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VISION

A premier university in historic


Cavite recognized for excellence
in the development of morally
upright and globally competitive
individuals.

Republic of the Philippines


CAVITE STATE UNIVERSITY
Don Severino Delas Alas Campus
Indang, Cavite

College of Nursing

Written Output

Cancer of the Cervix

Submitted by:
Mizchelle A. Villador
BS Nursing III - I

Submitted to:
Evelyn Delmundo, RN, MAN, PhD

Date:
June 25, 2016

MISSION
Cavite State University shall provide
excellent, equitable and relevant
educational opportunities in the arts,
science and technology through quality
instruction and relevant research and
development activities. It shall produce
professional, skilled and morally upright
individuals for global competitiveness.

ANATOMY OF THE CERVIX

Cervix is a narrow reproductive organ that connects uterus to the vagina. It 2 cm in length
and is mainly composed of two main parts which is endocervix and exocervix. The main cervix
functions as the connection of uterus and vagina which serves as the passageway of the
endometrial cells when it shed of during menstruation. In addition, cervix consists of mucusproducing gland. During menstrual cycle it secretes mucus plug that traps the sperm to enter the
uterus. In ovulation, the thickness of the mucus changes to allow the sperm to enter the uterus and
fertilize the egg cell. Lastly, cervix also plays important role during labor and childbirth.

CANCER OF THE CERVIX


Carcinoma of the cervix is predominantly squamous cell cancer (10% are
adenocarcinomas). During the past 20 years, the incidence of invasive cervical cancer has
decreased from 14.2 cases per 100,000 women to 7.8 cases per 100,000 women. It is less common
than it once was because of early detection of cell changes by Pap smear. However, it is still the

third most common female reproductive cancer and affects about 13,000 women in the United
States every year (American Cancer Society, 2002). Cervical cancer occurs most commonly in
women ages 30 to 45, but it can occur as early as age 18. Risk factors include multiple sex
partners, early age at first coitus, short interval between menarche and first coitus, sexual contact
with men whose partners have had cervical cancer, exposure to the HPV virus, and smoking.
PATHOPHYSIOLOGY

Clinical Manifestations
There are several different types of cervical cancer. Most cancers originate in squamous cells,
while

the

remainders

are

adenocarcinomas

or

mixed

adenosquamous

carcinomas.

Adenocarcinomas begin in mucus-producing glands and are often due to HPV infection.

Early symptoms may go unnoticed such as a thin watery vaginal discharge often noticed

after intercourse or douching.


symptoms such as discharge, irregular bleeding, or bleeding after sexual intercourse occur,

the disease may be advanced.


In advanced cervical cancer, the vaginal discharge gradually increases and becomes

watery and, finally, dark and foul-smelling from necrosis and infection of the tumor.
Bleeding which occurs at irregular intervals between periods (metrorrhagia) or after
menopause, may be slight (just enough to spot the undergarments) and occurs usually after

mild trauma or pressure (eg, intercourse, douching, or bearing down during defecation).
As the disease continues, the bleeding may persist and increase. Leg pain, dysuria, rectal
bleeding, and edema of extremities signal advanced disease.

As the cancer advances, it may invade the tissues outside the cervix, including the lymph
glands anterior to the sacrum. 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.
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.

STAGING OF CERVICAL CANCER


PREINVASIVE
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 7mm

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

Stage III

Carcinoma extends to one or both pelvic walls

Involves lower third of 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 nonfunctioning


kidney, or both

Stage IV

Extension of carcinoma beyond the true pelvis


Clinical involvement of the mucosa of the bladder or rectum

Stage IVa

Spread of carcinoma to adjacent organs

Stage IVb

Spread to distant organs

ASSESSMENT AND DIAGNOSTIC FINDINGS


Preinvasive cancer

Biopsy
Pap smear
Pelvic examination

Invasive cervical cancer

x-rays
laboratory tests
special examinations (punch biopsy and colposcopy)
other tests
dilation and curettage (D & C)
computed tomography (CT) scan
magnetic resonance imaging (MRI)
intravenous urography
cystography
barium x-ray studies

Medical Management

PRECURSOR OR PREINVASIVE LESIONS


Conservative treatment may consist of:
1. Cryotherapy (freezing with nitrous oxide), or laser therapy.
2. Loop electrocautery excision procedure (LEEP) may also be used to remove abnormal
cells. In this procedure, a thin wire loop with laser is used to cut away a thin layer of
cervical tissue. LEEP is an outpatient procedure usually performed in a gynecologists
office; it takes only a few minutes. Analgesia is given before the procedure, and a local
anesthetic agent is injected into the area. This procedure allows the pathologist to examine
the removed tissue sample to determine if the borders of the tissue are disease-free.
3. Cone biopsy or conization (removing a cone-shaped portion of the cervix) is performed
when biopsy findings demonstrate CIN III or HGSIL, equivalent to severe dysplasia and
carcinoma in situ. If a woman has not completed childbearing and invasion is less than 1
mm, a cone biopsy may be sufficient. Frequent re-examinations are necessary to monitor
for recurrence.
4. Hysterectomy is performed if preinvasive cervical cancer (carcinoma in situ) occurs when
a woman has completed childbearing.
5. Radical trachelectomy is a newly developed procedure which is an alternative to
hysterectomy in women with cervical cancer who are young and want to have children
(Dargent, Martin, Sacchetoni & Mathevet, 2000). In this procedure the cervix is gripped
with retractors and pulled into the vagina until it is visible. The affected tissue is excised
while the rest of the cervix and uterus remain intact. A drawstring suture is placed to close
the cervix.
INVASIVE CANCER
Surgery and radiation treatment (intracavitary and external) are most often used.

1. Hysterectomy - when tumor invasion is less than 3 mm. Invasion exceeding 3 mm usually
requires a radical hysterectomy with pelvic node dissection and aortic node assessment.
Stage 1B1 tumors are treated with radical hysterectomy and radiation. Stage 1B2 tumors
are treated individually because no single correct course has been determined, and many
variable options may be seen clinically.
2. Frequent follow-up after surgery by a gynecologic oncologist is imperative because the
risk of recurrence is 35% after treatment for invasive cervical cancer. Recurrence usually
occurs within the first 2 years. Recurrences are often in the upper quarter of the vagina,
and ureteral obstruction may be a sign. Weight loss, leg edema, and pelvic pain may be
signs of lymphatic obstruction and metastasis.
3. Radiation, which is often part of treatment to reduce recurrent disease, may be delivered
by an external beam or by brachytherapy a method by which the radiation source is
placed near the tumor) or both. The field to be irradiated and dose of radiation are
determined by stage, volume of tumor, and lymph node involvement. Treatment can be
administered daily for 4 to 6 weeks followed by one or two treatments of intracavitary
radiation.
4. Interstitial therapy may be used when vaginal placement has become impossible due to
tumor or stricture.
5. Platinum-based agents are being used to treat advanced cervical cancer. They are often
used in combination with radiation therapy, surgery, or both. Studies are ongoing to find
the best approach to treat advanced cervical cancer. Vaginal stenosis is a frequent side
effect of radiation. Sexual activity with lubrication is preventive, as is use of a vaginal
dilator to avoid severe permanent vaginal stenosis.
6. Some patients with recurrences of cervical cancer are considered for pelvic exenteration,
in which a large portion of the pelvic contents is removed. Unilateral leg edema, sciatica,
and ureteral obstruction indicate likely disease progression. Patients with these symptoms

have advanced disease and are not considered candidates for this major surgical
procedure. Surgery is often complex because it is performed close to the bowel, bladder,
ureters, and great vessels. Complications can be considerable and include pulmonary
emboli, pulmonary edema, myocardial infarction, cerebrovascular accident, hemorrhage,
sepsis, small bowel obstruction, fistula formation, urinary obstruction of ileal conduit,
bladder dysfunction, and pyelonephritis, most often in the first 18 months. Vein
constriction must be avoided postoperatively. Patients with varicose veins or a history of
thromboembolic disease may be treated prophylactically with heparin. Pneumatic
compression stockings are prescribed to reduce the risk for deep vein thrombosis. Nursing
care of these patients is complex and requires coordination and care by experienced health
care professionals. This is a complex, extensive surgical procedure
that is reserved for those with a high likelihood of cure.
NURSING MANAGEMENT
PREVENTION
Regular pelvic examinations and Pap tests for all women, especially older women past
childbearing age (decreases the chance of dying from cervical cancer from 1 in 250 to 1 in

2,000 women)
Education related to reproductive health and safer sex
Smoking cessation
Undergo Papsmear and HPV test
Getting vaccinated