Cervical cancer

Presented by
Shashi Tripathi
 Introduction
• Cervical cancer occurs when abnormal cells on
the cervix grow out of control. The cervix is the
lower part of the uterus that opens into the vagina.
Cervical cancer can often be successfully treated
when it's found early. It is usually found at a very
early stage through a Pap test.
• Pap smear has reduced the incidence of cervical
cancer by nearly 80% and death by 70%.
 Epidemiology
• In India the prevalence is more amongst the comparatively younger age
group. Carcinoma cervix is rare in women who are sexually not active
(nuns, virginal women).

• Worldwide, cervical cancer is second most common and the fifth

deadliest cancer in women. It affects about 16 per 100,000 women per
year and kills about 9 per 100,000 per year. Approximately 80% of
cervical cancers occur in developing countries Worldwide, in 2008, it
was estimated that there were 473,000 cases of cervical cancer, and in
2010 225,000 deaths.
 Gross pathology
• The site of the lesion is predominantly in the ectocervix
(80 %) and rest (20%) are in the endocervix.
Etiology

• Infection with some types of human papilloma virus

(HPV) is the greatest risk factor for cervical cancer,
followed by smoking. Other risk factors include human
immunodeficiency virus. Not all of the causes of
cervical cancer are known, however, and several other
contributing factors have been implicated.
 Human papillomavirus

• Human papillomavirus type 16 and 18 are the cause of

75% of cervical cancer globally while 31 and 45 are the
cause of another 10%.
• Women who have many sexual partners (or who have
sex with men who have had many other partners) have a
greater risk
• Of the 150-200 types of HPV known, 15 are classified as
high-risk types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58,
59, 68, 73, and 82), 3 as probable high-risk (26, 53, and
66), and 12 as low-risk (6, 11, 40, 42, 43, 44, 54, 61, 70,
72, 81, and CP6108).
• Smoking
• Genetic
• Other sexually transmitted infections
• A weakened immune system
• Oral contraceptive pill
• Social Class
• Pregnancy
 Clinical manifestation
• The early stages of cervical cancer may be completely
asymptomatic
• Symptoms of advanced cervical cancer may include-:
 Loss of appetite
 Weight loss
 Fatigue
 Pelvic pain
 Back pain
 Leg pain
• Swollen legs
• Heavy bleeding from the vagina
• Leakage of urine
• Pelvic pain
• Pain during sexual intercourse( dysperiunia)
•
Staging
• Stage I: Cancer cells are found only in the cervix.
• Stage II: The tumor has grown through the cervix and invaded
the upper part of the vagina. It may have invaded other nearby
tissues but not the pelvic wall (the lining of the part of the
body between the hips) or the lower part of the vagina.
• Stage III: The tumor has invaded the pelvic wall or the lower
part of the vagina. If the tumor is large enough to block one or
both of the tubes through which urine passes from the kidneys,
lab tests may show that the kidneys aren't working well.
• Stage IV: The tumor has invaded the bladder or rectum. Or,
the cancer has spread to other parts of the body, such as the
lungs.
 Stage I: Cancer cells are found only in the cervix.

• Stage Ia-: preclinical carcinoma of the cervix that is,

those diagnosed only by microscopy.
• Stage Ia1-: minimal microscopically event stromal
invasion, not exceeding 3mm.
• Stage Ia2-: microscopically measured invasion greater
than 3mm, and not greater than 5mm.
• StageIb1-: lesion not exceeding 4cm.
• stageIb2-: lesion exceed 4cm in size.
 Stage II: The tumor has grown through the cervix
and invaded the upper part of the vagina. It may
have invaded other nearby tissues but not the
pelvic wall (the lining of the part of the body
between the hips) or the lower part of the vagina.

• Stage IIa-: no obvious parametrical involvement.

• Stage Iib-:obvious parametrical involvement
Stage III: The tumor has invaded the
pelvic wall or the lower part of the vagina.
If the tumor is large enough to block one or
both of the tubes through which urine
passes from the kidneys, lab tests may
show that the kidneys aren't working well.

• Stage IIIa-: no extension to the pelvic wall but to the

lower third of vagina.
• Stage IIIb-: extension in to the pelvic wall and/ or
hydronephrosis or nonfunctioning kidney.
Stage IV: The tumor has invaded the bladder
or rectum. Or, the cancer has spread to other
parts of the body, such as the lungs.
• Stage IVa-: spread of growth to adjacent organs.
• Stage Ivb-: spread to distant organs.
•
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 Mode of spread
• Direct Extension
common pattern of spread is distal, to involve the vaginal
fornices and later (and with larger volume tumors) the
midportion and distal third of the vagina. It may spread
posteriorly to involve the rectum or the uterosacral
ligaments. Rectal spread is usually associated with
posterior vaginal involvement. Anterior spread to the
bladder is unusual in the absence of large-volume tumors
with parametrial extension.
 Lymphatic
• The primary group involved are-:
Parametrical nodes, internal iliac nodes, obdurate external
iliac nodes and sacral node.
Secondary nodes involved are-:
Common iliac group the inguinal nodes are par aortic
nodes.
Haematogenous Spread
Blood borne metastasis is late and usually by veins rather
than the arteries.
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 Diagnostic test
• History
• Physical examination ( pelvic examination)
• Biopsy
• Pap test
• CT scan
• MRI
• Colposcopy
• Lymph node palpation
• Endo cervial curettage
• Blood test
 Physical examination ( pelvic examination)

• A pelvic examination carried out under general

anaesthetic – women womb, vagina, rectum and bladder
will be checked for cancer
Biopsy
Pap test

• A Pap smear, also called

a Pap test, is a procedure
to test for cervical cancer
in women. A Pap smear
involves collecting cells
from patient cervix —
the lower, narrow end of
patient uterus that's at the
top of patient vagina.
 CT scan
• Scans are taken of the inside of patient body and a
computer is used to assemble them into a detailed
three-dimensional image; this is useful for showing up
cancerous tumours and checking whether the
cancerous cells have spread.

• MRI-: This type of scan uses strong magnetic fields and

radio waves to produce detailed pictures of the inside
of patient body; it can also be used to check whether
cancer has spread.
 Colposcopy
• During a colposcopy, a small microscope with a light
source at the end (colposcope) is used. As well as
examining patient cervix, patient gynaecologist may
remove a small tissue sample (biopsy) so that it can be
checked under a microscope for cancerous cells.
Endo cervial curettage

• A procedure that uses a

small, spoon-shaped
instrument called a curette to
scrape tissue from inside the
cervical opening.
• If the area of abnormal cell
growth is small, these biopsy
procedures may be able to
remove all of the affected
area. The tissue removed
during biopsy is sent to a
laboratory to be analyzed.
Blood test

• Blood tests – these can be used to help assess

the state of liver, kidneys and bone marrow
• CA 125 blood test, this test is tumor marker .
 Treatment
• Surgery
• Radiation therapy
• Chemotherapy
Surgery
• Abdominal hysterectomy. The uterus is removed
through an incision in the abdomen.
• Vaginal hysterectomy. The uterus is removed through
the vagina.
• Laparoscopic hysterectomy. The operation is performed
using surgical instruments inserted through small
incisions.
 Radical Trachelectomy

• Radical trachelectomy is a surgical procedure that

removes the cervix, upper part of the vagina and lymph
nodes in the pelvis to treat early stage cervical cancer.
Some women may be given chemotherapy before having
a radical trachelectomy to try to shrink the size of the
cervical tumour.
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 Radiotherapy
• Brachytherapy
• Low dose rate (LDR) brachytherapy
• High dose rate (HDR) brachytherapy
• Pulsed dose rate (PDR) brachytherapy

Low dose rate (LDR) brachytherapy-: uses sources that

give out a low level of radiation. To deliver the total dose
of radiation, the sources have to remain next to the
cancer for an extended period of time. Therefore,
treatment is usually spread out over the course of one
week and requires a stay in hospital
• high dose rate (HDR) brachytherapy-:
• uses sources that give out a higher level of radiation. The
total dose of radiation can therefore be given in shorter
sessions than LDR brachytherapy.1 As such, patients can
often receive treatment on an outpatient basis (i.e. you
may not need an overnight stay in hospital). However,
each session of treatment has to be spread out. Typically,
2-5 short sessions of treatment are required, each a few
days to a week apart. HDR brachytherapy is more
commonly used to treat cervical cancer than LDR
brachytherapy as it is often more convenient for
patients.
• Pulsed dose rate (PDR) brachytherapy -:
• is a cross between LDR and HDR brachytherapy. It
provides short pulses of radiation to the cancer using a
source that gives out a high level of radiation. However
these pulses are spread out (e.g. one short pulse every
hour) so that it simulates LDR brachytherapy
Chemotherapy
• Early-stage and locally advanced cervical cancer
• Chemotherapy may be used to treat larger tumours that
are just in the cervix or those that have spread locally (to
the surrounding area). It’s commonly combined with
radiotherapy to make the radiotherapy more effective –
this is called chemoradiation. Usually the chemotherapy
is given once a week during the course of radiotherapy.
• Advanced-stage cancer
• Chemotherapy may also be given to women whose
cancer has spread to other parts of the body. It’s used
in this situation to try to shrink and control the cancer
and relieve symptoms, to prolong a good quality of life.
In some women the chemotherapy will achieve this.
Unfortunately for others the chemotherapy will not
shrink the cancer, and in this situation the treatment
will be stopped to avoid the side effects it may cause
 Prevention
• Screening-: Pap smear for cervical cancer has been
credited with dramatically reducing the number of cases
of and mortality from cervical cancer in developed
countries
• Vaccination-: There are two HPV vaccines (Gardasil and
Cervarix) which reduce the risk of cancerous or
precancerous changes of the cervix and perineum by
about 93%.
• Condoms-: Prevent the sexually transmitted disease.

• Nutrition-: Vitamin A is associated with a lower risk as is

vitamin B12, vitamin C, vitamin E, and beta-carotene.
 Nursing management
• Take the proper history from the patient.
• Complete physical examination.
• Preoperative care
• Post operative care
• Care after chemotherapy
 Nursing diagnosis
• Acute pain related to an enlarge tumor or surgical
incision manifestated by verbalization of patient
• Anxiety related to the threat of a malignancy and lack
of knowledge about of the disease process and
prognosis manifested by patient
• Disturbed body image related to the loss of body part
and loss of good health manifested by