Transcript Cervical Cancer: Prevention & Treatment

Cervical Cancer:
Prevention and Treatment
By Mary Alice Tinari, RN, AOCN, MSN
Nursing made Incredibly Easy!
November/December 2008
2.5 ANCC/AACN contact hours
Online: www.nursingcenter.com
© 2008 by Lippincott Williams & Wilkins. All world rights reserved.
Two Main Types
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Squamous cell carcinoma—responsible for the
majority of cervical cancers; typically occurs in
the transformation zone of the cervix
Adenocarcinoma—responsible for 20% of
cervical cancers; arises from the mucusproducing gland cells of the endocervix
Mixed adenosquamous carcinoma is also possible
Picturing Cervical Cancer
Two Grading Systems
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Cervical intraepithelial neoplasia (CIN) grading
system
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CIN I describes mild dysplasia
CIN II describes moderate dysplasia
CIN III describes severe dysplasia or a lesion that
involves the full thickness of the epithelium
National Cancer Institute’s (NCI) Bethesda system
provides further details about the quality of Pap
test results
Risk Factors
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Exposure to human
papillomavirus (HPV)
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Present in 99% of
cervical cancers
One-third of
American women
infected with HPV by
age 24
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Family history of
cervical cancer
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Low socioeconomic
status
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Sexual activity
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Multiple sex partners
Early age at first
intercourse
Sex with a
promiscuous partner
History of sexually
transmitted diseases
Smoking and
exposure to
secondhand smoke
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Multiple pregnancies
or early childbearing
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Long-term
contraceptive use
HPV
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Over 100 different types of HPV; types 6 and 11
responsible for genital warts
Affinity for epithelial cells
HPV proteins bind with p53 tumor suppressor,
interfering with normal cell growth
Most individuals are unaware of contracting HPV
because symptoms may not develop for years
Signs & Symptoms
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Bleeding between menstrual periods or after
intercourse, douching, or pelvic exam
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Increased vaginal discharge
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Pelvic pain or pain after intercourse
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Locally advanced disease may cause pain in the
legs, back, or pelvis; bleeding from the rectum;
or blood in the urine
Cancer spread outside the pelvis can cause bone
pain, fractures, or lung problems
Diagnostic Testing
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Pap test—microscopic exam of cells from the
cervix
Results fall into six major categories
After cervical cancer is diagnosed, it’s staged
using the International Federation of Gynecology
and Obstetrics (FIGO) system or the TNM (tumor,
node, metastasis) system
Pap Test Categories
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Normal—most frequent result; 90% to 95% of
the time
Atypical squamous cells of undetermined
significance (ASC-US)—60% of women are
HPV-negative; 40%, HPV-positive
Atypical glandular cells of undetermined
significance (AGC-US)—50% of women will
have normal histology; high-grade lesions may be
found in 20% to 50% of women with this result
Pap Test Categories
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Low-grade squamous intraepithelial lesions
(LSIL)—typically an HPV infection result in 75%
women age 35 and younger; in older women, due
to declining estrogen
High-grade squamous epithelial lesions—
90% of women will show cell changes due to HPV
Cancer—either squamous cell carcinoma or
adenocarcinoma
Pap Results and Care
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For ASC-US:
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Standard of care is to repeat the PAP test in 4 to 6
months
If HPV testing is positive, colposcopy is indicated
If HPV-negative, the PAP test is repeated in 1 year
Post-menopausal women may have estrogen therapy
for 3 months and then repeat the PAP test
For AGC-US:
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Requires colposcopy and endometrial biopsy for
women over age 35 with bleeding
Pap Results and Care
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For LSIL in sexually active adolescents:
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Colposcopy indicated
For LSIL in post-menopausal women:
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Treated with 3 months of estrogen therapy, if not
contraindicated
The Pap test is then repeated 1 week after estrogen
therapy is stopped
If vaginal atrophy is absent, the woman is treated
as if the Pap result was ASC-US
The FIGO Staging System
Treatment Options
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Women with CIN 1 or LSIL have the option of no
treatment because 50% to 70% of these lesions
spontaneously resolve; a PAP test is required
every 6 months
If lesions progress and don’t resolve within 2
years, treatment includes:
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Cryotherapy—freezing used to treat CIN 1 lesions
Loop electrosurgical excision—uses a thin wire
loop through which an electric current is passed,
turning the loop into an effective cutting tool
Laser ablation—indicated for lesions that extend
into the cervical canal
Cold-knife conization—uses a scalpel to remove
the portion of the cervix that contains the abnormal
cells
Other Treatments Options
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If invasive cancer is found, a total hysterectomy is
performed
For more advanced cancers, a radical
hysterectomy is performed
Chemotherapy/radiation is used when margins of
normal tissue are difficult to obtain or if cervical
cancer relapses
Fertility-sparing surgery may be an option for
early-stage cervical cancer
Picturing Total Hysterectomy
Follow-Up Care
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PAP test every 3 months for the first year
following successful treatment
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PAP test every 4 months for the second year
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PAP test every 6 months for the third year
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Annually thereafter
Patient Teaching and Prevention
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Explain testing
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Offer emotional support
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Reinforce the need for regular monitoring after an
abnormal PAP test result
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Screening by Pap test should be started when a
woman becomes sexually active or by age 21,
regardless of sexual activity
Quadrivalent human papillomavirus (types 6, 11,
16, 18) recombinant vaccine for young women
ages 9 to 26, given I.M. in three doses over 6
months; 99% effective in preventing precancerous
cervical changes