Carcinoma of the Cervix

(Cervical Cancer)
K. NYATHI
 OBJECTIVES
By end of lesson the student should be able to:
• Define cervical cancer
• Describe the staging of cervical cancer
• State the causes of cervical cancer
• Outline the risk factors of cervical cancer
• Outline the clinical features of cervical cancer
• Outline the investigations of cervical cancer
 Cont..
• Describe the management of cervical
cancer
• Outline the complications of cervical
cancer
 Introduction
• The cervix is the lower part of the uterus
that opens at the top of the vagina.
• Cervical cancer is cancer that starts in the
cervix.
• Cervical cancer is a malignant neoplasm
arising from cells originating in the
cervix.
 Definition
• Cervical cancer is a disease in which
the cells of the cervix become
abnormal and start to grow
uncontrollably, forming tumors
 INCIDENCE
• One study has shown that the rate of
cervical cancer is higher among
women of working age in manual
than non manual classes.
STAGING OF CERVICAL CANCER
 Carcinoma in Situ (Stage 0)

• In carcinoma in situ (stage 0), abnormal

cells are found in the innermost lining of the
cervix.
• These abnormal cells may become cancer
and spread into nearby normal tissue.
• Millimeters (mm). A sharp pencil point is
about 1 mm, a new crayon point is about 2
mm, and a new pencil eraser is about 5 mm.
 Stage I

• In stage I, cance is found in the cervix

only. Stage I is divided into stages IA and
IB, based on the amount of cancer that is
found.
• Stage IA1 and IA2 cervical cancer. A very
small amount of cancer that can only be
seen with a microscope is found in the
tissues of the cervix.
 Cont…
• In stage IA1, the cancer is not more than
3 millimetres deep and not more than 7
millimetres wide.
• In stage IA2, the cancer is more than 3
but not more than 5 millimetres deep,
and not more than 7 millimetres wide.
Stage IA1 and IA2 cervical cancer
Stage IB1 and IB2 cervical cancer
– In stage IB1:
• the cancer can only be seen with a microscope and is
more than 5 millimeters deep and more than 7
millimeters wide; or
• the cancer can be seen without a microscope and is 4
centimeters or smaller.
– In stage IB2, the cancer can be seen without a
microscope and is larger than 4 centimeters.
Stage IB1 and IB2 cervical cancer
 Stage II
• In stage II, cancer has spread beyond the
cervix but not to the pelvic wall (the
tissues that line the part of the body
between the hips) or to the lower third
of the vagina.
• Stage II is divided into stages IIA and IIB,
based on how far the cancer has spread.
 Stage IIA:
• Cancer has spread beyond the cervix to the
upper two thirds of the vagina but not to
tissues around the uterus.
• Stage IIA is divided into stages IIA1 and IIA2,
based on the size of the tumor.
– In stage IIA1, the tumor can be seen without a
microscope and is 4 centimeters or smaller.
– In stage IIA2, the tumor can be seen without a
microscope and is larger than 4 centimeters.
 Stage IIB:
• Cancer has spread beyond the cervix to
the tissues around the uterus.
Stage II
 Stage III

• In stage III, cancer has spread to the

lower third of the vagina, and/or to the
pelvic wall, and/or has caused kidney
problems.
• Stage III is divided into stages IIIA and
IIIB, based on how far the cancer has
spread.
 Stage IIIA cervical cancer
• Cancer has spread to the lower third of
the vagina but not to the pelvic wall.
• Cancer has spread to the lower third of
the vagina but not to the pelvic wall.
Stage IIIA cervical cancer
 Stage IIIB cervical cancer
• Cancer has spread to the pelvic wall; and/or
the tumor has become large enough to block
the ureters (the tubes that connect the
kidneys to the bladder).
• The drawing shows the ureter on the right
blocked by the cancer.
 Cont…
• This blockage can cause the kidney to enlarge
or stop working.
– Cancer has spread to the pelvic wall; and/or
– the tumor has become large enough to
block the ureters (the tubes that connect
the kidneys to the bladder). This blockage
can cause the kidneys to enlarge or stop
working.
Stage IIIB cervical cancer
 Stage IV
• In stage IV, cancer has spread to the
bladder, rectum, or other parts of the
body.
• Stage IV is divided into stages IVA and
IVB, based on where the cancer is found.
 Stage IVA cervical cancer
• Cancer has spread to nearby organs,
such as the bladder or rectum.
Stage IVA cervical cancer
 Stage IVB cervical cancer
• Cancer has spread to parts of the body
away from the cervix, such as the liver,
intestines, lungs, or bones.
• Cancer has spread to other parts of the
body, such as the liver, lungs, bones, or
distant lymph nodes.
Stage IVB cervical cancer
 CAUSES
• HPV infection
 Risk Factors
• Having sex at an early age.
• Having multiple sexual partners.
• Having a partner or many partners
who are active in high-risk sexual
activities.
• Not getting the HPV vaccine.
• Being poor (Social Class)
 Cont..
• Weakened immune system e.g. in
AIDS patients.
• Smoking.
• Hormonal Contraceptives.
 Cont…
• High number of children.
• Women who have had 7 or more
children have double the risk of women
with only 1 or 2 children.
• Having first baby early, before 17, also
doubles the risk, compared to having
first baby at 25 or older.
 Clinical manifestations
• The early stages of cervical cancer may
be completely asymptomatic.
• Vaginal bleeding, contact bleeding, or
(rarely) a vaginal mass may indicate the
presence of malignancy.
• moderate pain during sexual intercourse
and vaginal discharge are symptoms of
cervical cancer.
 Cont…
• Symptoms of advanced cervical
cancer may include:
• loss of appetite,
• weight loss,
• fatigue,
• pelvic pain,
 Cont…
• back pain,
• leg pain,
• swollen legs,
• heavy bleeding from the vagina,
• bone fractures,
• and/or (rarely) leakage of urine or faeces
from the vagina.
 Investigations
CT scan (CAT scan):
• A dye may be injected into a vein or
swallowed to help the organs or tissues
show up more clearly.
• Chest x-ray
• Cystoscopy : A procedure to look inside the
bladder and urethra to check for abnormal
areas.
 Cont…
• PET scan (positron emission
tomography scan): A procedure to
find malignant tumor cells in the
body.
• Ultrasound exam
 Cont…
• Laparoscopy
• Cervical Biopsy.
• Cold cone biopsy.
• Pap Smear.
• Visual Inspection with Acetic Acid (VIAC).
The Normal – Aceto - Negative
The Abnormal – Aceto – Positive
VIA positive suspicious of cancer
The Worst – Suscipicious of Cancer
 MANAGEMENT

PREVENTING
• Cervical screening by the Papanicolaou
test, or Pap smear, for cervical cancer
Pap smear screening every 3–5 years
with appropriate follow-up can reduce
cervical cancer incidence by up to 80%.
• Visual Inspection with acetic Acid (VIAC)
 cont..

Vaccination
two HPV vaccines (Gardasil and Cervarix) reduce
the risk of cancerous or precancerous changes
of the cervix and perineum by about 93% and
62%, respectively.
• HPV vaccines are typically given to women age
9 to 26 as the vaccine is only effective if given
before infection occurs.
 cont…

Condoms
• Condoms are thought to offer some
protection against cervical cancer.
• They also provide protection against
other STDs, such as HIV and Chlamydia,
which are associated with greater risks of
developing cervical cancer.
 cont…

Nutrition
• Vitamin A is associated with a lower
risk as is vitamin B12, vitamin C,
vitamin E, and beta-carotene.
 Medical management
• Cryotherapy
• Conization – removal of the cone
• Loop electro-surgical excision- removal of
abnormal tissue with a thin wire loop
 Cont….
• Bilateral pelvic lymphadenoctomy
• Pelvic exentaration-removal of the pelvic
organs including the bladder or rectum
and lymph nodes. Construction of
diversional conduit
 cont..
• Microinvasive cancer (stage IA) may be treated by
hysterectomy (removal of the whole uterus
including part of the vagina).
• For stage IA2, the lymph nodes are removed as
well. Alternatives include local surgical procedures
such as a loop electrical excision procedure (LEEP)
or cone biopsy.
• For 1A1 disease, a cone biopsy (aka cervical
conization) is considered curative.
 Cont…
• If a cone biopsy does not produce clear
margins trachelectomy can be done.
• This attempts to surgically remove the
cancerous area while preserving the ovaries
and uterus, providing for a more conservative
operation than a hysterectomy.
• It is a viable option for those in stage I cervical
cancer which has not spread.
 Cont…
• Early stages (IB1 and IIA less than 4 cm)
can be treated with radical hysterectomy
with removal of the lymph nodes or
radiation therapy.
• Radiation therapy is given as external
beam radiotherapy to the pelvis and
brachytherapy (internal radiation).
 Cont…
• Larger early stage tumors (IB2 and IIA more
than 4 cm) may be treated with radiation
therapy and cisplatin-based chemotherapy,
hysterectomy (which then usually requires
adjuvant radiation therapy), or cisplatin
chemotherapy followed by hysterectomy.
• When cisplatin is present, it is thought to be
the most active single agent in periodic
diseases.
 Cont…
• Advanced stage tumors (IIB-IVA) are
treated with radiation therapy and
cisplatin-based chemotherapy.
 COMPLICATIONS
• Lymphoedema__If the lymph nodes in your
pelvis are removed, it can sometimes disrupt
the normal workings of your lymphatic
system.
• Narrowing of the vagina__Radiotherapy to
treat cervical cancer can often cause your
vagina to become narrower, which can make
having sex painful or difficult.
 CONT..
• Early menopause__If your ovaries are
surgically removed or they're damaged during
treatment with radiotherapy, it will trigger an 
early menopause
• Bleeding__If the cancer spreads into your
vagina, bowel or bladder, it can cause
significant damage, resulting in bleeding.
 Conclusion
• Cervical cancers start in the cells on the surface of
the cervix.
• Cervical cancer usually develops slowly.
• It starts as a precancerous condition called dysplasia.
• This condition can be detected by a Pap smear and
or Visual Inspection with Acetic Acid (VIA) and is
100% treatable.
• It can take years for these changes to turn into
cervical cancer.
 Preoperative
• Focuses on psychological pre and preoperative
teaching.
• Provide emotional support in a caring or
informative manner.
• Complete exploration of treatment options is given.
• Include the family especially spouse/partner in all
discussions for a successful discussion.
• The Dr discusses stages of the disease and
treatment options.
 Contd
• Cultural issues are addressed.
• Delay between biopsy and definitive treatment is
helpful as opposed to frozen section and proceed.
• Some may want to read and discuss any available
information.
• Use outside resources e.g. association and
facilitate a talk from another client who has had
mastectomy.
• Assist with a grieving process.
 Post-Operative Care

Relieving Pain and Discomfort

• Pain relief methods: medications, relaxation,
sleep, rest, positioning.
 Promoting positive body image

• Assess the patient’s readiness to accept

condition and provide gentle
encouragement.
• Provide privacy while assisting her as she
views the incision; this allows her to
express feelings safely to the nurse.
 Promoting positive adjustment and coping

• Social support systems mobilization i.e.

encouraging patient to discuss issues and
concerns with other patients who had
cervical cancer and
trachelectomy/hysterectomy.
 Improving sexual function

• Change of image affects sexual

function.
• Counseling i.e. a referral can be
made for counseling with the
psychologist, psychiatrist, social
worker, sex therapist may be helpful.
 Nursing diagnosis
• Risk for ineffective individual coping related to
threat of malignancy, inadequate support
system
Expected outcome
• Patient demonstrates positive coping strategies
as evidenced by expression of feelings and
hopes, realistic goal setting for the future, and
use of available resources and support systems
 Ongoing assesment
• Assess patient’s knowledge of disease and
treatment
• Assess for coping mechanisms used in
previous illnesses or prior personal problems
• Evaluate resources/support systems available
to patient at home and in the community
 Interventions
• Establish open lines of communication
• Define your role as patient informant and
advocate
• Provide opportunities for patient/significant
other to openly express feelings, fears, and
concerns .Provide reassurance and hope as
indicated
• Assist patient to become involved as co manager
of treatment plan
• Provide information the patient wants and
needs. Do not provide more than the patient can
handle
• Encourage patient to communicate feelings with
others
• Encourage participation in self help groups as
available
 Nursing diagnosis
• Altered sexuality
• Anxiety
• High risk for infection
• Impaired physical mobility
• Impaired skin integrity
• Sexual dysfunction
 REFERENCES
• Phipps, W. J, Monahan F. D, Sands J K and Marek
J. F (2003) Medical Surgical Nursing. Health and
Illness Perspectives. 7th Edition, Mosby, St Louis.
• Smeltzer, S. C and Bare, B (2004) Brunner and
Suddarth’s Textbook of Medical Surgical Nursing.
10th Edition. Lippingcott. Williams and Wilkins.
Philadelphia.
• Waston, J (2000) Medical Surgical Nursing and
Related Physiology, Sanders, Philadelphia.