Cervical cancer
Cervical cancer: Excerpt from Handbook of Diseases
The third most common cancer of the female reproductive system, cervical cancer is classified as either microinvasive or invasive.
Precursors to cervical cancer include:
❑ minimal cervical dysplasia (squamous intraepithelial lenar), in which the lower third of the epithelium contains abnormal cells
❑ carcinoma in situ, also known as cervical intraepithelial neoplasia, in which the full thickness of epithelium contains abnormally proliferating cells.
Dysplasia is curable 75% to 90% of the time with early detection and proper treatment. If untreated (and depending on the form in which it appears), it may progress to invasive cervical cancer. Mild dysplasia may regress and not progress in 80% to 85% of women, so treatment isn’t necessary in all cases, although close follow-up is always appropriate.
With invasive carcinoma, cancer cells penetrate the basement membrane and can spread directly to contiguous pelvic structures or disseminate to distant sites by lymphatic routes. Invasive carcinoma of the uterine cervix is responsible for 8,000 deaths annually in the United States alone.
In almost all cases (95%), the histologic type is squamous cell carcinoma, which varies from well-differentiated cells to highly anaplastic spindle cells. Only 5% are adenocarcinomas. Invasive carcinoma usually occurs in patients between ages 30 and 50, though in rare cases it can occur in those younger than age 20.
Causes
The human papillomavirus (HPV) is accepted as the cause of virtually all cervical dysplasias and cervical cancers. Certain strains of the HPV (16, 18, 31) are associated with an increased risk of cervical cancer. Several predisposing factors have been related to the development of cervical cancer: intercourse at a young age (younger than age 16), multiple sexual partners, and herpesvirus 2 and other bacterial or viral venereal infections.
Signs and symptoms
Cervical dysplasia produces no symptoms or other apparent changes. Early invasive cervical cancer can cause abnormal vaginal bleeding, persistent vaginal discharge, and postcoital pain and bleeding. In advanced stages, cervical cancer causes pelvic pain, vaginal leakage of urine and stool from a fistula, anorexia, weight loss, and anemia.
Diagnosis
A cytologic examination (Papanicolaou [Pap] test) can be used to detect cervical cancer before symptoms appear. Abnormal cervical cytology generally calls for colposcopy, which can detect the presence and extent of preclinical lesions requiring a biopsy and histologic examination.
Staining with Lugol’s solution (strong iodine) or Schiller’s solution (iodine, potassium iodide, and purified water) may identify areas for a biopsy when the smear shows abnormal cells but there is no obvious lesion. Although the tests are nonspecific and have a high rate of false-positives, they do distinguish between normal and abnormal tissues: Normal tissues absorb the iodine and turn brown; abnormal tissues are devoid of glycogen and don’t change color.
Additional studies — such as cystography, magnetic resonance imaging, computed tomography and bone scans — can be used to detect metastasis.
Treatment
Appropriate treatment depends on accurate staging. Preinvasive lesions may be treated with a loop electrosurgical examination procedure, cryosurgery, laser destruction, conization (and frequent Pap test follow-up) or, rarely, hysterectomy. Therapy for invasive squamous cell carcinoma may include radical hysterectomy and radiation therapy (internal, external, or both). Radiation is effective for all stages, but surgery is preferable for some premenopausal women.
Special considerations
❑ If the patient needs a biopsy, drape and prepare her as for a routine Pap test and pelvic examination. Have a container of formaldehyde ready to preserve the specimen during transfer to the pathology laboratory. Explain to the patient that she may feel pressure, minor abdominal cramps, or a pinch from the punch forceps. Reassure her that pain will be minimal because the cervix has few nerve endings.
❑ If the patient is having cryosurgery, drape and prepare her as for a routine Pap test and pelvic examination. Explain that the procedure takes about 15 minutes, during which time refrigerant will be used to freeze the cervix. Warn the patient that she may experience abdominal cramps, headache, and sweating, but reassure her that she’ll feel little, if any, pain. Also, warn her she’ll have profuse, watery discharge for days or weeks.
❑ If the patient is having laser therapy, drape and prepare her as for a routine Pap test and pelvic examination. Explain that the procedure takes about 30 minutes and may cause abdominal cramps.
❑ Tell the patient to expect a discharge or spotting for about 1 week after an excisional biopsy, cryosurgery, or laser therapy, and advise her not to douche, use tampons, or engage in sexual intercourse during this time. Tell her to watch for and report signs of infection. Stress the need for a follow-up Pap test and a pelvic examination within 3 to 4 months after these procedures and periodically thereafter.
❑ If the patient is having a hysterectomy, tell her what to expect postoperatively.
❑ After surgery, monitor vital signs every 15 minutes for 1 hour, every 30 minutes for the next hour, every hour for 2 hours, then every 4 hours or as per protocol.
❑ Watch for signs and symptoms of complications, such as bleeding, abdominal distention, severe pain, and breathing difficulties.
❑ Administer an analgesic, a prophylactic antibiotic, and subcutaneous heparin, as needed.
❑ Encourage the patient to perform deep-breathing and coughing exercises.
❑ Find out whether the patient is to have internal or external radiation therapy, or both. Usually, internal radiation therapy is the first procedure.
❑ Explain the internal radiation procedure, and answer the patient’s questions. Internal radiation requires a 2- to 3-day facility stay, bowel preparation, a povidone-iodine vaginal douche, a clear liquid diet, and nothing by mouth the night before the implantation; it also requires an indwelling urinary catheter.
❑ Tell the patient that the internal radiation procedure is performed in the operating room, that general anesthesia is used, and that an applicator containing radioactive material (such as radium or cesium) will be implanted.
Clinical tip Remember that safety precautions — time, distance, and shielding — begin as soon as the radioactive source is in place. Inform the patient that she’ll require a private room.
❑ Encourage the patient to lie flat and limit movement while the implant is in place. If she prefers, elevate the head of the bed slightly.
❑ Check vital signs every 4 hours; watch for skin reaction, vaginal bleeding, abdominal discomfort, or evidence of dehydration. Make sure the patient can reach everything she needs without stretching or straining.
❑ Assist the patient in range-of-motion arm exercises (leg exercises and other body movements could dislodge the implant). If needed, 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.
❑ Inform visitors of safety precautions, and hang a sign listing these precautions on the patient’s door.
❑ Explain that external radiation therapy, when necessary, continues for 4 to 6 weeks on an outpatient basis.
❑ Teach the patient to watch for and report uncomfortable adverse reactions. Because radiation therapy may increase susceptibility to infection by lowering the white blood cell count, warn the patient to avoid persons with obvious infections during therapy.
❑ Teach the patient to use a vaginal dilator to prevent vaginal stenosis and to facilitate vaginal examinations and sexual intercourse.
❑ Reassure the patient that this disease and its treatment shouldn’t radically alter her lifestyle or prohibit sexual intimacy.
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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