Cervical Cancer

- predominantly squamous cell carcinoma

- 3rd most common female reproductive cancer
- 11,300 women affected with cervical cancer
- less common because of early detection of cell changes by pap smear
Types:
 Squamous cell carcinoma (SCC) is the most common type of cervical cancer, accounting for 85% to 90% of all
cases. It develops from the cells that line the inner part of the cervix, called the squamous cells. It usually begins
where the part of the cervix that connects with the vagina (called the ectocervix) meets the part of the cervix that
opens into the uterus (called the endocervix).
 Adenocarcinoma develops from the column-shaped cells that line the mucous-producing glands of the cervix.
In rare instances, adenocarcinoma originates in the supportive tissue around the cervix. Adenocarcinoma
accounts for about 10% of all cervical cancers.
 Mixed carcinomas (for example, adenosquamous carcinomas) combine features of both squamous cell
carcinoma and adenocarcinoma.

Risk Factors:
o Sexually active (multiple sex partners)
o Early age (↓ 20) at first coitus
o Sex w/ uncircumcised male
o Sexual contact w/ males whose partners have had cervical cancers
o Early child bearing
o Exposure to HPV (16 and 18)
o HIV infection & other immunodeficiency
o Smoking and exposure to second-hand smoke
o Exposure to DES in utero
o Family history
o Low socioeconomic status (early marriage and early child bearing)
o Nutritional deficiencies (Folate, beta-carotene and Vit. C)
o Chronic cervical infection
o Overweight status
Prevention:
1. Papaniculao test is the best way to find cervical cell changes that can lead to cervical cancer. Regular Pap
tests almost always show these cell changes before they turn into cancer.
2. If age is 26 or younger, HPV vaccine can be acquired which protects against two types of HPV that cause
cervical cancer.
3. Practice safe sex.

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 - using condoms and limiting the number of sex partners

Stages of Invasive Cervical Cancer:

 Stage I: the cancer has penetrated into several layers of the cervix. The extent of this invasion determines the
substage, IA, IA2, IB1, or IB2.
 Stage II: cancer has spread beyond cervix. In stage IIA, the upper two-thirds of the vagina are involved. In
stage IIB, the pelvic region, but not pelvic wall, is affected.
 Stage III: the malignancy affects the lower third of the vagina (stage IIIA), or the pelvic wall and/or blocks
urination and causes kidney dysfunction (stage IIIB).
 Stage IV: the cancer has spread to the bladder or rectum (stage IVA) or to outside the pelvic region to distant
sites (stage IVB).
Clinical Manifestations:
*Early cervical cancer rarely produces symptoms
1. Thin, watery vaginal discharges
2. Irregular bleeding, pain or bleeding after sexual intercourse, disease may be in an advanced state

S/S in advanced cervical cancer:

1. Vaginal discharges gradually increases
-becomes watery, dark and foul smelling from necrosis and infection of the tumor
2. Bleeding which occurs at irregular intervals between periods (metrorrhagia) or after menopause, may be slight
which occurs usually after trauma (intercourse, douching & bearing down after defecation)
- as the diseases continues, bleeding may persist and increase
3. Leg pain, dysuria, rectal bleeding & edema of the extremities signal advanced disease state
4. May invade the tissues outside the cervix, lymph glands anterior to the sacrum
- 1/3 of the px w/ invasive cervical cancer, diseases involves the fundus
5. Excruciating pain in the back and legs w/c can be relieved only by large opioid analgesic
6. Extreme emaciation and anemia w/ fever due to secondary infection and ulcerating mass and fistula
formation

Assessment and Diagnostic Findings:

Pap smear- abnormal results
- In early stage, invasive cervical cancer is found microscopically by pap smear

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Biopsy -identifying severe dysplasia cervical intraepithelial neoplasia III (CIN type III), high-grade squamous
intraepithelial lesions (HGSIL) also referred to as HSIL, or carcinoma in situ
o HPV infections are usually implicated in these conditions
o Carcinoma in situ 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
o often referred to as preinvasive cancer

Pelvic examination reveals a large, reddish growth or a deep, ulcerating lesion

TNM system is used in staging and grading cervical cancer

x-rays, laboratory tests, and special examinations, for cancer evaluation:

1. punch biopsy
2. colposcopy
3. D & C

*Depending on the stage of the cancer, other test and procedures may be performed to determine the extent of
disease and appropriate treatment:
1. CT
2. MRI
3. IV urography/ pyelogram- Urography is a radiologic technique used for the evaluation of the genitourinary
system: specifically, the kidneys, ureters, and bladder. Although originally performed using plain radiographic
techniques, advanced imaging modalities have been progressively refined such that computed tomography (CT)
and/or magnetic resonance imaging (MRI) have largely replaced excretory urography (EU) as the optimal way to image
the genitourinary system.
- a contrast dye is injected into a vein and the dye travels in the bloodstream, concentrates in the kidneys, and
is passed out into the ureters with urine made by the kidneys.
* Contrast nephrotoxicity leading to renal insufficiency may occur wherein a rapid deterioration of renal function
happens after the administration of contrast media
4. Cystography
- a procedure used to visualise the urinary bladder.
Using a urinary catheter, radiocontrast is instilled in the bladder, and X-ray imaging is performed. Cystography
can be used to evaluate bladder cancer,vesicoureteral reflux, bladder polyps, and hydronephrosis. It requires less
radiation than pelvic CT, although it is less sensitive and specific than MRI or CT. In adult cases, the patient is typically
instructed to void three times, after which a post voiding image is obtained to see how much urine is left within the

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bladder, which is useful to evaluate bladder contraction dysfunction. A final radiograph of the kidneys after the
procedure is finished is performed to evaluate for occult vesicoureteral reflux that was not seen during the procedure
itself.

5. Positron emission tomography

-is a nuclear medicine, functional imaging technique that produces a three-dimensional image of functional
processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-
emitting radionuclide (tracer) that was injected into the blood circulation, which is introduced into the body on a
biologically active molecule. If the biologically active molecule chosen for PET is fludeoxyglucose (FDG), an
analogue of glucose, the concentrations of tracer imaged will indicate tissue metabolic activity by virtue of the regional
glucose uptake. Use of this tracer to explore the possibility of cancer metastasis (i.e., spreading to other sites) is the
most common type of PET scan in standard medical care (90% of current scans).

6. Barium x-rays

Medical Management:
A. Precursor or Preinvasive Lesions
Low Grade Squamous Intraepithelial Lesion (LGSIL) or CIN I and II or mild to moderate dysplasia

1. Colposcopy and biopsy

2. Careful monitoring by frequent pap smears
3. Cryotherapy (freezing w/ nitrous oxide
4. Laser therapy
5. Loop Electrocautery Excision procedure (LEEP):
- can be done as an outpatient procedure
- allows the pathologist to examine the removed tissue sample to determine if the border of the disease tissue
are disease free
6. Cone Biopsy or Conization-
Conization -removal of the cone shape portion of the cervix
Cone biopsy - refers to an excision of a cone-shaped sample of tissue from the mucous membrane of
the cervix. 
- When biopsy findings demonstrates CIN III or HGSIL
7. Hysterectomy- removal of the uterus- procedure use in pre-invasive cervical cancer when a woman completed
childbearing
8. Conization - if a woman has not completed child bearing and if invasion is less than 1mm
- Frequent follow up examination to monitor recurrence

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B. Invasive Cancer:
*Treatment for invasive depends on the stage of the lesion, patient’s age, general condition and the judgment and
experience of the surgeon
*Surgery and radiation are most often used

Surgical Procedure:
1. Total Hysterectomy – removal of the cervix, uterus and ovaries

2. Radical Hysterectomy – removal of the uterus, ovaries, fallopian tubes, proximal vagina, and bilateral lymph
nodes through an abdominal incision

3. Radical Vaginal Hysterectomy – vaginal removal of the uterus, ovaries, fallopian tubes, and proximal vagina

4. Pelvic extenteration – removal of the pelvic organs, including the bladder or rectum and pelvic lymph nodes,
and construction of diversional conduit, colostomy, and vagina

5. Radical Trachelectomy – removal of the cervix and the selected nodes to preserve childbearing capacity in a
woman of reproductive age with cervical cancer

* Frequent follow up after surgery due to the risk of recurrence

* recurrence usually occurs within the first two years
*recurrence are often in the upper quarter of the vagina, and urethral obstruction may be a sign
*weight loss, leg edema and pelvic pain may be signs of lymphatic obstruction and metastasis

Radiation:
- reduces the recurrence of disease
- external beam or brachytherapy
- can be administered for 4-6 wks
- may be followed by intracavitary radiation

Nursing Management:
1. Because early cervical cancer is usually asymptomatic, establish a thorough history with particular attention to the
presence of the risk factors and the woman’s menstrual history. Establish a history of later symptoms of cervical cancer
and a history of chronic cervical infections.
2. Conduct a pelvic examination. Observe the patient’s external genitalia for signs of inflammation, bleeding, discharge,

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or local skin or epithelial changes. Observe the internal genitalia. The normal cervix is pink and nontender, has no
lesions, and has a closed os.
Cervical tissue with cervical cancer appears as a large reddish growth or deep ulcerating crater before any
symptoms are experienced; lesions are firm and friable.
The Pap smear is done before the bimanual examination. Palpate for motion tenderness of the cervix
(Chandelier’s sign); a positive Chandelier’s sign (pain on movement) usually indicates an infection. Also examine the
size, consistency (hardness may reflect invasion by neoplasm), shape, mobility (cervix should be freely movable),
tenderness, and presence of masses of the uterus and adnexa.
Conduct a rectal exam; palpate for abnormalities of contour, motility, and the placement of adjacent structures.
Nodular thickenings of the uterosacral and cardinal ligaments may be felt.
3. Teaching about and providing access to regular Pap screening tests for high-risk and other women are the most
important preventive interventions. 
4. Teach the patient about vaginal discharges that may follow a surgical procedure.
Teach the patient that she will probably have to refrain from douching, using tampons, and coitus until healing
occurs.
Discuss any changes that may affect the patient’s sexual function or elimination mechanisms.
Explain to the patient that she will feel fatigued and that she should gradually increase activity, but should not
do heavy lifting or strenuous or rough activity or sit for long periods.
Encourage the patient to explore her feelings and concerns about the experience and its implications for her
life and lifestyle. Provide the patient who has undergone a hysterectomy with information about what to expect.
5. If internal radiation is the treatment, the primary focus of the nursing interventions is to prepare the patient for the
treatment, to promote her comfort, and to lessen her sense of isolation during the treatment.
Explain to the patient and significant others the reason for the time-restricted visits while the insert is in place.
Nursing care is of shorter duration and of essential nature only during this time; therefore, ensure that before the
insertion of the implant, the patient has a bath and clean bed linen.
Decrease the patient’s feelings of isolation by providing diversionary activities and frequent interaction from a
safe distance.
If the patient has external radiation, teach her about how the treatment is given, how the skin is prepared, and
how blood tests to monitor white blood cell count are done. Explain that her immunity to common colds and other
illnesses is lessened, and teach the patient the proper use of antiemetics and antidiarrhetics.