Cervical Cancer

1. Cervical Cancer Cindy Harding Shay Cargile ShellaMansell Patti Burris Joe Collie Ruby Cline

2. Objectives • 1.Risk Factors • 2.Clinical Manifestations • 3.How is the cancer diagnosed? • 4.Medical Treatment • Nutritional concepts • 5.Nursing Management

3. Risk Factors Several risk factors increase your chance of developing cervical cancer. Women without any of these risk factors rarely develop cervical cancer. Although these risk factors increase the odds of developing cervical cancer, many women with these risks do not develop this disease. When a woman develops cervical cancer or pre-cancerous changes, it may not be possible to say with certainty that a particular risk factor was the cause.

4. Risk Factors • Human papilloma virus infection: The most important risk factor for cervical cancer is infection by the human papilloma virus (HPV). HPV is a group of more than 100 related viruses. They are called papilloma viruses because some of them cause a type of growth called a papilloma.

5. Risk Factors • Papillomas are not cancers, and are more commonly called warts. HPV is passed from one person to another during skin-to-skin contact. HPV can be spread during sex - including vaginal intercourse, anal intercourse, and even during oral sex.

6. Risk Factors • Certain types of HPV are called "high-risk" types because they are often the cause of cancer of the cervix. These types include HPV 16, HPV 18, HPV 31, HPV 33, and HPV 45, as well as some others. About two-thirds of all cervical cancers are caused by HPV 16 and 18.

7. Risk Factors • Smoking: Women who smoke are about twice as likely as non-smokers to get cervical cancer. Smoking exposes the body to many cancer-causing chemicals that affect more than the lungs. These harmful substances are absorbed by the lungs and carried in the bloodstream throughout the body. Tobacco by-products have been found in the cervical mucus of women who smoke. Researchers believe that these substances damage the DNA of cervix cells and may contribute to the development of cervical cancer.

8. Risk Factors • Immunosuppression: Human immunodeficiency virus (HIV), the virus that causes AIDS, damages the body's immune system and seems to make women more at risk for HPV infections. This may be what increases the risk of cervical cancer in women with AIDS. Scientists believe that the immune system is important in destroying cancer cells and slowing their growth and spread. In women with HIV, a cervical precancer might develop into an invasive cancer faster than it normally would.

9. Risk Factors • Chlamydia infection: Chlamydia is a relatively common kind of bacteria that can infect the reproductive system. It is spread by sexual contact. Some studies have seen a higher risk of cervical cancer in women whose blood test results show past or current chlamydia infection (compared with women with normal test results). Infection with chlamydia often causes no symptoms in women. A woman may not know that she is infected at all unless she is tested for chlamydia when she gets her pelvic exam. Long-term chlamydia infection can cause pelvic inflammation, leading to infertility.

10. Risk Factors • Diet: Women with diets low in fruits and vegetables may be at increased risk for cervical cancer. Also overweight women are more likely to develop this cancer.

11. Risk Factors • Oral contraceptives (birth control pills): There is evidence that taking oral contraceptives (OCs) for a long time increases the risk of cancer of the cervix. Research suggests that the risk of cervical cancer goes up the longer a woman takes OCs, but the risk goes back down again after the OCs are stopped. In a recent study, the risk of cervical cancer was doubled in women who took birth control pills longer than 5 years, but the risk returned to normal 10 years after they were stopped.

12. Multiple pregnancies: Women who have had many full-term pregnancies have an increased risk of developing cervical cancer. No one really knows why this is true. One theory is this may be because some of the women may have been exposed more to HPV through un-protected sexual contact. Also, studies have pointed to hormonal changes during pregnancy as possibly making women more susceptible to HPV infection or cancer growth. Another thought is that the immune system of pregnant women might be weaker, allowing for HPV infection and cancer growth.

13. Risk Factors • Low socioeconomic status: Poverty is also a risk factor for cervical cancer. Many women with low incomes do not have ready access to adequate health care services, including Pap tests. This means they may not get screened or treated for pre-cancerous cervical disease.

14. Risk Factors • Diethylstilbestrol (DES): DES is a hormonal drug that was given to some women to prevent miscarriage between 1940 and 1971. Women whose mothers took DES (when pregnant with them) develop clear-cell adenocarcinoma of the vagina or cervix more often than would normally be expected. There is about 1 case of this type of cancer in every 1,000 women whose mothers took DES during pregnancy. This means that about 99.9% of "DES daughters" do not develop these cancers.

15. Risk Factors • Family history of cervical cancer: Cervical cancer may run in some families. If your mother or sister had cervical cancer, your chances of developing the disease are increased by 2 to 3 times. Some researchers suspect that some instances of this familial tendency are caused by an inherited condition that makes some women less able to fight off HPV infection than others. In other instances, women from the same family as a patient already diagnosed may be more likely to have one or more of the other non-genetic risk factors.

16. In office Colposcopy done after an abnormal pap smear result Vinegar solution is applied to cervix, abnormal tissue will turn white in color with a cobblestone appearance. A small biopsy is taken of the abnormal tissue to send to pathology

17. Clinical Manifestations • Early cervical cancer is often asymptomatic. • A woman usually develops symptoms when the cancer invades nearby tissues. • The first sign of disease is usually an abnormal pap smear.

19. Clinical ManifestationsSigns and Symptoms • Urinary disturbances- d/t proximity of the female reproductive system to the bladder and urethra, tumors or swelling can cause symptoms such as UTI’s, burning with urination, or bladder spasms. • Changes in the vulva or vagina-lumps, bumps, sores, or color changes • Increased vaginal discharge Abnormal vaginal bleeding( e.g. bleeding between periods, spotting after sexual intercourse, bleeding after menopause) *Most Common Symptom!* Abnormal vaginal discharge( yellow or odorous, may be tinged with blood) Low back pain Painful sexual intercourse(dyspareunia) Painful urination(dysuria) Pelvic Pain (below the umbilicus) GI disturbances- tumors or swelling pressing on the digestive system can cause symptoms such as constipation, diarrhea, gas, or a feeling of fullness regardless of the last meal. Any change in bowel habits that lasts 2-3 wks should be reported to the doctor.

20. Clinical ManifestationCervical Cancer that has spread or metastasized to the other organs may cause these symptoms: Constipation Blood in urine (hematuria) Abnormal opening in the cervix(Fistula) d/t leakage of urine or fecal content into the vagina Weight Loss Ongoing pelvic, leg, or back pain Anemia

21. How is the cancer diagnosed? • A Pap test is a simple procedure - Though not infallible, when performed properly the Pap smear detects a significant majority of cervical cancers - usually in the early stages when the likelihood of a cure is greatest, according to the American Society of Clinical Pathologists.

22. New Technology for Cervical Cancer Screening and Diagnosis • Newer liquid-based Pap tests such as ThinPrep and SurePath use a solution that helps preserve the cells scraped from the cervix (the Pap smear), as well as remove mucus, bacteria and other cells from the specimen that may interfere with examining the cervical cells. Test vials preserve specimens for up to three weeks from the date of collection, giving the physician an opportunity to request HPV testing on a patient if a borderline Pap test results. • The tests improve the detection of many lesions and reduce the need for unnecessary repeat tests.

23. Other technology includes: • AutoPap 300 QC Automatic Pap Screener System: a fully automated quality control system that re-screens all Pap smear slides for fewer false negative results-when tests fail to detect existing abnormalities. • Cervicography: creates enlarged photographs of the cervix to be used along with Pap tests. • papnet Testing System: a computer system that selects the 128 worst cells obtained by the Pap test for evaluation by a cytologist.

24. Other technology includes: • papSure: a cervical screening device with a tiny light attached to the speculum that enables a health care professional to directly visualize abnormalities at the time of the pelvic exam. The blue light on papSure is designed to cause abnormal tissue to appear bright white. • Pathfinder System: an automated computer-based microscope that helps cytotechnologists identify, mark and record suspicious cells on Pap tests.

25. These tests were designed to more accurately interpret Pap smear slides and to reduce the incidence of false negative results.

26. A Pap test is a screening tool; other procedures are necessary to confirm Pap test abnormalities and diagnose conditions. All abnormal Pap tests should have some form of follow-up. This may include a "watch and wait" approach with retesting in several months. Or, depending on the degree of abnormality, your health care provider may order other tests, including:

27. including: • Colposcopy: The doctor uses a colposcope to magnify and focus light on the vagina and cervix to view these areas in greater detail. Depending on these findings, your health care professional may then use one or more of the following tests: • Biopsy: During this procedure, sample tissue is taken from the cervical surface. Often several areas are biopsied. • Endocervical curettage: Cells are scraped from inside the cervical canal using a spoon-shaped instrument called a curette to help make a more precise diagnosis. This procedure evaluates a portion of the cervix that cannot be seen. • Cone biopsy: When biopsy or endocervical curettage reveals a problem that requires further investigation, a cone biopsy may be performed. A "cone" of tissue is removed from around the opening of the cervical canal. In addition to diagnosing an abnormality, cone biopsy can be used as a treatment to remove the suspect tissue. • Loop Electrocautery Excision Procedure (LEEP): The suspicious area is removed with a loop device and the remaining tissue is electrocoagulated (vaporized with radio waves). LEEP is both a diagnostic test and a treatment. A pathologist examines tissue removed during LEEP.

28. If cancer of the cervix is diagnosed, more tests will be conducted to learn if cancer cells have spread to other parts of the body. These tests may include: • Cystoscopy: This test is performed to see if the cancer has spread to the bladder. The doctor examines the inside of the bladder using a lighted tube. • Proctoscopy: Similar to a cystoscopy, this test is performed to see if the cancer has spread to the rectum. • Examination of the pelvis under anesthesia to check for further spread. • Chest x-ray to see if the cancer has spread to the lungs. • Other imaging tests such as CT (computed tomography) scans to see if the cancer has spread to lymph nodes or other organs.

29. HPV = Cervical Cancer • The key to curing cervical cancer is prevention. • Sexual abstinence • Monogamy • Condoms • Vaccination (Gardensil) • All these methods have shown to prevent HPV which in turn will greatly reduce the risk for cervical cancer. (nearly 100 percent preventable)

30. HPV • Regular screenings (PAP Smears) • There is no treatment for HPV, but most people’s bodies do eventually fight the virus off.  There are treatments for the health problems that HPV can cause—like genital warts, cervical cell changes, and cervical cancer. Once abnormal cells are treated (removed), you may need to get Pap tests more often to make sure they do not come back.

32. Medical Treatment Cervical Cancer • There are two types of cells on the cervix that can become malignant, squamous cells and glandular cells. The treatment of cervical cancer depends more on the severity of the disease (staging) than the cell type.

33. Medical Treatment • Squamous and glandular (adenocarcinomas) tumors are generally treated similarly although some feel that the adenocarcinomas have a worse prognosis when compared to the squamous type of cancer. In the United States, the majority of cervical carcinoma patients are diagnosed with early stage disease. Among the 13,458 patients with cervical carcinoma who were registered by the SEER program between 1973 and 1987, 71% were diagnosed with early disease (FIGO stage l-llA tumors). Most of these women with early lesions are cured with surgery or radiation (RT) alone

34. Medical Treatment • However, patients with metastatic disease or those with more advanced lesions are at significant risk of recurrence and account for the majority of cervical cancer deaths in the United States. These deaths occur despite current surgical and radiotherapy protocols.

35. Medical Treatment • Chemotherapy • intravenous cisplatin and fluorouracil every three weeks for four cycles • Adding paclitaxel, doubling the cisplatin dose, or adding ifosfamide all have been shown to increase response rates but not to a degree that results in prolonging the survival time.

36. Nursing Management & Nursing Considerations for Clients with Cervical Cancer

37. CANCER AND NUTRITION

38. Raw vegetables and vegetable juices fruit whole grains lightly cooked vegetables sweet potatoes white potatoes Beans yogurt small amounts of organically raised meat small amounts of poached fish nuts and/or nut milks herb teas vegetable soup cruciferous vegetables. Cancer experts recommend a 70% raw food diet (uncooked), however, others seem to feel that 50% is recommended Foods to Use

39. Foods to Use • Grains • Twenty percent of your diet should be whole grains. • Avoid all refined, polished grains and flours and products made from them. • Brown rice, kashi, millet, rye, buckwheat, barley, oats and oat brans, corn are recommended.

40. Foods to Use • Superfoods • Superfoods are: • alfalfa, barley, and wheat grasses, spirulina, chlorella, blue green algae, and certain sea weeds. • They are filled with minerals, nutrients, vitamins, and chlorophyll and can help your body detoxify.

41. Coffee tea Sugar white flour white rice Milk oils (except olive oil) liquor fried food meat from animals that have been raised with hormones or antibiotics citrus vitamins that are not indicated for you specifically refined salt Cocoa over-processed foods foods with additives and drugs (these include all over-the-counter remedies, i.e., pain relievers, antacids, cough and cold medicines). avoid all sugars any foods containing partially hydrogenated oils CANCER LOVES SUGAR FOODS TO ELIMINATE OR AVOID

42. FOODS TO ELIMINATE OR AVOID • Animal Products • Limit your animal products to two or three small (2 oz.) servings per week. • White fleshed fish (preferably cod, haddock, salmon, or trout), or white meat poultry are preferred. • Poultry and meat should be raised free range without additional hormones, antibiotics, and pesticides.

43. FOODS TO ELIMINATE OR AVOID • Fats and Oils • Most fats/oils should be kept to a minimum especially if they are human made or over processed • Sugars • All sugars are out. • Cancer loves sugar.

44. FOODS TO ELIMINATE OR AVOID • Avoid salt-cured, pickled, or smoked foods. • Avoid all processed foods and trans-fatty oils. • Avoid inorganically raised foods.

45. Foods that Fight Cancer • Fiber • A high fiber/low fat diet is a cancer preventer and fighter. • Starch • strong association between starch consumption and cancer of the large bowel, colon and rectum. • Cruciferous Vegetables • Cauliflower, broccoli, Brussels sprouts, cabbage, kale, and Chinese vegetables.

46. Nursing Management & Nursing Considerations for Clients with Cervical Cancer • The nursing management for a client with cervical cancer will vary depending on the medical treatment the client is having. For the nurse taking care of the client post-operatively, an assessment must be done to determine the priority of needs. • The nurse must assess post-operative pain related to surgery or radiation implant. Pain should be assessed frequently and managed so that it does not get out of control. A back rub may be especially helpful for a client who was in the lithotomy position during surgery. Massage the upper back and shoulders of clients with radium implants, who are not allowed position changes.

47. Nursing Management & Nursing Considerations • The nurse will monitor for fluid volume deficit due to operative, post-operative or post-implant bleeding. Assess post-operative bleeding every 2-4 hrs by noting the amount and quality of drainage on dressings and perineal pads. If an implant is in place, check for vaginal bleeding, a sign that erosion is occurring. If a closed drainage system is used, note the amount of drainage and report drainage greater than 50ml/hr for 2 hrs. Inspect the abdomen for distention and assess client for presence of severe abdominal pain. Both are indicators of internal bleeding. Review CBC lab values for evidence of bleeding. Inform the client and significant other about the signs of excessive bleeding and the need to alert staff immediately if they occur. Monitor vital signs every 2-4 hrs during the first 24 hrs after surgery. Be alert to indicators of hemorrhage and impending shock.

48. Nursing Management & Nursing Considerations • The nurse will monitor intake & output and document every shift. Notify the health care provider if the urine output falls below 30ml/hr for 2 hrs in the presence of adequate intake. Ensure patency of an indwelling catheter. Administer oral and parenteral fluids as prescribed. Assess for bladder distention by inspecting the suprapubic area and percussing or palpating the bladder. • The nutritional management of the client with cervical cancer focuses on maximizing the intake of nutrients and fluids. The nurse should use creative approaches to manage alterations in taste and smell. Clients with cancer typically complain of anorexia and taste distortions and most cancer treatments cause nutritional problems.

49. Nursing Management & Nursing Considerations • Before discharge from the hospital, the nurse should make sure the client and significant other are able to clarify any questions or concerns they may have as well as be able to communicate concerns with each other. • When providing patient – family teaching, the nurse should focus on sensory information and avoid giving excessive information, which may be overwhelming to the client. The nurse may provide materials by organizations such as the American Cancer Society and arrange for a contact person from such an organization if appropriate. It may be beneficial for the nurse to initiate a visiting nurse referral for any necessary follow up teaching.