Republic of the Philippines
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal St. Extension, West Rembo, Makati City
1215 Philippines
Center of Nursing
Uterine Cancer
(Endometrial carcinoma)
&
Prostate Cancer
In Partial Fulfillment of the Requirements for the Degree of Bachelor of Science in Nursing
Submitted by:
Templo, Sheana Camille T.
Submitted to:
Prof. Clement John Nevarette, RN, MAN, PhD
July 2017
Endometrial Carcinoma (Uterine Cancer)
Endometrial cancer starts when cells in the inner lining of the uterus (endometrium)
begin to grow out of control. Cells in nearly any part of the body can become
cancer, and can spread to other areas of the body.
Illustration showing the fallopian tubes, body of uterus, vagina and cervix
About the uterus and endometrium
The uterus is a hollow organ, which is normally about the size and shape of a
medium-sized pear. The uterus is where a fetus grows and develops when a woman
is pregnant. The uterus has 2 main parts (see image below):
The cervix is the lower end of the uterus that extends into the vagina.
The upper part of the uterus is called the body or the corpus. (Corpus is the Latin
word for body.)
Although the cervix is technically part of the uterus, when people talk about cancer
of the uterus, they usually mean the body, not the cervix.
illustration showing the female reproductive organs including location of
endometrium, myometrium, serosa, fallopian tubes, ovaries, cervix and vagina
The body of the uterus has 2 main layers. The inner layer or lining is called the
endometrium. The outer layer of muscle is known as the myometrium. This thick layer
of muscle is needed to push the baby out during birth. The tissue coating the outside
of the uterus is the serosa.
During a woman's menstrual cycle, hormones cause the endometrium to change.
During the early part of the cycle, before the ovaries release an egg (ovulation), the
ovaries produce hormones called estrogens. Estrogen causes the endometrium to
thicken so that it could nourish an embryo if pregnancy occurs. If there is no
pregnancy, estrogen is produced in lower amounts and more of the hormone
called progesterone is made after ovulation. This prepares the innermost layer of the
lining to shed. By the end of the cycle, the endometrial lining is shed from the uterus
and becomes the menstrual flow (period). This cycle repeats until the womans goes
through menopause (change of life).
There are many variants (or sub-types) of endometrioid cancers including:
Adenocarcinoma, (with squamous differentiation)
Adenoacanthoma
Adenosquamous (or mixed cell)
Secretory carcinoma
Ciliated carcinoma
Villoglandular adenocarcinoma
Clear-cell carcinoma, mucinous adenocarcinoma, and papillary serous
adenocarcinoma are less common types of endometrial adenocarcinomas. These
types tend to be more aggressive than most endometrial cancers. They tend to
grow quickly and often have spread outside the uterus at the time of diagnosis.
The following factors may raise a womans risk of developing uterine cancer:
Age. Uterine cancer most often occurs in women over 50; the average age is 60.
Obesity. Fatty tissue in women who are overweight produces additional
estrogen, a sex hormone which can increase the risk of uterine cancer. This risk
increases with an increase in body mass index (BMI; the ratio of a person's weight
and height). About 40% of cases are linked to obesity.
Race. White women are more likely to develop uterine cancer than black
women.
Genetics. Uterine cancer may run in families where colon cancer is hereditary.
For instance, women in families with Lynch syndrome or hereditary non-polyposis
colorectal cancer (HNPCC), have a higher risk for uterine cancer. It is
recommended that women under the age of 60 with endometrial cancer should
have their tumor tested for Lynch Syndrome even if they dont have a family
history of bowel cancer or other cancers. About 2% to 5% of women with
endometrial cancer have Lynch Syndrome. In the United States, about 1,000 to
2,500 women diagnosed with endometrial cancer each year may have this
genetic condition. Read about Lynch Syndrome.
Other health conditions. Women may have an increased risk of uterine cancer if
they have had endometrial hyperplasia or if they have diabetes.
Other cancers. Women who have had breast cancer, colon cancer or ovarian
cancer may have inherited a genetic mutation (a change) that also causes an
increased risk of uterine cancer. Such gene mutations
include PTEN, MLH1, MSH2, MSH6, PMS2, and possibly BRCA1/2. Women should
discuss the possibility of having a genetic mutation with their doctors and, in
some cases, with an expert genetic counselor.
Tamoxifen. Women taking the drug tamoxifen (Nolvadex) to prevent or treat
breast cancer have an increased risk of developing uterine cancer. However,
the benefits of tamoxifen usually outweigh the risk of developing uterine cancer,
but all women should discuss the benefits and risks of tamoxifen with their doctor.
Radiation therapy. Women who have had previous radiation therapy for another
cancer in the pelvic area, which is the lower part of the abdomen between the
hip bones, have an increased risk of uterine cancer.
Diet. Women who eat foods high in animal fat may have an increased risk of
uterine cancer.
Estrogen. Longer exposure to estrogen and/or an imbalance of estrogen is
relevant to many of the following risk factors:
Women who started having their periods before age 12 and/or go
through menopause later in life. Learn more about menopause and
cancer risk.
Women who take hormone replacement therapy (HRT) after menopause,
especially if they are only taking estrogen, which is also an important risk
factor. The risk is lower for women taking estrogen with another sex
hormone called progesterone.
Women who have never been pregnant.
Pathophysiology
Oestrogen: the ability of oestrogen to function as a mitogen is clear, while
its ability to act as a mutagen in stimulating cellular division and organ
growth is controversial. The former effects seem to occur via stimulation of
the transcription of genes for cyclin D, proto-oncogenes, growth factors,
and growth factor receptors. Oestrogen may affect the expression of
genes, leading to altered regulation of cellular signals in the development
of endometrial hyperplasia. PTEN (phosphatase and tensin homologue)
gene mutation with loss of expression of the PTEN protein is an early event
in this progression, while mutations of ras and mismatch repair genes
occur later.
PTEN tumour suppressor gene mutation: paraffin tissue
immunohistochemistry (IHC) with anti-PTEN antibody shows that over half
of endometrioid endometrial adenocarcinomas and their precursor IEN
lesions have lost PTEN protein.
K-ras gene mutation: endometrioid adenocarcinomas, which are
oestrogen-dependent (and account for 80% of all endometrial cancers),
contain K-ras mutations in 20% of cases.
Microsatellite instability and mismatch repair (MMR) genes: endometrioid
adenocarcinomas, which are oestrogen-dependent, show microsatellite
instability in 20% to 30% of cases. Germline mutations in the mismatch-
repair genes MLH1, MSH2, MSH6, and PMS2 lead to the development of
the Lynch syndrome (hereditary non-polyposis colon cancer [HNPCC]),
conferring a strong susceptibility to cancer, including endometrial,
ovarian, and colon cancer.
p53 gene mutation: mutation of the p53 tumour suppressor gene is not
found in endometrial hyperplasia, but can be detected in 20% of cases of
endometrioid carcinoma and in more than 90% of serous tumours of the
endometrium (which are oestrogen-independent and arise from atrophic,
rather than hyperplastic, endometrium).
HER-2/neu gene mutation: uterine serous carcinoma (USC), a biologically
distinct subtype of endometrial cancer, metastasises early with a pattern
of spread similar to serous ovarian cancer (transcelomically to the
peritoneum) and may be associated with developing p53 mutations, DNA
repair abnormalities, and HER-2/neu over-expression or amplification.
Stages of endometrial cancer include:
Stage I cancer is found only in your uterus.
Stage II cancer is present in both the uterus and cervix.
Stage III cancer has spread beyond the uterus, but hasn't reached the rectum
and bladder. The pelvic area lymph nodes may be involved.
Stage IV cancer has spread past the pelvic region and can affect the bladder,
rectum and more-distant parts of your body.
Symptoms of uterine cancer
Uterine cancer can cause different signs and symptoms as the cancer grows. Other
health conditions can cause the same symptoms as uterine cancer.
The most common symptom of uterine cancer is abnormal vaginal bleeding. This
includes a change in menstruation (heavier periods, periods that last longer or periods
that occur more often than normal), bleeding between periods, bleeding after
menopause or spotting.
Other signs and symptoms of uterine cancer include:
unusual vaginal discharge, which can be foul-smelling, pus-like or blood-tinged
pain during intercourse
pelvic pain or pressure
pain during urination, difficult urination or blood in the urine
pain during bowel movements, difficult bowel movements or blood in the stool
bleeding from the bladder or rectum
buildup of fluid in the abdomen (called ascites) or in the legs (called
lymphedema)
weight loss
lack of appetite
difficulty breathing
Diagnostic Procedures:
Office endometrial biopsy
o Generally accepted as the first step in the diagnosis of endometrial
cancer in the patient with postmenopausal bleeding. It will diagnose up
to 90% of endometrial cancers depending on technique and the
experience of the operator. The use of office biopsies has proven cost-
effective by reducing the number of women who will need a curettage
under general anesthesia.
The technique of dilatation & curettage (D&C) is still the gold standard for
the diagnosis of endometrial cancer. If the office biopsy is negative or
inadequate, if the endometrial thickness by ultrasound is greater than 5
mm, or if there is a high degree of suspicion, the patient will need
curettage under anesthesia to exclude malignancy.
Dilation and curettage (D&C)
o Formal curettage is typically reserved for patients with negative or
inadequate endometrial biopsies and either continued symptomatic
genital bleeding or high-risk factors for endometrial cancer.
Hysteroscopy
o With the D&C, hysteroscopy is a helpful tool in providing a diagnosis for
abnormal bleeding and guiding directed biopsies of suspicious areas.
Hysteroscopy can also be useful in evaluation of the endocervical canal.
Sonohysterography (SHG)
o Rarely used in diagnosis of endometrial cancer for the same reasons as
hysteroscopy. Information obtained from SHG includes tumor size, site of
origin, and cervical involvement. Though this correlates to intraoperative
findings, it contributes little to the preoperative management plan. It is
more useful when the suspicion of endometrial cancer is low. Most
physicians opt for formal D&C without hysteroscopy.
Treatment
Treatment depends on the stage and grade of the cancer and the general health of the
woman.
Stage 1a cancers, surgery with total abdominal hysterectomy and bilateral salpingo-
oopherectomy is usually sufficient treatment.
Women with stage 1b or 2 disease adjuvant pelvic radiotherapy is given, which reduces
the rate of local recurrence.
Radiotherapy may be used as the primary treatment in women unfit to undergo surgery
or in women with locally advanced disease (stage 3 and 4a).
Chemotherapy using carboplatin and paclitaxel, or cisplatin and doxorubicin can
improve disease control and symptoms in patients with recurrent disease but the impact
on survival is limited.
Prognosis
Endometrial cancer has the best prognosis of all the gynecological cancers.
Poor prognostic indicators include older age, advanced stage, high-grade tumors and
adenosquamous histology.
Nursing diagnosis
1. Anticipatory Grieving
2. Situational Low Self-Esteem
3. Acute Pain
4. Altered Nutrition: Less Than Body Requirements
5. Risk for Fluid Volume Deficit
6. Fatigue
7. Risk for Infection
8. Risk for Altered Oral Mucous Membranes
9. Risk for Impaired Skin Integrity
10. Risk for Constipation/Diarrhea
11. Risk for Altered Sexuality Patterns
12. Risk for Altered Family Process
13. Fear/Anxiety
Nursing Intervention
1. Listen to the patients fears and concerns, and offer reassurance when appropriate.
2. Encourage the patient to use relaxation techniques to promote comfort during the
diagnostic procedures.
3. Monitor the patients response to therapy through frequent tests and biopsies as ordered.
4. Watch for complications related to therapy by listening to and observing the patient.
5. Monitor laboratory studies and obtain frequent vital signs.
6. Understand the treatment regimen and verbalize the need for adequate fluid and
nutritional intake to promote tissue healing.
7. Explain any surgical or therapeutic procedure to the patient, including what to expect
both before and after the procedure.
8. Review the possible complications of the type therapy ordered.
9. Remind the patient to watch for and report uncomfortable adverse reactions.
10. Reassure the patient that this disease and its treatment shouldnt radically alter her
lifestyle or prohibit sexual intimacy.
Explain the importance of complying with follow up visits to the gynecologist and oncologist.
WHAT IS THE PROSTATE?
Only men have a prostate. It is a small gland that
sits below the bladder near the rectum. It
surrounds the urethra, the passage in the penis
through which urine and semen pass.
The prostate gland is part of the male
reproductive system. It produces most of the fluid
that makes up semen that enriches sperm. The
prostate needs the male hormone testosterone
to grow and develop.
The prostate is often described as being the size
of a walnut and it is normal for it to grow as men
age. Sometimes this can cause problems, such
as difficulty urinating. These problems are
common in older men and not always symptoms
or signs of cancer.
What is prostate cancer?
Prostate cancer occurs when abnormal cells develop in the prostate. These abnormal
cells can continue to multiply in an uncontrolled way and sometimes spread outside
the prostate into nearby or distant parts of the body.
Prostate cancer is generally a slow growing disease and the majority of men with low
grade prostate cancer live for many years without symptoms and without it spreading
and becoming life-threatening. However, high grade disease spreads quickly and can
be lethal. Appropriate management is key.
WHAT ARE THE SYMPTOMS?
In the early stages, there may be no symptoms. In the later stages, some symptoms of
prostate cancer might include:
Feeling the frequent or sudden need to urinate
Finding it difficult to urinate (for example, trouble starting or not being able to
urinate when the feeling is there or poor urine flow)
Discomfort when urinating
Finding blood in urine or semen
Pain in the lower back, upper thighs or hips.
These symptoms may not mean you have prostate cancer, but if you experience
any of them, go and see your doctor.
Pathophysiology
WHAT ARE THE RISK FACTORS?
Factors that are most strongly linked to an increased chance of developing prostate
cancer:
Age: Prostate cancer is an age-dependent disease, which means the chance of
developing it increases with age. The risk of getting prostate cancer by the age of 75 is
1 in 7 men. By the age of 85, this increases to 1 in 5.
Family history: If you have a first degree male relative with prostate cancer, you have a
higher chance of developing it than men with no such history. The risk increases again if
more than one male relative has prostate cancer. Risks are also higher for men whose
male relatives were diagnosed when young.
OTHER FACTORS THAT MAY INCREASE THE RISK OF DEVELOPING PROSTATE CANCER:
Factors that are most strongly linked to an increased chance of developing prostate
cancer:
Genetics: Genes are found in every cell of the body. They control the way the cells in
the body grow and behave. Every person has a set of many thousands of genes
inherited from both parents. Changes to genes can increase the risk of prostate cancer
being passed from parent to child. Although prostate cancer cant be inherited, a man
can inherit genes that can increase the risk.
Diet: There is some evidence to suggest that eating a lot of processed meat or food
that is high in fat can increase the risk of developing prostate cancer.
Lifestyle: There is evidence to show that environment and lifestyle can affect the risk of
developing prostate cancer.
HOW IS PROSTATE CANCER DETECTED AND DIAGNOSED?
A doctor will usually do a blood test and/or physical examination to check the
health of the prostate.
Blood test (Prostate Specific Antigen (PSA) test): The result shows whether there is an
increase in this specific protein. Depending on the result, you might need further
investigation by a specialist. A high PSA test result does not necessarily mean cancer.
Prostate diseases other than cancer can also cause a higher than normal PSA level.
Digital Rectal Examination (DRE): Because of where the prostate is located, the doctor
inserts a gloved, lubricated finger into the rectum to check the size of the prostate and
assess if there are any abnormalities. A normal DRE result does not rule out prostate
cancer.
DIAGNOSIS
If your tests show you may be at risk of prostate cancer, the next step is a biopsy.
A biopsy is the only way a firm diagnosis of prostate cancer can be made.
An urologist removes small samples of tissue from your prostate, using very thin,
hollow needles guided by an ultrasound. The prostate is either accessed through
the rectum (transrectal) or the perineum (transperineal), which is the area
between the anus and the scrotum. A biopsy is usually done as an out-patient
procedure and the doctor will likely advise a course of antibiotics afterwards to
reduce the chance of infection. The tissue is sent to a pathologist to identify
whether the cells are malignant (cancerous) or benign (not cancerous).
Treatment
Hormone therapy
Hormone therapy is treatment to stop your body from producing the male hormone
testosterone. Prostate cancer cells rely on testosterone to help them grow. Cutting
off the supply of hormones may cause cancer cells to die or to grow more slowly.
Hormone therapy options include:
Medications: luteinizing hormone-releasing hormone (LH-RH) agonists prevent the
testicles from receiving messages to make testosterone.
E.g. leuprolide (Lupron, Eligard), triptorelin (Trelstar) and histrelin (Vantas). Other
drugs sometimes used include ketoconazole and abiraterone (Zytiga).
anti-androgens prevent testosterone from reaching your cancer cells.
Examples include bicalutamide (Casodex), flutamide, and nilutamide (Nilandron).
The drug enzalutamide (Xtandi) may be an option when other hormone therapies
are no longer effective.
Freezing prostate tissue
Cryosurgery or cryoablation involves freezing tissue to kill cancer cells.
During cryosurgery for prostate cancer, small needles are inserted in the prostate
using ultrasound images as guidance. A very cold gas is placed in the needles,
which causes the surrounding tissue to freeze. A second gas is then placed in the
needles to reheat the tissue. The cycles of freezing and thawing kill the cancer cells
and some surrounding healthy tissue.
Initial attempts to use cryosurgery for prostate cancer resulted in high
complication rates and unacceptable side effects. However, newer technologies
have lowered complication rates, improved cancer control and made the
procedure easier to tolerate. Cryosurgery may be an option for men who haven't
been helped by radiation therapy.
Biological therapy
Biological therapy (immunotherapy) uses your body's immune system to fight
cancer cells. One type of biological therapy called sipuleucel-T (Provenge) has
been developed to treat advanced, recurrent prostate cancer.
This treatment takes some of your own immune cells, genetically engineers them
in a laboratory to fight prostate cancer, then injects the cells back into your body
through a vein. Some men do respond to this therapy with some improvement in
their cancer, but the treatment is very expensive and requires multiple treatments.
Radiation therapy
Radiation therapy uses high-powered energy to kill cancer cells. Prostate cancer
radiation therapy can be delivered in two ways:
Radiation that comes from outside of your body (external beam radiation). During
external beam radiation therapy, you lie on a table while a machine moves around
your body, directing high-powered energy beams, such as X-rays or protons, to your
prostate cancer. You typically undergo external beam radiation treatments five
days a week for several weeks.
Radiation placed inside your body (brachytherapy). Brachytherapy involves placing
many rice-sized radioactive seeds in your prostate tissue. The radioactive seeds
deliver a low dose of radiation over a long period of time. Your doctor implants the
radioactive seeds in your prostate using a needle guided by ultrasound images. The
implanted seeds eventually stop giving off radiation and don't need to be removed.
Side effects of radiation therapy can include painful urination, frequent urination
and urgent urination, as well as rectal symptoms, such as loose stools or pain when
passing stools. Erectile dysfunction can also occur.
Chemotherapy
Chemotherapy uses drugs to kill rapidly growing cells, including cancer cells.
Chemotherapy can be administered through a vein in your arm, in pill form or both.
Chemotherapy may be a treatment option for men with prostate cancer that
has spread to distant areas of their bodies. Chemotherapy may also be an option
for cancers that don't respond to hormone therapy.
including docetaxel (Taxotere), cabazitaxel (Jevtana) and mitoxantrone
(Novantrone).
Surgery to remove the prostate
Surgery for prostate cancer involves removing the prostate gland (radical
prostatectomy), some surrounding tissue and a few lymph nodes.
Nursing Diagnosis and Nursing Interventions
1. Impaired Urinary Elimination related to an enlarged prostate, and bladder
distension.
Intervention:
Encourage the patient to urinate every 2-4 hours and when it suddenly felt.
Observation of the flow of urine, note the size and strength.
Percussion / palpation of the suprapubic area.
Encourage fluid intake to 3000 ml per day.
Monitor vital signs closely
Collaboration in the provision of drugs.
2. Risk for Infection related to invasive procedures (tools during surgery)
Intervention:
Maintain a sterile catheter system, provide catheter care and give regular antibiotic
ointment around the catheter.
Perform ambulation with dependent drainage bag.
Observation of wound drainage around suprapubic catheter.
Replace dressings with frequent (supra incision / retropubic and perineal), cleaning and
drying of the skin over time.
Collaboration in the provision of antibiotics.
3. Imbalanced Nutrition, Less Than Body Requirements related to the nausea and
weight loss
Intervention:
Assess the patient's nutritional status.
Encourage the patient to eat small amounts frequently.
Collaborate with a nutritionist.
Collaborate with the physician in the delivery of antiemetic drugs.
REDUCING THE RISK OF DEVELOPING PROSTATE CANCER
There is no evidence that the following protective factors can stop prostate cancer
from developing, but they can improve your overall health and possibly reduce the risk
of prostate cancer:
Diet: Eat meals that are nutritious. Refer to the Australian Guide to Healthy Eating.
What is good for the heart is good for the prostate.
Physical activity/exercise: There is some evidence to show that physical activity and
regular exercise can be protective factors for cancer. Try to exercise at least 30
minutes of a day.
