Cervical Cancer Is a common gynecologic malignancy. Most commonly occurs in women age 35 to 55.

5. Major risk factors include early sexual activity, multiple sexual partners, and history of sexually transmitted diseases especially human papilloma virus and herpes simplex virus. Cervical cancer may involve the bladder, rectum, and may metastasize to the lungs, mediastinum, bones, and liver. Types of cervical cancer includes: Dysplasia atypical cells with some degree of surface maturation. Carcinoma in Situ (CIS) which is confined to the cervical epithelium. Invasive carcinomas the stroma is involved, 90% are of the squamous cell type. Invasive cancer spreads by local invasion and lymphatics to the vagina and beyond.

Clinical Manifestation Abnormal cervical cell changes rarely cause symptoms. But you may have symptoms if those cell changes grow into cervical cancer. Symptoms of cervical cancer may include:

Bleeding from the vagina that is not normal or a change in your cycle that you can't explain.

Bleeding when something comes in contact with your cervix, such as during sex or when you put in a diaphragm.

Pain during sex. Vaginal discharge that is tinged with blood.

Pathophysiology The ectocervix is covered by stratified squamousepithelium The canal of the cervix is lined by columnar epithelium. point where these two epithelia meet is called the squamocolumnar Junction. It lies just at the external os, but as the cervix increases in volume during puberty and also pregnancy, the SCJ is said to roll out onto the ectocervix. The delicate columnar epithelium exposed to the acid environment

of the vagina undergoes a process of metaplasia whereby it becomes squamous epithelium. The transformation zone is that part of the cervix that extends from the widest part of skins that was originally columnar epithelium into the current SCJ. Dysplasiaoccurs in the stratifies squamous epitheliumleading to disordered squamous epithelium. HPV is a factor in the dysplastic changes. Smoking and immune suppression appear to be additional factors.

 Dysplastic epithelium lacks the normal maturation of cells. Dysplasias are now usually referred to as cervical intraepithelial neoplasia (CIN).

Diagnostic Procedures Pap smear - The most common form of diagnosis for detecting cervical cancer in its early stages. This test is painless, normally takes less than 5 minutes to complete and can be performed in a doctors office. Women who are 18 or older or who are sexually active are recommended to undergo annual Pap smear tests. Pelvic examination - The exam is very similar to the Pap smear. A woman lies on her back while a doctor inserts a speculum into her vagina. A doctor will then examine a womans vagina and surrounding organs both visually and manually. He will insert gloved fingers and gently feel the cervix and surrounding organs with his fingers, while his other hand presses gently on the patients stomach. Colposcopy - This procedure involves the use of a special binocular microscope that is called a colposcope and is very similar to a Pap smear. A woman will lie on her back while a doctor inserts a speculum into her vagina. He will also apply a local anesthetic to her cervix as well as a special solution that will stain any abnormal cells white. The doctor can then view the cells using the high-powered microscope to detect any abnormal cancerous cells.

Diagnotic Procedures Treatment for cervical cancer depends on several factors, such as the stage of the cancer, other health problems you may have and your preferences about treatment. Treatment options may include: Surgery - to remove the uterus (hysterectomy) is typically used to treat the early stages of cervical cancer. A simple hysterectomy involves the removal of the cancer, the cervix and the uterus. Simple hysterectomy is typically an option only when the cancer is at a very early stage invasion is less than 3 millimeters (mm) into the cervix. A radical hysterectomy removal of the cervix, uterus, part of the vagina and lymph nodes in the area is the standard surgical treatment when there's invasion greater than 3 mm into the cervix. Radiation - uses high-powered energy to kill cancer cells. Radiation therapy can be given externally using external beam radiation or internally (brachytherapy) by placing devices filled with radioactive material near your cervix. Both methods of radiation therapy can be combined. Radiation therapy can be used alone, with chemotherapy, before surgery to shrink a tumor or after surgery to kill any remaining cancer cells. Premenopausal women may stop menstruating as a result of radiation therapy and begin menopause. Chemotherapy - uses drugs to kill cancer cells. Chemotherapy drugs, which can be used alone or in combination with each other, are

usually injected into a vein, and they travel throughout your body killing rapidly growing cells, including cancer cells. Low doses of chemotherapy are often combined with radiation therapy, since chemotherapy may enhance the effects of the radiation. Higher doses of chemotherapy are used to control advanced cervical cancer that may not be curable. Certain chemotherapy drugs may cause infertility and early menopause in premenopausal women.

If cervical cancer is diagnosed, the health care provider will order more tests. These help determine how far the cancer has spread. This is called staging. Tests may include: Chest x-ray CT scan of the pelvis Cystoscopy Intravenous pyelogram (IVP) MRI of the pelvis

Medical Management

Early cervical cancer can be cured by removing or destroying the precancerous or cancerous tissue. There are various surgical ways to do this

without removing the uterus or damaging the cervix, so that a woman can still have children in the future. Types of surgery for early cervical cancer include:

Loop electrosurgical excision procedure (LEEP) -- uses electricity to remove abnormal tissue Cryotherapy -- freezes abnormal cells Laser therapy -- uses light to burn abnormal tissue

Treatment for more advanced cervical cancer may include: Radical hysterectomy, which removes the uterus and much of the surrounding tissues, including lymph nodes and the upper part of the vagina. Pelvic exenteration, an extreme type of surgery in which all of the organs of the pelvis, including the bladder and rectum, are removed.

Assessment

Early disease is usually asymptomatic. Initial symptoms are postcoital bleeding, irregular vaginal bleeding or spotting between periods or after menopause, and malodorous discharge. As disease progresses, bleeding becomes more constant and is accompanied by pain that radiates to buttocks and legs.

 Weight loss, anemia, and fever signal advance disease.

Diagnostic Evaluation Papanicolaou (Pap) smear for cervical cytology is usual screening test. A computerized screening program may increase the accuracy of manual laboratory Pap screening by as much as 30%. If Pap test is abnormal, colposcopy, and biopsy or conization may be done. Additional testing includes metastatic workup (chest x-ray, I.V. urogram, cystoscopy, barium studies of colon and rectum, sigmoidoscopy)

Therapeutic Interventions 1. Intracavitary radiation for earlier localized stages radium by way of applicator in endocervical canal. 2. External radiation for generalized pelvis effect in later stages. 3. Laser therapy may be used to treat dysplasia. 4. Chemotherapy may be used as adjuvant to surgery or radiation treatments. Surgical Interventions 1. Conization is performed for microinvasize stage if child-bearing is desired. 2. Cryosurgery, laser ablation, and loop electrosurgical excision procedure may be done for dysplasia or CIS. 3. Hysterectomy, simple or radical depending on stage.

4. Pelvic

exenteration

for

very

advanced

disease

if radiation

therapy cannot be used; also for recurrent cancer. Nursing Interventions 1. During intracavitary radiation, check radioisotope applicator position every 8 hours, and monitor amount of bleeding and drainage (a small amount is normal). 2. Observe for signs and symptoms of radiation sickness such as nausea, vomiting, fever, diarrhea, abdominal cramping. 3. Monitor for complications of surgery bleeding, infection. 4. Help the patient seek information on stage of cancer, treatment options. 5. Provide emotional support during treatment. 6. Advise patient to discharge after surgical procedures and need to report excessive, foul-smelling, discharge or bleeding. 7. Explain the importance of life-long follow up regardless of treatments to determine the response to treatment and to detect spread of cancer. 8. Encourage all women to receive regular cervical cancer screening.

The HPV Vaccine The human papilloma virus (HPV) vaccine prevents infection with certain serotypes of humanpapilloma virus associated with the development of cervical cancer, genital warts, and some less common cancers. The HPV vaccine is recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series. Note: The vaccine is not recommended for pregnant women.