Cervical Cancer

Alabe | Aquino | Aquino | Bernardo |

Binwag
Prevalence
Prevalence

Cervical cancer is the fourth most common cancer in women

worldwide.

World Health Organization (WHO) estimated 530 000 new

cases of cervical cancer globally (2012), with approximately
270 000 deaths (representing 7.5% of all female cancer
deaths).

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Prevalence

More than 85% of these deaths occurred in low- and middle-

income countries.

The highest estimated incidence rates for cervical cancer are

in sub-Saharan Africa, Melanesia, Latin America and the
Caribbean, south-central Asia and south-east Asia.

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Causes/Risk factors
CAUSES/RISK FACTORS

■ HPV infection
■ Cigarette smoking
■ Younger age at first intercourse
■ Multiple sex partners
■ Immunodeficiency

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Pathophysiology
5-MINUTE-VIDEO
Signs and Symptoms
● Abnormal Menstrual bleeding
● Menstrual bleeding that is longer and heavier than
usual
● Bleeding after Menopause

● Vaginal discharge with unpleasant smell

● Increased vaginal discharge

● Pain during sexual intercourse

● Pain when urinating
● Vaginal discomfort
● Unexplained persistent pelvic or back pain
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Tests to examine the
cervix
History taking and physical exam

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Pelvic examination

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Pap test

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Human papillomavirus (HPV) test

■ Laboratory test used to check DNA or RNA for certain

types of HPV infection

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Endocervical curettage

■ Procedure to collect cells or tissue from the cervical

canal using a curette

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Colposcopy

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Diagnostic test
 Screening

Pap test (or Pap smear) - detect

abnormal cells in the cervix,
including cancer cells and cells
that show changes that increase
the risk of cervical cancer.
■ HPV DNA test - testing cells
collected from the cervix for
infection with any of the types
of HPV that are most likely to
lead to cervical cancer.
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 Diagnostic Examinations

Punch biopsy, which involves

using a sharp tool to pinch off
small samples of cervical tissue.

Endocervical curettage, which

uses a small, spoon-shaped
instrument (curet) or a thin brush
to scrape a tissue sample from the
cervix.
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 Other Diagnosing Examinations

Loop Electrosurgical Excision

Procedure (LEEP), which uses a thin,
low-voltage electrified wire to obtain a
small tissue sample.

Cone biopsy (conization), to obtain

deeper layers of cervical cells for
laboratory testing.

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 Staging

Further tests to determine the extent (stage) of the cancer.

The cancer's stage is a key factor in deciding on treatment.
Imaging tests. Tests such as X-ray, CT,
MRI and Positron emission tomography
(PET) helps determine whether the
cancer has spread beyond the cervix.
Visual examination of the bladder and
rectum. Use of special scopes to see the
bladder and rectum (e.g. Cystoscopy)
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Imaging studies

■ Computed tomography scan

■ Magnetic resonance imaging
■ Intravenous urography
■ Positron emission tomography (PET)

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Stages
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Stage I

■ Stage IA
○ Stage IA1: Less than
3 mm in depth
○ Stage IA2: 3 mm to
less than 5 mm in
depth

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Stage IB

■ Stage IB1: 5 mm or more

in depth and less than 2
cm wide
■ Stage IB2: 2 cm or more
in depth; Less than 4 cm
wide
■ Stage IB3: 4 cm or more
in width

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Stage II

■ Stage IIA
○ Stage IIA1: Less than 4 cm
wide
○ Stage IIA2: 4 cm or more in
width
■ Stage IIB
○ Tumor has spread to
parametrial area
○ Tumor does not reach pelvic
wall
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Stage III

■ Stage IIIA: Involves the lower third of vagina; has not

grown into pelvic wall

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Stage III

■ Stage IIIB: Has grown

into pelvic wall and/or
affects a kidney
■ Stage IIIC: Involves
regional lymph nodes
○ Stage IIIC1: Has spread to
lymph nodes in pelvic
○ Stage IIIC2: Has spread to
para-aortic lymph nodes

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Stage IV

■ Stage IVA: Has spread to the bladder or rectum

■ Stage IVB: Has spread to the other parts of the body

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Surgery treatment
Surgical Treatment

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Stage IA

■ Conization
■ Total hysterectomy with or without bilateral salpingo-
oophorectomy

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Stage IB and IIA Cervical Cancer

■ Radiation therapy with chemotherapy given at the same

time
■ Radical hysterectomy and removal of pelvic lymph
nodes with or without radiation therapy to the pelvis,
plus chemotherapy
■ Radical trachelectomy
■ Chemotherapy followed by surgery
■ Radiation therapy alone

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Stage IIB, III and IVA

■ Radiation therapy with chemotherapy given at the same

time
■ Surgery to remove pelvic lymph nodes followed by
radiation therapy with or without chemotherapy
■ Internal radiation therapy
■ Clinical trial of chemotherapy to shrink the tumor
followed by surgery
■ Clinical trial of chemotherapy to shrink the tumor
followed by surgery
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Stage IVB

■ Radiation therapy as palliative therapy to relieve

symptoms caused by the cancer and improve quality of
life
■ Chemotherapy and targeted therapy

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Treatment for recurrent
cervical cancer
■ Immunotherapy
■ Radiation therapy and chemotherapy
■ Chemotherapy and targeted therapy
■ Chemotherapy as palliative therapy to relieve symptoms
caused by the cancer and improve quality of life
■ Pelvic exenteration
■ Clinical trials of new anti-cancer drugs and drug
combinations

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Medications
Avastin (Bevacizumab)

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 Drug Name Mechanism of Contraindication Side Effects Nursing
Action Intervention

Generic Name: Binds to vascular Pregnancy Body as a Whole: Monitor for S&S of an
BEVACIZUMAB endothelial growth (category C), Asthenia , pain, wound infusion reaction
factor (VEGF) and dehiscence.
prevents the
lactation; nephrotic CNS: Syncope,
(hypersensitivity);
Brand Name: interaction of VEGF to syndrome; active headache, dizziness, infusion should be
Avastin its receptors on the bleeding; surgery confusion, abnormal interrupted in all
surface of endothelial within 28 d; dental gait. patients with severe
Classification: cells. This blocks work within 20 d. CV: DVT, infusion reactions and
MONOCLONAL endothelial cell Safety and hypertension , heart appropriate therapy
proliferation and new failure, intra-abdominal instituted.
ANTIBODY blood vessel formation
effectiveness in thrombosis,
in tumor cells. children are not cerebrovascular
Stock Dose: established. Monitor BP at least
events.
every 2–3 wk; if
25 mg/mL injection GI: Abdominal pain,
diarrhea , constipation, hypertension develops,
nausea, vomiting, monitor more
Recommended
anorexia, stomatitis, frequently, even after
Dose: dyspepsia, weight loss, discontinuation of
IV 5 mg/kg q14d flatulence, dry mouth, bevacizumab.
until disease colitis, gastrointestinal
progression perforation.

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Drug Name Mechanism of Contraindication Side Effects Nursing
Action Intervention

Hematologic: Withhold drug and

Leukopenia, promptly notify
neutropenia ,
physician for S&S of
thrombocytopenia,
thromboembolism . CHF, hemorrhage
Metabolic: (e.g., epistaxis,
Hypokalemia, hemoptysis, or GI
hyperbilirubinemia. bleeding), or
Musculoskeletal: unexplained abdominal
Myalgia. Respiratory: pain.
Upper respiratory
infection, epistaxis, Lab tests: Urinalysis
dyspnea, hemoptysis.
for proteinuria and 24 h
Skin: Exfoliative
dermatitis, alopecia. urine if protein 2+ or
Special Senses: Taste greater.
disorder, increased
tearing. Urogenital: Monitor for dizziness,
Proteinuria , urinary lightheadedness, or
frequency/urgency. loss of balance. Take
appropriate safety
measures.

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Bleomycin Sulfate

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 Drug Name Mechanism of Contraindication Side Effects Nursing Intervention
Action

Generic Name: A toxic drug with History of Body as a Whole: Monitor patient closely for
BLEOMYCIN low therapeutic hypersensitivity or Hypersensitivity at least 24 h (vital signs,
(anaphylactoid
SULFATE index; intensely idiosyncrasy to reaction); mild febrile
auscultation of chest,
cytotoxic. By bleomycin; reaction careful observations).
Brand Name: unclear women of CNS: Headache,
Blenoxane mechanism, blocks childbearing age, mental confusion. Therapeutic effectiveness:
DNA, RNA, and pregnancy GI: Stomatitis, Favorable response, if
Classification: protein synthesis. A (category D), ulcerations of tongue any, is expected within 2
and lips, anorexia, wk for treatment of
ANTINEOPLASTIC; cell cycle-phase lactation. nausea, vomiting,
ANTIBIOTIC nonspecific agent. Hodgkin's or testicular
diarrhea, weight loss. tumor, and within 3 wk for
Widely used in Hematologic:
squamous cell cancers.
Stock Dose: combination with Thrombocytopenia,
30 units powder other leukopenia, (rare).
Respiratory:
Monitor vital signs. Febrile
chemotherapeutic reaction (mild chills and
Pulmonary toxicity
agents because it (dose and age- fever) is relatively
lacks significant related); interstitial common in patients
myelosuppressive pneumonitis, receiving bleomycin
activity. pneumonia, or therapy.
fibrosis.

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 Drug Name Mechanism of Contraindicati Side Effects Nursing Intervention
Action on

Skin: Diffuse Monitor for and report any of

Recommended alopecia (reversible), the following: Unexplained
hyperpigmentation,
Dose: bleeding or bruising;
pruritic erythema,
SC, IM, IV 10–20 vesiculation, acne, evidence of deterioration of
U/m2 or 0.25–0.5 thickening of skin renal function; evidence of
U/kg 1–2 times/wk and nail beds, patchy pulmonary toxicity
(max: 300–400 U) hyperkeratosis, (nonproductive cough, chest
striae, peeling, pain, dyspnea).
bleeding. Other: Pain
at tumor site; Report symptoms of skin
phlebitis; necrosis at toxicity promptly. May
injection site.
develop in second or third
week of treatment and after
150–200 U of bleomycin
have been administered.
Therapy may be
discontinued.

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Hycamtin (Topotecan Hydrochloride)

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 Drug Name Mechanism of Contraindication Side Effects Nursing
Action Intervention

Generic Name: Antitumor Previous Body as a Whole: Lab tests: Obtain CBC
TOPOTECAN mechanism is hypersensitivity to Asthenia, fever, counts with differential
fatigue.
HYDROCHLORIDE related to inhibition topotecan, frequently; periodically
GI: Nausea, vomiting,
of activity of irinotecan, or other diarrhea, constipation, monitor ALT.
Brand Name: topoisomerase I, an camptothecin abdominal pain,
Hycamtin enzyme required analogs; acute stomatitis, anorexia, Assess for GI distress,
for DNA replication. infection; transient elevations in respiratory distress,
Classification: Topoisomerase I is pregnancy liver function tests. neurosensory
Hematologic: symptoms, and S&S of
ANTINEOPLASTIC, essential for the (category D), Leukopenia,
CAMPTOTHECIN relaxation of lactation. infection throughout
neutropenia , anemia, therapy.
AGENT; supercoiled double- thrombocytopenia.
TOPOISOMERASE stranded DNA, Respiratory: Dyspnea.
I INHIBITOR which enables Skin: Alopecia.
replication and
Stock Dose: transcription to
4 mg vials proceed. Topotecan
binds to the DNA-
topoisomerase I
complex.

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 Drug Name Mechanism of Contraindication Side Effects Nursing
Action Intervention

Recommended
Dose:
IV 1.5 mg/m2 daily
for 5 d starting on
day 1 of a 21 d
course. Four
courses of therapy
recommended.
Subsequent doses
can be adjusted by
0.25 mg/m2
depending on
toxicity

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Keytruda (Pembrolizumab)

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 Drug Name Mechanism of Contraindication Side Effects Nursing
Action Intervention

Generic Name: Pembrolizumab is a None Monotherapy: OB: Pregnancy

Pembrolizumab humanised Immune-mediated
immunoglobulin G4 adverse reactions (may cause fetal
Brand Name: monoclonal eg, hypothyroidism, harm);
Keytruda antibody which hyperthyroidism,
binds to the cell pneumonitis, colitis,
Classification: surface receptor hepatitis, Lactation:
Monoclonal programmed death- hypophysitis,
Discontinue
Antibodies; 1 (PD-1), a nephritis, type 1
Antineoplastic negative DM; diarrhea, pembrolizumab or
Agents. immunoregulatory pyrexia, arthralgia, discontinue breast
protein, and back pain, cough,
Stock Dose: prevents it from vitiligo, abdominal feeding.
100mg/4ml interacting with pain, pruritus, rash, .
(25mg/ml) ligands PD-L1 and hyponatremia.
PD-L2.

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 Drug Name Mechanism of Contraindication Side Effects Nursing
Action Intervention

Recommended Blockade of the Combination

Dose: PD-1 pathway therapy w/
2 mg/kg or 200 mg results in the permetrexed &
once every 3 weeks reactivation of T- carboplatin:
until disease lymphocytes and Fatigue, nausea,
progression or induction of constipation,
unacceptable immune response vomiting, diarrhea,
toxicity. to tumour cells. rash, pruritus,
Synonym: alopecia, dyspnea,
lambrolizumab. headache, upper
resp tract
infections.

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 Nursing
problems & interventions
 Nursing problems

■ Acute pain r/t swelling and nerve damage

■ Fatigue r/t heavy vaginal bleeding
■ Anxiety r/t the dx of cancer, perceived loss of femininity
■ Urinary Incontinence
■ Impaired physical mobility
■ Leg pain
■ Impaired skin integrity
■ Loss of appetite
■ Disturbed body image r/t to altered fertility, fears about sexuality.

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Nursing interventions

■ Listen to the patient’s fears and concerns, and offer

reassurance
■ Maintaining skin integrity: Cleansing the skin
■ Prevent infection
■ Provide activities that require minimal movement
■ Reducing pain: Promoting comfort
■ Preventing additional trauma

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Prevention
Primary Prevention

HPV vaccination
■ 9-13 years old (before they become sexually active)

Two HPV vaccines:

■ Bivalent vaccine (Cervarix) targets HPV types 16 and 18
■ Quadrivalent vaccine (Gardasil) targets HPV types 6, 11,
16, and 18

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WHO (March, 2016) recommended schedule for HPV vaccines:

■ Females <15 years at the time of first dose: a 2-dose schedule

6 month after. (If the interval between doses is shorter than 5
months, then a third dose should be given at least 6 months
after the first dose.)
■ Females ≥15 years at the time of first dose: a 3-dose schedule
of 0, 1-2, 6 months.

Fun Fact:
*Male circumcision have shown a significant protective effect against
HPV transmission
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Secondary Prevention

Early detection, by screening all women in the target age

group (30-49 years) followed by treatment of detected
precancerous lesions can prevent the majority of cervical
cancers. Cervical cancer screening detects pre-cancer and
cancer among women who have no symptoms and may feel
perfectly healthy.

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Tertiary Prevention

The goal of tertiary prevention is to decrease the number of

deaths due to cervical cancer.
■ Appropriate treatment in early stage of cancer can result
in cure.
■ In advanced stage of cancer treatment and palliative care
can improve quality of life, control symptoms and
minimize pain suffering.

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According to Department of Health (DOH)

■ a one-partner sexual relationship between partners

should be observed
■ delay on the first sexual intercourse
■ use of barrier contraceptives like condoms during sexual
intercourse

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Thank you and God bless!