Uterine cancer
Uterine cancer: Excerpt from Handbook of Diseases
Cancer of the endometrium, or uterine cancer, is the most common gynecologic cancer. It 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 another hormonal imbalance.
Uterine cancer has an incidence of 1% to 2% in the United States.
Causes
Uterine cancer seems linked to several predisposing factors:
❑ low fertility index and anovulation
❑ abnormal uterine bleeding
❑ obesity, hypertension, or diabetes
❑ familial tendency
❑ history of atypical endometrial hyperplasia
❑ estrogen therapy (still controversial).
Generally, 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 uterine tumors include adenoacanthoma, endometrial stromal sarcoma, lymphosarcoma, mixed mesodermal tumors (including carcinosar- coma), and leiomyosarcoma.
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 gradually becomes more bloody. Other symptoms, such as pain and weight loss, don’t appear until the cancer is well advanced.
Diagnosis
Unfortunately, a Pap smear, so useful for detecting cervical cancer, doesn’t dependably predict early-stage uterine cancer. Diagnosis of uterine cancer requires endometrial biopsy and the following tests for baseline data and staging:
❑ complete physical examination
❑ chest X-ray or computed tomography scan
❑ complete blood count
❑ proctoscopy or barium enema studies, if bladder and rectal involvement are suspected.
Treatment
Uterine cancer treatment varies, depending on the extent of the disease. Generally, treatment involves surgery and radiation therapy, depending on the stage and depth of the myometrial invasion.
Surgery
Surgery generally involves total adominal hysterectomy, bilateral salpingo-oophorectomy or, possibly, omentectomy with or without pelvic or para-aortic lymphadenectomy.
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 hydroxyprogesterone 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
Chemotherapy is not very successful in advanced endometrial carcinoma. Varying combinations of cisplatin, doxorubicin, carboplatin, or paclitaxel, as well as others, are usually tried when other treatments have failed.
Special considerations
❑ Patients with uterine cancer require teaching to help them cope with surgery, radiation, and chemotherapy. Also provide good postoperative care and psychological support.
Before surgery:
❑ Reinforce any previous teaching about the surgery, and explain routine tests (such as repeated blood tests the morning after surgery) and postoperative care.
❑ 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 crossmatched.
❑ If the patient is premenopausal, inform her that removal of her ovaries will induce menopause.
After surgery:
❑ Measure fluid contents of the blood drainage system every 8 hours. Be alert for drainage that exceeds 400 ml/8 hours.
❑ If the patient has received subcutaneous heparin, continue administration until she’s fully ambulatory again.
❑ Check vital signs every 4 hours. Watch for any sign of complications, such as bleeding, abdominal distention, severe pain, wheezing, or other breathing difficulties. Provide analgesics.
❑ Regularly encourage the patient to breathe deeply and cough to help prevent complications. Promote the use of an incentive spirometer once every waking hour to help keep lungs expanded.
❑ Find out whether the patient is to have internal or external radiation or both. Usually, internal radiation therapy is done first.
If the patient receives internal radiation:
❑ 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 will receive a general anesthetic. She’ll be placed in a dorsal position, with her knees and hips flexed and her heels resting in footrests.
If the radioactive source isn’t implanted in the operating room, it may be implanted by a member of the radiation team while the patient is in her room.
CLINICAL TIP: Remember that safety precautions, including time, distance, and shielding, must be imposed immediately after the 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 necessary, administer a tranquilizer to help her relax and remain still. If she prefers, elevate the head of the bed slightly. Make sure she can reach everything she needs (call bell, telephone, water) without stretching or straining.
❑ Assist the patient in range-of-motion arm exercises (leg exercises and other body movements could dislodge the source). 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 antidiarrheal medication 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.
❑ Explain that except in total pelvic exenteration, the vagina remains intact and that once she recovers, sexual intercourse is possible.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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