CARE OF PATIENTS

WITH CANCER OF THE

CERVIX AND UTERUS
CERVICAL CANCER
What is Cervical Cancer? • Cervical
cancer is a type of cancer that occurs in the cells of the cervix — the lower part of the
uterus that connects to the vagina.
• Various strains of the human papillomavirus (HPV), a sexually transmitted
infection, play a role in causing most cervical cancer.
• When exposed to HPV, the body's immune system typically prevents the virus
from doing harm. In a small percentage of people, however, the virus survives for
years, contributing to the process that causes some cervical cells to become
cancer cells.
• You can reduce your risk of developing cervical cancer by having screening tests
and receiving a vaccine that protects against HPV infection.
Types of Cervical Cancer
The type of cervical cancer that you have helps determine your prognosis and
treatment. The main types of cervical cancer are:
• Squamous cell carcinoma. This type of cervical cancer begins in the thin, flat cells
(squamous cells) lining the outer part of the cervix, which projects into the vagina.
Most cervical cancers are squamous cell carcinomas.
• Adenocarcinoma. This type of cervical cancer begins in the column-shaped
glandular cells that line the cervical canal.
• Sometimes, both types of cells are involved in cervical cancer. Very rarely, cancer
occurs in other cells in the cervix.

Risk Factors:
• Many sexual partners. The greater your number of sexual partners — and the greater your
partner's number of sexual partners — the greater your chance of acquiring HPV.
• Early sexual activity (younger than 20). Having sex at an early age increases your risk of
HPV.
• Other sexually transmitted infections (STIs). Having other STIs — such as chlamydia,
gonorrhea, syphilis and HIV/AIDS — increases your risk of HPV.
• A weakened immune system. You may be more likelyto develop cervical cancer if your
immune system is weakened by another health condition and you have HPV.
• Smoking. Smoking is associated with squamous cell cervical cancer.

• Exposure to miscarriage prevention drug. If your mother took a drug called

diethylstilbestrol (DES) while pregnant in the 1950s, you may have an increased risk of a
certain type of cervical cancer called clear cell adenocarcinoma.

Pathophysiology
• Cervical cancer begins when healthy cells in the cervix develop changes
(mutations) in their DNA. A cell's DNA contains the instructions that tell a cell
what to do.
• Healthy cells grow and multiply at a set rate, eventually dying at a set time. The
mutations tell the cells to grow and multiply out of control, and they don't die. The
accumulating abnormal cells form a mass (tumor). Cancer cells invade nearby
tissues and can break off from a tumor to spread (metastasize) elsewhere in the
body.
• It isn't clear what causes cervical cancer, but it's certain that HPV plays a role. HPV
is very common, and most people with the virus never develop cancer. This means
other factors — such as your environment or your lifestyle choices — also
determine whether you'll develop cervical cancer.

Assessment Findings:
 Subjective Cues Objective cues

• Fatigue • Weight loss due to the caloric needs of the tumor, taking away from the
• Loss of appetite needs of the body.
• Generalized weakness • • Anorexia.
Discomfort in the pelvis • Vagina bleeding after intercourse, between periods or after menopause •
area Watery, bloody vaginal discharge that may be heavy and have a foul odor •
Pelvic pain or pain during intercourse

Special Notation
• Surgical removal of the cervix (trachelectomy)
 • hysterectomy

• Lymph node dissection

• Radiation therapy.

• Radiation therapy to decrease tumor size.

• Oxygen therapy to supplement the needs of the body. •

High-protein, high-calorie diet to meet the needs of the body.

Surgical Procedures done for Cervical

Cancer
Surgical procedures that may be carried out to treat
cervical cancer include the following:
• Radical hysterectomy—removal of the uterus, ovaries,
• Total hysterectomy—removal of the uterus, cervix, fallopian tubes, proximal vagina, and bilateral lymph
and ovaries nodes through an abdominal incision (Note: “radical”
 indicates that an extensive area of the paravaginal,
• Pelvic exenteration—removal of the pelvic organs,
paracervical, parametrial, and uterosacral tissues is
removed with the uterus.) including the bladder or rectum and pelvic lymph
nodes, and construction of diversional conduit,
• Radical vaginal hysterectomy—vaginal removal of the colostomy, and vagina
uterus, ovaries, fallopian tubes, and proximal vagina
• Radical trachelectomy—removal of the cervix and
• Bilateral pelvic lymphadenectomy—removal of the selected nodes to preserve childbearing capacity in a
common iliac, external iliac, hypogastric, and woman of reproductive age with cervical cancer
obturator lymphatic vessels and nodes

Laboratory/Diagnostic Findings:
• Pelvic exam

• Pap smear (all women aged between 21 and 65 should get an annual pap smear)

• HPV DNA test. The HPV DNA test involves testing cells collected from the cervix for
infection with any of the types of HPV that are most likely to lead to cervical cancer.
• Biopsy is confirmative for cancer.
• Endo-cervical curettage

• Cone biopsy

• Ultrasonography to further delineate the mass.

• CT scan to check for metastasis

• MRI and Positive emission tomography scan

Medications • epirubincin

• vincristine

Chemotherapy before surgery to shrink • paclitaxel

some tumors, or after surgery:
• cyclophosphamide

• methotrexate • Docetaxel
• fluorouracil

• doxorubicin
 • Administer analgesics for pain control:
Hormonal therapy: • morphine, fentanyl

• tamoxifen • Progesterone based hormones

• anastrozole

UTERINE CANCER
What is Uterine Cancer?
• Cancer of the uterine
endometrium
(fundus or corpus) has
increased in incidence,
partly because people
 are living longer and because reporting is more accurate. Most uterine cancers are
endometrioid (that is, originating in the lining of the uterus).
• After breast, colorectal, and lung cancer, endometrial cancer is the fourth most common
cancer in women and the most common pelvic neoplasm. Cumulative exposure to
estrogen is considered the major risk factor.
• This exposure occurs with the use of estrogen replacement therapy without the use of
progestin, early menarche, late menopause, never having children, and anovulation.
Other risk factors include infertility, diabetes, hypertension, gallbladder disease, and
obesity.
• Tamoxifen may also cause proliferation of the uterine lining, and women receiving this
medication for treatment or prevention of breast cancer are monitored by their
oncologists.

Risk Factors for Uterine Cancer

• Age: at least 55 years; median age, 61 years

• Postmenopausal bleeding

• Obesity that results in increased estrone levels (related to excess weight) resulting
from conversion of androstenedione to estrone in body fat, which exposes the
uterus to unopposed estrogen
• Unopposed estrogen therapy (estrogen used without progesterone, which offsets
the risk of unopposed estrogen)
• Other: nulliparity, truncal obesity, late menopause (after 52 years of age) and,
possibly, use of tamoxifen

Assessment Findings
• Endometrial aspiration or biopsy
• Ultrasonography

Medical Management
• Treatment of endometrial cancer consists of total hysterectomy (discussed later in this chapter) and
bilateral salpingo-oophorectomy and node sampling. Depending on the stage, the therapeutic
approach is individualized and is based on stage, type, differentiation, degree of invasion, and node
involvement.

• Whole pelvis radiotherapy is used if there is any spread beyond the uterus. Preoperative and
postoperative treatments for stage II and beyond may include pelvic, abdominal, and vaginal
intracavitary radiation.

• Recurrent cancer usually occurs inside the vaginal vault or in the upper vagina, and metastasis usually
occurs in lymph nodes or the ovary. Recurrent lesions in the vagina are treated with surgery and
radiation. Recurrent lesions beyond the vagina are treated with hormonal therapy or chemotherapy.
Progestin therapy is used frequently. Patients should be prepared for such side effects as nausea,
depression, rash, or mild fluid retention with this therapy.