early childbearing ● Exposure to diethylstilbestrol
● Smoking (DES) in utero
● Nutritional deficiencies (folate, beta-carotene, and
vitamin C levels are lower in women with cervical
cancer than in women without it)
 Focus Anatomy and Physiology

Females have five internal reproductive organs: the vagina, cervix, uterus, ovaries and fallopian
tube. The uterus can be divided into two regions; the first one is the cervix that opens the vagina and can
be found in the lower part. The cervix is lined with a mucous membrane that is soft. Through a channel in
the cervix, the sperm can enter and menstrual blood can exit the uterus. The cervical canal is usually
narrow, but during labor, the canal widens to let the baby through. The second region is the corpus. The
corpus is highly muscular and can easily expand to hold a developing baby.
The cervix is a cylinder-shaped neck of tissue that connects the vagina and uterus. It is a
fibromuscular tissue about one to two inches in size. It has two portions: the ectocervix, the one closest to
the vaginal opening, is the one that opens to create a passage between the uterus and the vagina. The
endocervix, also called the endocervical canal, is a tunnel that allows transportation of sperm into the
uterine cavity, allows blood to pass from the uterus during menstruation, and it produces mucus that
lubricates the reproductive tract that changes in consistency during the menstrual cycle to prevent or
promote pregnancy. The area where the endocervix and the ectocervix meet is called the transformation
zone.

The cervix has mainly three functions:

(1) It cleans the vagina as it is responsible for creating a natural vaginal secretion called
“discharge” or cervical mucus that changes throughout the menstrual cycle.
(2) It facilitates a woman’s pregnancy by naturally changing its position during ovulation and helps
the sperm into the uterus with the cervical mucus as it becomes thin and slippery. The softness and the
high positioning of the cervix may help in leading the sperm to the eggs for fertilization. During labor, it
dilates wide enough up to 10 cm to accommodate the baby’s head into the vagina. When not in ovulation,
the cervix is at a lower part of the body and feels harder.
(3) During a menstrual cycle when the estrogen is at its peak, it produces as much as 700 ml of
mucus per day. During pregnancy, more mucus is produced, it forms a seal, called a mucus plug, that
keeps out ascending infections and protects the fetus as the mucus plug is at the opening of the vagina.

Laboratory and Diagnostic Procedures

Laboratory Purpose Procedure Result

PAP SMEAR It is widely used 1. Woman lie on an
to screen for examination table as a
healthcare professional
precancerous or
inserts the speculum
cancerous
changes in 2. Certain sample cells are
cervical cells. scraped from the cervix
(using a cervical brush)
3. Cells will be further
examined to know if there
are abnormalities in the cells
Atypical cells are found in the
cervix. This type of cells may
appear different from normal
cells may be due to infections
or irritation in the cervical lining
but they are not entirely specific
for a precancerous condition.
However, if left untreated, they
are more likely to progress to
cancer.

HPV TEST An HPV test This test has almost the same A positive test result indicates
looks for some procedure with the Pap Smear. that evidence of an infection
high-risk types of It collects and tests sample cells with a high-risk strain of HPV
the human from the cervix. was found in the sample of
papilloma virus, cervical cells.
including types Sometimes, the HPV test and
16 and 18, which Pap Smear is done at the same
cause most time which is called the
cases of cervical co-testing.
cancer.

If a woman tested positive in the screening tests mentioned above, she may be advised to do a follow up
diagnostic tests such as;

Diagnostics Purpose Procedure Result

COLPOS- A colposcopy 1. Patient will be asked to lie During the wiping of iodine
COPY can help confirm down on the exam table solution, which is called the
(heels in the stirrups at the Schiller Test, the iodine colors
and diagnose
 potential end of the table) healthy cells brown; abnormal
problems if a cells remain unstained, usually
woman tested 2. Speculum will be inserted (to appearing white or yellow.
open up the vagina and get
positive for HPV
a clearer view of cervix)
virus. This virus
may raise your 3. Cervix, vagina, and vulva If abnormalities are found on
risk for certain will be lightly wiped with a the cervix during colposcopy,
types of cancer, vinegar or iodine solution biopsy usually follows.
including (helps in better seeing
cervical, vaginal, abnormal areas)
and vulvar
4. Colposcope (a bright light
cancers. and magnifying instrument)
is positioned between legs
of the patient (close to
vagina as possible, but not
inserted inside body) for the
examination

BIOPSY It is done when Removal of small pieces of A positive test means that
abnormalities tissues to be examined by a cancer or precancerous cells
are found during pathologist. have been found and treatment
the colposcopy. may be needed.
Two Different Methods
A biopsy are the
only way to tell Punch biopsy:
for sure whether Use an instrument called “biopsy
abnormal cells forceps” and the cervix might be
are cancerous, stained with a dye to make it
precancerous, or easier to see any abnormalities
reactive for
some other
reason

Cone biopsy:
Uses a scalpel or laser to
 remove large, cone-shaped
pieces of tissue from the cervix.
Given a general anesthetic for
sedation

The type of procedure used will

depend on the reason for your
biopsy and your medical history.

Treatment and Management (from the book)

Medical Management

Precursor or Preinvasive Lesions

When precursor lesions, like low-grade squamous intraepithelial lesions are found by:
● Colposcopy
● Biopsy
● Frequent Pap smear
Conservative treatment may consist of:
● Cryotherapy - freezing with liquid nitrogen
● Laser therapy
● Loop Electrocautery Excision Procedure (LEEP) - a thin wire loop with laser is used to cut
away a thin layer of cervical tissue (can also be used to remove abnormal cells;
Analgesia is given before the procedure, and a local anesthetic agent is injected into the
area)
● Cone Biopsy or conization - removing a cone- shaped portion of the cervix

Invasive Cancer
Treatment of invasive cervical cancer depends on the stage of the lesion, the patient’s age and
general health, and the judgment and experience of the provider.

Surgical Procedures for Cervical Cancer

● Simple Hysterectomy: removal of uterus, cervix, and ovaries. Can be used to treat certain types
of severe CIN or certain types of very early cervical cancer.
Different types of ways to do hysterectomy:
■ Abdominal hysterectomy: uterus is removed through an incision in the front of the
abdomen.
 ■ Vaginal hysterectomy: uterus is removed through the vagina.
■ Laparoscopic hysterectomy: uterus is removed using laparoscopy
■ Robotic-assisted surgery: laparoscopy is done with special tools attached to
robotic arms that are controlled by the doctor to perform precise surgery.
○ Side Effects: any type of hysterectomy results in infertility; complications are unusual but
it could include bleeding, infection, or damage to the urinary or intestinal systems such as
the bladder and the colon.
● Radical Hysterectomy: removal of the uterus, ovaries, fallopian tubes, proximal vagina, and
bilateral lymph. Usually done through a large abdominal incision (open surgery).
○ Side Effects: any type of hysterectomy results in infertility; Because some of the nerves to
the bladder are removed, some women have problems emptying their bladder after this
operation and may need a catheter for a time; complications are unusual but it could
include bleeding, infection, or damage to the urinary or intestinal systems such as the
bladder and the colon.

● Radical Trachelectomy: removal of the cervix and selected nodes to preserve childbearing
capacity in a woman of reproductive age with cervical cancer. After the procedure some women
are able to carry a pregnancy to term and deliver a baby through C-section, although women who
have had this surgery done have higher risk for miscarriage.
 ● Pelvic Exenteration: removal of the pelvic organs, including the bladder or rectum and pelvic
lymph nodes, and construction of diversional conduit, colostomy, and vagina.
● Bilateral Pelvic Lymphadenectomy: removal of the common iliac, external iliac, hypogastric, and
obturator lymphatic vessels and nodes. Cervical cancer can spread to lymph nodes in the pelvis.
To check for lymph node spread, the surgeon might remove some of the lymph nodes, it is done
at the same time as hysterectomy or trachelectomy.
○ Side Effects: Removing lymph nodes can lead to fluid drainage problems in the legs. This
can cause severe leg swelling, a condition called Lymphedema.

Prevention and Control Program

Primary Prevention Secondary Prevention Tertiary Prevention

HPV VACCINATION SCREENING AND TREATMENT OF CERVICAL

TREATMENT OF CANCER AND PALLIATIVE
PRECANCEROUS LESIONS CARE

The public health goal is to
reduce the HPV infections.
Persistent HPV infections lead
to cervical cancer.
The public health goal is to The public health goal is to
decrease the incidence and the decrease the number of deaths
prevalence of cervical cancer caused by Cervical Cancer.
and the associated mortality, by
intercepting the progress from
pre-cancer to invasive cancer.

Primary prevention of cervical
cancer entails preventing the
acquisition of HPV infection and
the development of cellular
changes in the cervix.
The most effective strategy to
primarily prevent the occurrence
Screening refers to the testing of
women without symptoms to
detect cancer risk. The main
goal is to detect persistent HPV
infections and cancer precursor
lesions so that they can be
treated in time.
It focuses on people who are
already affected by invasive
cervical cancer, with the goal to
improve quality of life, reduce
disability, minimise
complications and restore
function. This is done by
diagnosing and treating the
 of HPV infection is through
vaccination. HPV vaccination is
targeted at girls 9 to 13 years
old.
There are several health
education and services that may
be employed within the primary
prevention interventions:
○ Sexual health education
tailored to the age group
○ Providing contraceptive
counseling and services
including condoms
○ Prevention of tobacco use
At a minimum, screening is
recommended for every woman
30–49 years of age at least once
in a lifetime. Women younger
than 30 years of age should not
undergo screening except for
women known to be
HIV-infected or living in a high
HIV prevalence area.
disease or providing palliative
care to ensure that patients with
life threatening cervical cancer
are provided with relief from pain
and suffering, both physical and
psychological.
Treatment must be available to
all women whenever cancer is
detected.

Complications

Irregular Bleeding
● Once the cancerous cells in the cervix spread into the nearby tissues such as the vagina, bowel
or bladder, it can cause significant damage that may eventually lead to bleeding. These bleeding
may happen in between periods, after intercourse, or even after menopause. Sometimes, it
passess through the means of urination resulting in blood-tinged urine. 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.

Pain
● If the cancer spreads into nerve endings, bones or muscles, it can often cause severe pain. 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.

Kidney Failure
● In some cases, the tumour can cause a build-up of urine inside the kidneys (hydronephrosis),
which can lead to loss of most or all of the kidneys' functions or kidney failure and it can cause a
wide range of symptoms, including:
○ Tiredness and feeling sick (due to buildup of toxins and impurities in the blood)
○ Swollen ankles, feet or hands (due to fluid retention)
○ Shortness of breath (due to buildup of fluid in lungs)
○ Hematuria (due to injury in the glomerular filtration barrier)
Fistula Formation
● In advanced cases, sometimes, due to the infection or inflammation, abscess forms that results in
fistula formation or an abnormal connection between two body parts which in this case is between
the bladder and the vagina or sometimes develop between the vagina and rectum.

Hypothetical Case Scenario

Patient CE is a 48 year old female patient admitted to the hospital claiming that while riding in a tricycle
she had a heavy vaginal bleeding and pain in the abdominopelvic area with a pain scale of 8/10. She
refused to go to the hospital due to financial inadequacy until 3 days later, when she experienced
dizziness and weakness at work. An hour prior to her admission she experienced heavy vaginal bleeding
that made her jeans stained and wet. The physician then ordered for a CBC, urinalysis, and cervical
biopsy.

The nurse then interviews Patient CE and records the following assessment findings: The patient’s
partner had multiple sex partners and was tested positive for HPV. She had reduced her smoking to less
than 10 cigarettes per day and she does not drink alcohol.

Vital Signs:
T: 36.3C
HR: 80 bpm
RR: 25 cpm
BP: 100/70 mmHg

Diagnostic:
Cervical Biopsy Result: Large (Cell) Non-keratinizing Squamous Cell Carcinoma
HPV Test Result: Positive (High-risk HPV was found)

Laboratory:
Urinalysis: RBC of more than 5.0 hpf

CBC:
● WBC: 7.0 x 1012/L
● RBC: 2.43 x 1012/L
● HGB: 6.6 g/dL
● HCT: 18.3%

Nursing Diagnoses (3)

1. Acute pain related to disease progression and metastasis as evidenced by abdominopelvic pain
of 8/10
2. Ineffective tissue perfusion related to interruption of blood flow as evidenced by abdominopelvic
pain
3. Fluid volume deficit related to cervical bleeding as evidenced by heavy bleeding and hypotension
 Pathophysiology

Lucidchart Link:
https://lucid.app/lucidchart/invitations/accept/inv_bb2cb7c7-ccdc-4d1d-86cd-68ddd4304ea8
 Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain related to Short Term: Independent: Independent: Short Term:
pressure in the left
Heavy vaginal bleeding inguinal region After 1 hour of nursing Perform a Helps in planning After 1 hour of nursing
intervention, the patient comprehensive optimal pain intervention, the patient
secondary to cervical
will be able to, assessment of pain. management strategies was able to,
Pain in the cancer as evidenced by ● Demonstrate Using the COLDSPA ● Demonstrate
abdominopelvic area pain scale of 8/10 techniques to method. techniques to
with a pain scale of help ease pain help ease pain
(8/10) ● Verbalize Obtain the patient’s vital To obtain baseline data ● Verbalize
alleviation of signs for comparison alleviation of
Objective: pain from 8/10 pain from 8/10
to 3 or less Listen to the patient’s To establish a trusting to 3 or less
Vital Signs: ● Maintain stable fears and concerns, and patient-nurse ● Maintain stable
T: 36.3C BP within offer reassurance when relationship BP within
HR: 80 bpm normal range appropriate normal range
RR: 25 cpm (from 100/70 to (from 100/70 to
120/80) Provide These methods provide 120/80)
BP: 100/70 mmHg
nonpharmacologic pain comfort by altering
management strategies psychological responses
Diagnostic: such as; distraction, to pain
Cervical Biopsy Result: guided imagery, and
Large (Cell) relaxation techniques
Non-keratinizing
Squamous Cell Evaluate and be aware A wide range of
of painful effects of discomforts are
Carcinoma
particular therapies and common, depending on
provide information to the procedure and agent
Laboratory: the patient and family being used.
Urinalysis: RBC of more about what to expect.
than 5.0 hpf
Place patient in Placing the patient in
complete bed rest their desired position
during feeling of pain may help them to
provide comfort and
alleviate pain

Evaluate pain relief and Goal is maximum pain

control at regular control with minimum
intervals. Adjust interference with ADLs.
medication regimen as
necessary.

Be aware of barriers to Patients may be

cancer pain reluctant to report pain
management related to for reasons such as fear
patient, as well as the that disease is worse.
healthcare system.

Dependent: Dependent:
Administer pain Analgesics may help to
medications as relieve pain and
prescribed by the discomfort
physician

Collaborative: Collaborative:
Refer patient to an An oncologist
oncologist specializes in treating
cancer and provides
medical care for a
person diagnosed with
cancer

Refer patient to local To help reduce stress,

cancer support groups and to encourage
in the community verbalization of feelings
and experiences.
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