cancer of cervi=x

1.  The area adjacent to the border of the endocervix
and ectocervix is known as the transformation
zone.
 The Transformation zone undergoes metaplasia
numerous times during normal life.
 When the endocervix is exposed to the harsh acidic
environment of the vagina it undergoes metaplasia
to squamous epithelium which is better suited to
the vaginal environment. .
 Similarly when the ectocervix enters the less harsh
uterine area it undergoes metaplasia to become
columnar epithelium

2. Times in life when this metaplasia of the
transformation zone occurs:
 puberty; when the endocervix everts (moves
out) of the uterus
 with the changes of the cervix associated with
the normal menstrual cycle
 post-menopause; the uterus shrinks moving
the transformation zone upwards

3.  Cervical cancer is one of the most common cancers
affecting women (6% of all female malignancies).
and is the leading cancer in India.
 In India it would increase from 0.11 million in the
year 2000 to 0.16 million in 2010
 Over 80% cervical cancer present at advanced
stage and around 80,000 deaths are reported due to
cervical cancer in India.
 More than 371,100 new cases are diagnosed each
year .
 An estimated 190,000 women die each year as a
consequence of this disease
 It is currently the third leading cause of cancer
death in women.
 From 75% to 80% are squamous cell carcinomas.

4.  Associated risk factors include
 early age at first coitus,
 multiple sexual partners,
 multiparity,
 lower socioeconomic standing,
 cigarette smoking,
 history of sexually transmitted diseases,
 immunosuppression, and
 oral contraceptive use.
 Strong association with human papillomavirus (HPV)
 HPV serotypes 16, 18, 31, 33, 45, and 56 account for
more than 80% of all invasive cervical cancers.

5.  Male Partner Factors
 Addiction to Cigarettes
 Multiple Sex Partners
 Intercourse with prostitutes
 Carcinogenic work environment
 Penile warts (caused by HPV)
 Former spouses with history of cervical cancers

6.  Demographic Factors
 Race: Higher incidence among Latin American,
African American, and Native American
women
 Socioeconomic status: More prevalent in lower
socioeconomic classes
 Education: Higher incidence among
undereducated
 Age: More common in older women.

7.  Personal or Sexual Factors
 Sexual partners: History of more than six
sexual partners increases the relative risk
 Women married to a man whose previous
partner had had cervical cancer have a
threefold increase in the risk for developing the
disease.
 History of genital warts increases the incidence
by 18-fold. Penile cancer in a male sexual
partner places a woman at higher risk for
cervical cancer.
 If the age at first intercourse is before 18 year it
increases the risk

8.  Smoking
 Using oral contraceptive for more than 10 years
 Human immunodeficiency virus (HIV)

9.  Medical and Gynecologic Factors
 Parity: Incidence of cervical cancer is more
common among multiparous women
 Papanicolaou (Pap) smear: Prior abnormal Pap
smear or documented dysplasia is associated
with an increased risk.
 : Renal transplantation and HIV infection
increase the risk

10.  SCREENING
 Recommendations are as follows:
 Women should begin screening 3 years after the
onset of sexual activity or at 21 years, whichever is
earlier.
 Screening should end at age of 70, or earlier if a
woman has had a complete hysterectomy.
 .
 Interpretation is divided into nonmalignant
findings and epithelial cell abnormalities
including atypia, low-grade and high-grade
intraepithelial lesions, and squamous cell
carcinoma

11.  PRECURSOR LESIONS
 Mild, moderate, and severe dysplasias are also
known as CIN I, II, and III.
 Most mild-to-moderate dysplasias are more
likely to regress than progress. The rate of
progression of mild dysplasia to severe
dysplasia is 1% per year, whereas the risk of
progression of moderate dysplasia to severe
dysplasia is 16% within 2 years and 25% within
5 years (6).
 CIN III, if left untreated, will progress to
invasive cancer over a period of 20 years in
more than 12% of cases.

12. PATHOLOGY
 The epithelium of the cervix is composed of
 squamous epithelium that covers the exocervix
and glands and columnar epithelial cells that
line the endocervix.
 The border between the squamous and
columnar epithelium is called the
squamocolumnar junction, the site of ongoing
squamous metaplasia believed to be most
vulnerable to viral neoplastic transformation.

13.  With increasing age, the squamocolumnar
junction migrates from the exocervix into the
distal endocervical canal ( Fig. 91-2 ), with the
region between the original and subsequent
locations termed the transformation zone.
 The transformation zone is the most common
location for detection of early cervical cancers (
Fig. 91-3 ) Tumors arising on the ectocervix
typically are squamous cell carcinomas,
whereas adenocarcinomas are more likely to
have their epicenter in the endocervix.

15.  Diagnostic Procedures
 Pap smear, if no gross lesion
 Colposcopically directed biopsy
 Conization (subclinical tumor)
 Punch biopsies (edge of gross tumor)
 Dilation and curettage
 Cystoscopy and rectosigmoidoscopy / Barium
enema (stages IIB, III, IVA) if there are
symptoms referable to the bladder, colon, or
rectum

16.  Chest X ray : to rule out co – morbid conditions
 Ultrasonography Abdomen and Pelvis: Kidney
status, identify gross nodal disease
 CT Scan Abdomen and Pelvis
 MRI Pelvis / Whole body PET Scan

17.  Squamous Cell Carcinoma Antigen ( SCCA).
This expression of antigen is increased in
cervical squamouscancers.

18.  0 Carcinoma in situ Confined to cervix
 IA microscopic evidence of cancer
 IA1 measured stromal invasion no greater than 3.0
mm in depth and extension no wider than 7.0 mm
 IA2 measured stromal invasion greater than 3.0
mm and no greater than 5.0, with an extension no
wider than 7.0 mm
 IB clinically visible lesion limited to cervix uteri
 IB1 clinically visible lesions no greater than 4.0 cm
 IB2 clinically visible lesions greater than 4.0 cm
 II Carcinoma invades beyond the uterus but not to
pelvic wall or to lower third of vagina

19.  IIA no obvious parametrial involvement
 IIB obvious parametrial involvement
 III Extension to pelvic wall
 IIIA Tumor involves lower third of vagina, with
no extension to the pelvic wall
 IIIB Extension to the pelvic wall and/or
hydronephrosis or nonfunctioning kidney
 IV Extension beyond the true pelvis or has
clinically involved the mucosa of the bladder or
rectum
 IVA Spread to adjacent organs
 IVB Spread to distant organs

20.  Analysis showed paraaortic LN involvement as
the most important negative prognostic factor,
followed by pelvic LN involvement, larger
tumor size, younger age, and advanced stage.
 Lymph “vascular invasion and tumor grade is
a significant prognostic factor.
 Five-year survival (%) depends on the stage: 0:
95% to 100%; I: 80%; II: 60%; III: 30%; and IV:
5%.

21. 
 Cervical intraepithelial neoplasia
 Squamous cell carcinoma in situ
 Squamous cell carcinoma – Keratinizing, non –
keratinizing
 Adenocarcinoma in situ
 Endometroid carcinoma
 Clear cell adenocarcinoma
 Adenosquamous carcinoma
 Adenoid cystic carcinoma
 Small cell carcinoma
 Undiffrentiated carcinoma


22.  Squamous and adenocarcinoma account for
90 – 95 % of cervical cancers. Early operable
adenocarcinomas are best treated with radical
hysterectomy followed by appropriate
adjuvant therapy as indicated.
 Cisplatin based systemic therapy is for small
cell and undifferentiated cancers.

23.  Stage 0 Cervical Cancer ( carcinoma in situ)
 Extent of the disease is the most important
factor in the treatment decision . The other
factors that influence the treatment decision
include age of the patient and fertility
preservation.

24.  Loop electrosurgical excision proceudre (
LEEP)
 Laser Therapy
 Conization
 Cryotherapy

25.  LEEP uses wire-loop electrodes in conjunction
with a radiofrequency alternating current to
excise the entire transformation zone and distal
canal under local anesthesia
 Complications
 cervical stenosis (1%),
 rarely pelvic cellulitis or adnexal abscess

27.  Newest of the current treatment. Laser stands
for light amplification by stimulated emission
of radiation.
 The beam vaporizes tissue and must reach a
death of 5 to 7 mm.

28.  Physicians and Nurses should take precaution
to protect the eyes.
 Smoke and steam that may contain HPV are
created with the tissue vaporization, therefore
mask should be worn.
 Patient should be informed that some pain
occurs during the procedure and some
bleeding after words may be there.
 Should use pads and to refrain from
intercourse and should not use tampons until
the watery discharge has resolved.

30.  For those who wish to preserve fertility, a
conization with negative margins is adequate
therapy.
 If no vascular or lymphatic channel invasion is
noted .

32.  If the most effective treatment option.
 It is relatively painless, is low cost and can be done on
an out patient basis.
 The gas refrigerant used is carbon dioxide or nitrous
oxide. The correct size probe if quoted with
lubricating jelly and applied to the cervix until and ice
ball 4 to 5 mm. in diameter is formed. The cervix is
allowed to thaw for 2 to 3 minutes and the probe is
reapplied to form another 4 to 5 mm. ice ball.
 The patient should be instructed by the nurse that a
watery discharge will be present for approximately
two weeks. Should use pads and to refrain from
intercourse and should not use tampons until the
watery discharge has resolved.

33.  Laser or cold knife conization: to preserve the
uterus and avoid radiation
 Total abdominal or vaginal hysterectomy for
the post reproductive age group and is when
the metastasis extents to the inner cone margin.
 For medically inoperable patients as single
intracavitary insertion to a dose of 80 Gy.

34.  Stage IA1 : Micro invasive ( diagnosed only
under microscope)
 Treatment Options
 Conization
 Total Abdominal Hysterectomy
 Brachytherapy

36.  Intracavitary Brachytherapy – I A 1
 If no capillary lymphatic invasion is seen then
external beam radiation is not required.
 One or 2 intracavitary insertions will be done
up to a dose of 100 – 125 Gy to the vaginal
surface in women who are not fit for surgery.

37.  Treatment Options:
 Radical Hysterectomy with pelvic node
dissection
 Radiation Therapy

38.  If fertility is desired
 1} Large cone biopsy plus extra peritoneal or
laparoscopic pelvic lymphadenectomy
 2} radical trachelectomy and extra peritoneal or
laparoscopic pelvic lymphadenectomy

39.  Radical intracavitary radiotherapy or
intracavitary plus external pelvic irradiation
who are not fit for surgery.

40. Carcinoma cervix
stage IA
Cone biopsy with
endocervical curettage
Margins –ve
< = 3mm
depth of
invasion
Margins +ve
TAH or
vaginal H
Radica
l
hyster
ectom

41.  Treatment options
 Radical hysterectomy with pelvic dissection
 Radical Radiation Therapy

42.  Involves the removal of entire uterus, upper
third vagina, bilateral parametria, uterosacral,
utero – vesical ligaments and bilateral pelvic
lymph nodes. Bilateral salphingio –
oophrectomy is discretionary.

43.  Laproscopic Surgery : Presently, laproscopic
radical hystercectomy with pelvic
lymphadenectomy can be offered to patients
with stage IB1 cervical cancer as an alternative
to abdominal hysterectomy in suitable patients.

44.  External beam pelvic irradiation combined
with intracavitary applications, which together
delivers the dose of equivalent to 80 Gy to
point A.

45.  Treatment options include
 Radical hysterectomy
 Radical radiation therapy( external plus
intracavitary)
 Concomitant chemo – radiation ( Radiation +
weekly cisplatin)

46.  High Risk :
 Lymph node metastases, +ve surgical margins,
parametrial extension.
 Adjuvant chemoradiation therapy with
external pelvic radiation therapy with
concurrent weeklt cisplatin is recommended.

47.  If there are positive nodes, positive parametria
or positive surgical margins
 Adjuvant concurrent chemoradiation( using
5FU + Cisplatin or cisplatin alone) improves
survival compared with pelvic irradiation
alone in such patients.

48. Carcinoma cervix stage IB/IIA
Appropriate investigations
Radical Hysterectomy Radical radiation therapy
+ +
Pelvic Lymphadenectomy Concurrent weekly
cisplatin
Risk grouping
Low risk Intermediate risk High risk
Observation pelvic Concurrent chemo
radiation

49.  A combination of external beam pelvic
irradiation covering the uterus , parametria
and pelvic nodes and intracavitary irradiation
primarily for central disease .
 Aim : To deliver a dose equivalent to 80Gy to
point .
 Concomitant chemo radiation should be
completed with in a period of 8 weeks without
break.
 Prolonged overall treatment time results in
poor outcome.

50.  A dose of 40 – 50 Gy in 20 – 25 fractions over a
period of 4 – 5 weeks is recommended.

51.  Brachytharpy plays a very important role in
obtaining high cure rates with minimum
complications.
 A good intacavitary insertion delivers a very
high radiation dose to the cervix , upper vagina
and medial parametria without exceeding the
tolerance doses for rectum and bladder.

52.  LDR or HDR brachytherapy may be used.
 HDR can be done as a day procedure
 LDR is approximately 20 hours of continous
treatment.

53.  LDR : Two intracavitary application, the first
application in the second week of external
radiation while the second is delivered just
after completion of external radiation.
 The task force committee strongly recommends
that use of LDR should be gradually phased
out.

54.  Five weekly intracavitary applications of 7 Gy
to point A each, starting from second week of
external radiation.

55.  Radiotherapy is the main treatment for
advanced stages.
 Platinum based chemo radiation improves
survival

56.  Treatment Options include :
 Neoadjuvant chemotherapy or concurrent
chemotherapy
 Palliative radiotherapy / chemotherapy
 Pelvic exenteration
 Best supportive care/ palliative care

57.  Patients with good general and renal status and
not suitable for surgical exenteration can be
treated with this approach.

58.  Stage IV A patients have poor general
condition and extensive local disease.
 They are best treated with palliative radiation
therapy/ chemotherapy.
 The major symptoms which can be palliated
are vaginal bleeding, profuse discharge, low
backache due to local disease.

59.  is classified as anterior (removal of the bladder,
vagina, cervix and uterus), posterior (removal
of the rectum,vagina, cervix and uterus) or
total exenteration where the bladder and
rectum are removed enbloc with the uterus,
cervix, vagina and the pelvic floor.

60.  Careful assessment of the patient’s general
condition and mental state is mandatory and
the surgery should be accompanied by
procedures that reconstruct and rehabilitate the
urinary and genital tracts as completely and
functionally as possible.

61.  Patients with poor general condition, extensive
local disease like fistula, symptoms of fistula
should be offered best supportive care /
palliative care only.

62.  The intent of treatment is palliative.
 Palliative treatment includes chemotherapy,
radiation therapy, best supportive care /
palliative care only.
 No standard chemotherapy regimen is proven
in patients with stage IV B cervical cancer.

63.  Chemotherapy is palliative, not curative. The
chemotherapeutic agents tested are listed
under the section Palliative Chemotherapy for
stage IVB (it provides low response rates, short
response duration, and low OS).
 Radiation may be given for relief of symptoms
 pelvic exenteration – should be reserved as
salvage surgery for women with recurrent
cervical cancer in the central pelvis whose
chemotherapy has failed.

64. TREATMENT OF CERVICAL CANCER IN
PREGNANCY
 Cervical cancer is the most common
gynecologic malignancy associated with
pregnancy, ranging from 1 in 1,200 to 1 in 2,200
pregnancies.
 No therapy is warranted for preinvasive lesion;
colposcopy is recommended to rule out
invasive cancer.

65.  Treatment of invasive cancer depends on the
tumor stage and gestational age. If cancer is
diagnosed before fetal maturity, immediate
appropriate cancer therapy for the relevant
stage is recommended. If diagnosis is made in
the final trimester, treatment may be delayed.
When acceptable fetal maturity is reached, a
classical caesarean section is done prior to
definitive treatment

66.  Optimal post treatment surveillance has not been
determined.
 Eighty percent to 90% of tumors recur in the first 2
years following therapy. Therefore, most
oncologists schedule follow-up visits frequently,
 every 3 to 4 months for 1 year,
 every 4 months for the next year,
 every 6 months for 3 years, and
 then annually to detect any potentially curable
recurrences.

67.  With advances in vaccine research, much attention
has been paid to the field of vaccination against the
etiologic pathogen for cervical cancer HPV. In
2002, the efficacy of vaccination was demonstrated.

Public health groups and statisticians have
postulated that vaccination in conjunction with
screening may be both an economic and effective
way to prevent invasive cervical cancers .

68.  Nursing
Care of a
patient with
Cancer of
Cervix

69. PAIN
 Although many
cancer patients
experience pain at
some point during
their illness or its
treatment, increasing
attention to effective
pain management has
lead to better pain
relief and improved
quality of life.
 Comfort measures.
 Relaxation techniques
 Pain medication as
ordered
• Non drug modality
to augment and not
replace
pharmacological
therapy for pain.

70.  Pain • For patients with
moderate-to-severe cancer
pain, pain management
often involves treatment
with an opioid pain
medication.
• Opioid pain medications
include morphine,
codeine, oxycodone, and
fentanyl,

71.  Managing Opioid-
related Constipation
 Patients are often treated
with a laxative that
stimulates peristalsis
(coordinated contractions
of the bowel muscle that
move the stool forward),
as well as a stool softener.
 Laxative use generally
continues for as long as
the patient is taking
opioids
 regular physical activity
 adequate fluid and fiber
 make it to a bathroom
whenever they feel the
urge to have a bowel
movement.

72.  Odor related to the
vaginal discharge
 Under clothings to be
changed periodically.
 Instruct the patients to
use pads which needs to
be changed frequently.

73.  The type of surgery
needs to be explained to
the patient.
 Teach the patient the
use of vaginal dilators.
 Shaving of the area to
be operated to done.
 Consent forms to be
signed and kept ready.
 Preoperative
preparations

74.  Fertility issues  Preservation of eggs /
ovum prior to
commencing of
treatment should be
explained to the patient
for the women who are
in the child bearing age.

75.  Menopause
 Radiotherapy for cancer of the cervix
affects the ovaries and brings on the
menopause, usually about three
months after the treatment starts.
 Furthermore, if the ovaries are removed
in a woman of child-bearing age,
menopause will be induced.
 Some of the side effects of early
menopause include hot flashes,
irritability, vaginal dryness, sweats and
nervousness ( should be explained)
 The menopausal side effects can be
reduced by taking hormone
replacement treatment (HRT)

76.  Vaginal stenosis/neo
vagina Realated to
radiation therapy, post
surgery
 Use of condom to decrease
irritation to mucosa from sperm
 Refrain from intercourse when
discomfort and mucositis begin
 Vaginal dilatation 2 weeks after
therapy is completed, daily for 10
min.
 Use dilators every other day for
rest of life
 Dilatation may be omitted, the
day patient has intercourse.
 Use clean dilators
 Start with small size dilator
 Apply water soluble lubricants
 Dilatation may be done at the
time of bath

77.  sexual relations can continue or recommence
post treatment
 May reduce the incidence of discomfort or
painful intercourse
 May reduce potential difficulties with future
partners if not in a sexually active relationship
at the time of treatment
 Allows the medical team to accurately examine
and assess the vaginal vault or cervix as part of
ongoing medical follow up, care and support
 Offers the opportunity to discuss sexual fears/
myths associated with pelvic radiotherapy

78.  Risk of lymphedema.
1. Avoid
 extreme heat from saunas,
hot tubs or heating pads
 strenuous, fatiguing
exercises
 airplane travel and high
altitudes (increased
pressure)
 excessive sun exposure

79. 2. Avoid
 blood pressure monitoring on affected appendage
 restrictive clothing or jewelry
 extreme cold (like an ice pack)
 carrying a handbag or luggage with affected arm
 crossing legs if leg has been affected
Using caution in order to avoid injury when participating
in the following daily activities:
 shaving
 gardening (arm/hands)
 housework (arm/hands)
 fingernail or toenail care

80.  Avoid needle sticks in affected arm or leg.
 Avoid puncturing or injuring the skin.
 See your doctor if you notice signs of
infections/rash.
 Carry antibiotics when you travel.
 Follow doctor recommended skin care, such as
using mild soaps and moisturizing lotions
daily.
 Avoid ingrown toenails and foot fungus.

81.  Exercise: The muscle contraction of moderate
exercise promotes lymph flow and an increased
absorption of protein.
 Obesity/ Overweight: Excess body fat is
associated with an increased load on the vascular
and lymphatic system
 Nutrition: A healthy, low-fat diet is associated
with improved overall health
Patients should also be aware of any signs of
lymphedema or infection and notify their doctor
immediately to receive proper care.

82.  Barrier creams to applied to protect the
perineal skin.
 Patient can be taught the use of tampons.
 Medications like Loperamide to be given to
make the stools firm

83.  Fatigue, is very common in people treated for
cancer. Exercise can help reduce fatigue.
 balance activity with rest.
 Studies have shown that patients
who follow an exercise program tailored
to their personal needs feel better
physically and emotionally and
can cope better, too.

84.  Cancer impacts woman's sexuality, sexual
functioning (illness, pain, anxiety, anger,
stressful circumstances and medications),
intimate relationships and sense of self.
 Matters of sexuality and intimacy greatly impact
quality of life of patients with gynecologic cancers
 Some patients may be uncomfortable to broach the
topic due to cultural and religious beliefs

85.  Believe that helping patient deal with changes
in sexuality is an integral part of holistic
nursing care
 Be careful not to impose your own beliefs on
patients
 Nurses need to understand that their failure or
hesitation to include sexuality counseling may
add to patients anxiety and fears about future
sexual activity

86.  BETTER model to assess sexuality
 BRING up the topic/ initiate conversation
 EXPLAIN sexuality is a part of life and contributes to
QOL
 TELL about resources available to them
 TIMING : inform patient that you are available when
they need to talk about sexual concerns
 EDUCATE patient about possible ways the
diagnosis/ treatment can affect sexual function
 RECORD in your nursing note that you broached the
subject with patient.

87.  To enhance comfort during sex, patient may
 Pain medications 30 – 45 minutes before sex,
 use of pillows for support
 Use of fantasy
 Creativity and explore new ways of pleasure
Skin is the largest sexual organ and brain ism the
most important sexual organ USE THEM
 ORGASM RELEASES ENDORPHINS THAT
MAY PROVIDE PAIN RELIEF IN SOME
INDIVIDUALS FOR UPTO 6 HOURS.

88.  Councelling  Bibliotherapy (use of
books and literature)
 Use of erotica (non
pornographic books/
movies)
 Position: patient need to
experiment what work
best for them.
Pamphlets and books
on different positions

89. This therapy uses the interconnectedness of
mind and body to improve health.
E.g. Psychotherapy, Meditation, Guided
imagery, Hypnosis, Biofeedback and Prayer.

90. It is a form of therapy in which pressure is applied to
points on the feet and the hands.
The treatment is relaxing and helps in curbing stress
and digestive problems.
Where there is a blockage the reflex can feel taut and is
often painful for the patient. The reflexologist gently
works at the point until the blockage is released.

92. Form of guided meditations. Visualization in healing is used
to break up blockages, tumors, heal wounds, and deal with
emotional problems.

93. Spiritual health
Spiritual distress:
Patient may experience a disturbance
in belief and value system
Source of spiritual distress may be
crisis of illness, suffering or death itself,
conflict between belief and treatment regime.