Uterine cancer
Uterine cancer: Excerpt from Professional Guide to Diseases (Eighth Edition)
Uterine cancer involves cancerous growth of the endometrial lining. The five-year survival rate is 75% to 95% for stage I cancers; as the stages progress, the survival rate diminishes. For stage II, there's a 50% survival rate; stage III, 30%; and there's less than a 5% survival rate for stage IV.
Causes and incidence
Uterine cancer seems linked to several predisposing factors:
❑abnormal uterine bleeding
❑diabetes
❑familial tendency
❑history of uterine polyps or endometrial hyperplasia
❑hypertension
❑low fertility index and anovulation
❑nulliparity
❑obesity
❑uninterrupted estrogen stimulation.
In most cases, uterine cancer is an adenocarcinoma that metastasizes late, usually from the endometrium to the cervix, ovaries, fallopian tubes, and other peritoneal structures. It may spread to distant organs, such as the lungs and the brain, through the blood or the lymphatic system. Lymph node involvement can also occur. Less common are adenoacanthoma, endometrial stromal sarcoma, lymphosarcoma, mixed mesodermal tumors (including carcinosarcoma), and leiomyosarcoma.
Uterine cancer usually affects postmenopausal women between ages 50 and 60; it's uncommon between ages 30 and 40 and extremely rare before age 30. Most premenopausal women who develop uterine cancer have a history of anovulatory menstrual cycles or other hormonal imbalance. About 37,000 new cases of uterine cancer are reported annually, with approximately 6,400 deaths predicted for 1999.
Signs and symptoms
Uterine enlargement, and persistent and unusual premenopausal bleeding, or any postmenopausal bleeding, are the most common indications of uterine cancer. The discharge may at first be watery and blood-streaked, but it gradually becomes more bloody. Other signs or symptoms, such as pain and weight loss, don't appear until the cancer is well advanced.
Diagnosis
Unfortunately, a Papanicolaou test, so useful for detecting cervical cancer, doesn't dependably predict early-stage uterine cancer. Diagnosis of uterine cancer requires endometrial, cervical, and endocervical biopsies. (See Staging uterine cancer.) Negative biopsies call for a fractional dilatation and curettage to determine the diagnosis. Positive diagnosis requires the following tests for baseline data and staging:
❑multiple cervical biopsies and endocervical curettage to pinpoint cervical involvement
❑ Schiller's test, staining the cervix and vagina with an iodine solution that turns healthy tissues brown; cancerous tissues resist the stain
❑ complete physical examination
❑ chest X-ray or computed tomography scan
❑ excretory urography and, possibly, cystoscopy
❑ complete blood studies
❑electrocardiogram
❑ proctoscopy or barium enema studies, if bladder and rectal involvement are suspected.
Treatment
Treatment varies, depending on the extent of the disease:
❑Surgery — Rarely curative, surgery generally involves total abdominal hysterectomy, bilateral salpingo-oophorectomy, or possibly omentectomy with or without pelvic or para-aortic lymphadenectomy. Total exenteration involves removal of all pelvic organs, including the vagina, and is done only when the disease is sufficiently contained to allow surgical removal of diseased parts. (See Managing pelvic exenteration, page 114.)
❑Radiation therapy — When the tumor isn't well differentiated, intracavitary or external radiation (or both), given 6 weeks before surgery, may inhibit recurrence and lengthen survival time.
❑ Hormonal therapy — Synthetic progesterones, such as medroxyprogesterone or megestrol, may be administered for systemic disease. Tamoxifen (which produces a 20% to 40% response rate) may be given as a second-line treatment.
❑ Chemotherapy — Varying combinations of cisplatin, doxorubicin, carboplatin, topotecan, paclitaxel, and gemcitabine are usually tried when other treatments have failed.
Special considerations
Patients with uterine cancer require patient teaching to help them cope with surgery, radiation, and chemotherapy. Also provide good postoperative care and psychological support.
Before surgery:
❑Reinforce what the physician told the patient about the surgery, and explain the routine tests (for example, repeated blood tests the morning after surgery) and postoperative care. If the patient is to have a lymphadenectomy and a total hysterectomy, explain that she'll probably have a wound drainage system for about 5 days after surgery. Also explain indwelling urinary catheter care. Fit the patient with antiembolism stockings for use during and after surgery. Make sure the patient's blood has been typed and cross-matched. If the patient is premenopausal, inform her that removal of her ovaries will induce menopause.
After surgery:
❑Measure fluid contents of the wound drainage system every shift. Notify the physician immediately if drainage exceeds 400 ml.
❑If the patient has received subcutaneous heparin, continue administration, as ordered, until the patient is fully ambulatory again. Give prophylactic antibiotics as ordered, and provide good indwelling urinary catheter care.
❑Check vital signs every 4 hours. Watch for and immediately report any sign of complications, such as bleeding, abdominal distention, severe pain, wheezing, or other breathing difficulties. Provide analgesics as ordered.
❑Regularly encourage the patient to breathe deeply and cough to help prevent complications. Promote the use of an incentive spirometer several times every waking hour to help keep lungs expanded.
For radiation therapy:
❑Find out if the patient is to have internal or external radiation or both. Usually, internal radiation therapy is done first.
❑Explain the internal radiation procedure, answer the patient's questions, and encourage her to express her fears and concerns.
❑Explain that internal radiation usually requires a 2- to 3-day hospital stay, bowel preparation, a povidone-iodine vaginal douche, a clear liquid diet, and nothing taken by mouth the night before the implantation.
❑Mention that internal radiation also requires an indwelling urinary catheter.
❑Tell the patient that, if the procedure is performed in the operating room, she'll receive a general anesthetic. She'll be placed in a dorsal position, with her knees and hips flexed and her heels resting in footrests.
❑Inform her that the radioactive source may be implanted in the vagina by the physician, or it may be implanted by a member of the radiation team while the patient is in her room.
❑Remember that safety precautions, including time, distance, and shielding, must be imposed immediately after the patient's radioactive source has been implanted.
❑Tell the patient that she'll require a private room.
❑Encourage the patient to limit movement while the source is in place. If she prefers, elevate the head of the bed slightly. Make sure the patient can reach everything she needs (call bell, telephone, water) without stretching or straining. Assist her in range-of-motion arm exercises (leg exercises and other body movements could dislodge the source). If ordered, administer a tranquilizer to help the patient relax and remain still. Organize the time you spend with the patient to minimize your exposure to radiation.
❑Check the patient's vital signs every 4 hours; watch for skin reaction, vaginal bleeding, abdominal discomfort, or evidence of dehydration.
❑Inform visitors of safety precautions and hang a sign listing these precautions on the patient's door.
If the patient receives external radiation:
❑Teach the patient and her family about the therapy before it begins. Tell the patient that treatment is usually given 5 days a week for 6 weeks. Warn her not to scrub body areas marked with indelible ink for treatment because it's important to direct treatment to exactly the same area each time.
❑Instruct the patient to maintain a high-protein, high-carbohydrate, low-residue diet to reduce bulk and yet maintain calories. Administer diphenoxylate with atropine, as ordered, to minimize diarrhea, a possible adverse effect of pelvic radiation.
❑To minimize skin breakdown and reduce the risk of skin infection, tell the patient to keep the treatment area dry, to avoid wearing clothes that rub against the area, and to avoid using heating pads, alcohol rubs, or any skin creams.
❑Teach the patient how to use a vaginal dilator to prevent vaginal stenosis and to facilitate vaginal examinations and sexual intercourse.
Remember, a patient with uterine cancer needs special counseling and psychological support to help her cope with this disease and the necessary treatments. Fearful about her survival, she may also be concerned that treatment will alter her lifestyle and prevent sexual intimacy. Explain that except in total pelvic exenteration, the vagina remains intact and that after she recovers, sexual intercourse is possible. Your presence and interest will help the patient, even if you can't answer every question she may ask.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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