CARCINOMA OF THE

CERVIX
Prepared by Mrs. V. Tshabadira
Anatomy of the female reproductive
system
The normal cervix
Cervical cancer
Definition
The term cancer, abbreviated Ca is a
collective term describing a large group of
diseases characterized by uncontrolled
group and spread of abnormal cells.
Ca cervix is a common malignancy in
women, preceded by several earlier
cervical changes evident only on
histological examination.
Classification
Two major types
1. Squamous cell cancers - from the Squamous
epithelium that covers the visible part of the cervix.
Squamous papilloma – benign
Squamous cell carcinoma – malignant

2. Adenocarcinomas/cystadenocarcinoma (malignant)
from the glandular lining of the endocervical canal.
About 85% of cervical cancers are Squamous cell
cancers.
INCIDENCE
Age group …………….No.
15 – 24 1
24 – 34 40
35 – 44 62
45 – 54 91
55 – 64 75
65+ 88
Not specified 11
TOTAL 368

Source: Epidemiology unit 2003

Etiology
Human Papilloma Virus (HPV) -
transmitted sexually
Condyloma virus

These alters the DNA of nuclei of immature

cervical cells
CARCINOGENESIS
Involves genetic changes in the affected
cell, especially those responsible for
regulating cell growth
Proto-oncogenes…promote normal
growth, maybe converted to cancer
causing genes - oncogenes
Predisposing factors
 Early sexual activity
 Multiple sexual partners
 Age
 Sex
 Low socio-economic status
 Use of birth control pills – less likely to use condoms
 HIV infection – lowers immunity
 Infections with sexually transmitted infections, may increase risk.
 Multiparity
 Smoking and alcohol ingestion
 Type of employment – mining
 Exposure to radiation – ultra violet(sun), ionizing radiation(x-rays)
 Viral infections - some
Pathophysiology
Chronic inflammatory responses, hormonal dysfunctions - - Alteration in DNA
of the nuclei of cells ( proto-oncogene – oncogenes --- ( ontogenesis) loss of
normal maturation

Gradual development of carcinoma in situ

Persistent cellular stimulation

(Atypical hyperplasia with atypia)

Cellular proliferation with cell abnormality
and invasive ca
Spreading to underlying connective tissues
(vaginal mucosa, lower uterine segment,
pelvic wall, bladder, bowel)
Pathophysiology CONT..
destruction of tissues

Cancers must make new blood vessels as they grow

Building of a supportive framework (stroma) to
supply tumor with oxygen + nutrients

blood vessels abnormal and break easily –

includes fibrous connective tissue and finely
branching thin walled blood vessels

Bleeding of tissues – hematuria( blood in urine,

bloody stools, anemia)
 Pathophysiology CONT..
cancer also outgrows some of its blood supply, so portions of
it are deficient in oxygen + Pressure of tumor on tissue n cell

Cell death and tissue infection

watery or foul discharge

Pain (back of thighs) and Leukorrhea – whitish vaginal

discharge
Signs and symptoms
 Watery and fowl smelling vaginal discharge
 Bleeding after intercourse
 Uterine bleeding between menses ( metrorrhagia)
 Increased frequency of menstrual bleeding(polymenorrhea)
 Post menopausal bleeding
 Spotting
 Pain - pressing on the nerves by the cancer (advanced cancer)
 Hematuria
 Bloody stools
 Anemia

NB: may be no symptoms of a very early cervical cancer

S/S cont..
 STAGING (Whenever a cancer is diagnosed the next step is
staging. This is a determination of the extent of the cancer.)

CLINICAL STAGES OF CANCER OF THE CERVIX

 Stage I - Cancer confined to the cervix

 IA Invasive cancer detectable microscopically only
 IA1 - Invasion less than 3 mm and width less than 7 mm
 IA2 - Invasion more than 3 mm but less than 5 mm IB All others, any
visible cancer
 IB1 - Cervix less than 4 cm in diameter
 IB2 - Cervix greater than 4 cm Stage II Spread to adjacent
structures
 IIA - Spread onto the vagina
Stages of ca cervix cont..
IIB - Spread laterally toward the pelvic wall
Stage
 III - More extensive but still within the pelvis
 IIIA - Extends to the lower vagina
IIIB - Extends onto the pelvic wall, obstructed
ureter
 IV - Distant spread or involvement of a pelvic
organ
 IVA - Involves the inside of the bladder or
rectum
IVB - Distant metastases, i.e. lung, liver or bone
FIGO* Staging for Cervical Cancer
 Stage 0:Preinvasive disease (carcinoma in situ)
 Stage I: Carcinoma strictly confined to the cervix
 Stage II:Carcinoma that extends into the parametrial
(but not onto the pelvic sidewall) or the upper two thirds
of the vagina
 Stage III:Carcinoma that has extended onto the pelvic
sidewall or involves the lower third of the vagina. (All
cases with a hydronephrosis or nonfunctioning kidney
should be included, unless they are known to be due to
other causes.)
 Stage IV:Carcinoma that has extended beyond the true
pelvis to distant organs or has clinically involved the
mucosa of the bladder, rectum, or both
COMPLICATIONS
Recurrent and persistent ca cervix
Anemia
Secondary infertility
DIAGNOSIS
HISTORY
Biographic: age, sex,marital status, occupation,
Chief complaint:

Present medical: Include signs and symptoms

and location, onset, effects on activities of daily
living, e.g. sleeping, working, sexual
disturbance. What makes the patient feels
better,e.g. drugs, herbs, source of prescription.
History cont.
Past medical history: Obstetric: no of
pregnancies, abortions, miscarriages, type
of deliveries, sexual abuse. Age at first
sexual activity
Family history: Cancers, history of spouse
or partners, e.g. STIs
Social History: Alcohol, smoking, hygiene
practices
PHYSICAL EXAMINATION
 INSPECTION
-Pallor, cyanosis, vaginal discharge and its characteristics on speculum
examination, vaginal bleeding and characteristics, facial
expressions of pain, e.g. guarding.
-inspect cervix for color, size of os, smoothness or abnormal growths.

 PALPATION
-Capillary refill, adnexa for pain, abdomen, groin lymph nodes, Cervical
motion tenderness.

-
INVESTIGATIONS
 Pap smear – effective in detecting precancerous and
cancerous cells from the cervix.
-repeated if results are positive (educate patients about the
role of cervical cytology, as well as to provide basic
information about some of the potential results)
- Client preparation
- scheduled between menstrual periods interfere with
results
- No douching, vaginal meds, sexual intercourse for 24hrs
before test
- Lithotomy position
- Relaxation techs;breathingpatterns
Pap smear cont..
 Equipment
-cytology brush
-cotton tip applicator
-Endocervical aspirator
-wooden or plastic spatula
Post procedure care
Provide perineal pad – bleeding from cervix
investigation
 Endocervical curettage ( scraping of the endocervix from
internal to external os)
 NPO after mid night, assess clients understanding of procedure
 POST OP: Vital signs till stable, assess pain,vaginal bleeding
-uncomfortable procedure
-encourage relaxation or breathing exercises to cope with the pain-
heating pads or hot water bottle and analgesics mild
-Bleeding may occur after the procedure for 2 weeks shud be slight
 Avoid sex,tampons for 2wks, vaginal discharge when stable
Investigations cont..
 FBC
 Liver function test
 Blood urea nitrogen and Creatinine
 Serum glucose tests
 CXR
(To rule out metastasis)
o Computed Tomography of the pelvis ( to identify the
origin and spread of the tumor)
o Lymphangiography – evaluates lymph node involvement
o Liver and bone scans to evaluate spread
INVESTIGATIONS CONT…
Dilation and curettage ( scraping of the cervix)
Colposcopic examination – Visualize the
transformation zone (zone where preinvasive lesions
occur located near the external os)-locate exact site –
indicated for abnormal pap smear results without abnormal physical
findings
Biopsies of cervical tissue done following abnormal
Colposcopic examination-done in proliferative stage of
menstrual cycle when cervix is least vascular
Post cervical biopsy
 No lifting of heavy objects till site is healed, sex, douche
tampons(2 wks)
 Rest for 24hrs after procedure
 Post op packing to be left for 8 to 24hrs
 Report excessive bleeding, signs of infection
 Keep perineum clean and dry with antiseptic solution
 Freq pads change
D and C
SURGICAL MANAGEMENT
Type of surgery depends on the extent of the disease and
whether client still want to conceive.

 CONIZATION
For lesions that cannot be visualized by Colposcopic exam.
Cone shaped area of the cervix is removed surgically –
sent to laboratory to determine extent of the malignancy.
Surgical management cont…

Conization risks
 Hemorrhage
 Uterine perforation
 Incompetent cervix
 Cervical stenosis-stricture of the internal cervical os.
 Preterm labor in future pregnancies
Conization
Cervical cone biopsy
colposcope
Surg. Management cont…
Hysterectomy
Removal of the uterus, including the cervix-- through the
vagina, called a vaginal hysterectomy.
- through the abdomen, called a total abdominal
hysterectomy.
- through a small incision in the abdomen using a
laparoscope, the operation is called a total laparoscopic
hysterectomy.
Surg. Cont..
Radical hysterectomy
Surgery to remove the uterus, cervix, and part of the
vagina.

The ovaries, fallopian tubes, or nearby lymph nodes may

also be removed
Hysterectomy management
Pre-op
-general pre-op mx with explore significance of loss of
uterus ( relates to self image, femininity, sexual function
if wish to have children
- Clear misconceptions about
hysterectomy(masculinazation, wt gain)
- Assess support system for adequate support- may fear
rejection by her partner
Post-op
 Assess vaginal bleeding (shud be 1 saturated pad 4hrly)
 Bleeding at incision site and intactness
 On Foley catheter for 24-48 hrs
 Pain medication as ordered
 Perineal care-sitz baths or ice packs
 Discharge- limit stair climbing for 1/12
-avoid sitting for long cause pooling of blood in
pelvic vessels
No strenuous activities and heavy lifting
Complications of hysterectomy
 Abdominal
-paralytic ileus
-thromboembolism
-atelectasis
-pneumonia
-wound dehiscence

 Vaginal
-hemorrhage
Urinary complications –infections, retention
-wound infection
Hysterectomy
 Teach about physical changes to be expected
 Exercise and activity
 Sexual activity
 Diet
 Complications
 Follow up care
Hysterectomy teaching
 Physical changes
-cessation of menses
-inability to become pregnant
 Exercise
-moderate; walking
 Diet
-protein
-iron
-vit c
 Sex
-none for 3-6wks
-painful sex at first coz of tight vaginal muscle to use water soluble
lubricants
Surg cont..
Cryosurgery/cryotherapy.
A procedure in which tissue is frozen to destroy
abnormal cells such as carcinoma in situ . This
is usually done with a special instrument that
contains liquid nitrogen or liquid carbon dioxide.
Also called cryoablation.
Management-patient may experience slight
cramping, heavy water discharge for several
weeks, avoid intercourse, tampons while
discharge is present coz cervix is fragile
Surg cont..
Laser surgery
A surgical procedure that uses a laser
beam (a narrow beam of intense light) as
a knife to make bloodless cuts in tissue or
to remove a surface lesion such as a
tumor
Surg cont..
Loop electrosurgical excision
procedure(LEEP)
A treatment that uses electrical current passed through a
thin wire loop as a knife to remove abnormal tissue or
cancer
Non surg management
radiation therapy
The use of high-energy radiation from x-rays, gamma
rays, to kill cancer cells and shrink tumors.
Radiation may come from a machine outside the body
(external-beam radiation therapy),
or it may come from radioactive material placed in the
body near cancer cells (internal radiation
therapy).
Non surg

Systemic radiation therapy

uses a radioactive substance, such as a radiolabeled
monoclonal antibody, that travels in the blood to tissues
throughout the body. Also called radiotherapy and
irradiation.
Non surg
 radiation therapy is given depending on the type and
stage of the cancer being treated.
 Mainly for advanced Ca cervix pre-op to destroy cancer
cells and post to prevent recurrence

 Management- strictly isolate

-strict bed rest flat on back or slightly elevate 20oc

External radiation- watch for skin breakdown especially

perineum, no bathing at treatment site

Complications-diarrhea, cystitis and loss of taste and

anorexia( altered nutrition)
Medical management
 Analgesics-Morphine sulphate, Pethidine, paracetamol,
Ibuprofen, Codeine phosphate
 Antibiotics – Metronidazole, Cotrimoxazole,
 Iron supplements(Ferrous folate), Erythro poeitin
 IV fluids
Nursing management
Nsg diagnosis implementation Scientific
rationale

Altered tissue -Assess amount and More than 1 saturated

perfusion related to type of bleeding, advise pad indicate excessive
decreased circulatory patient to report any bleeding
abnormal bleeding
blood volume sec to
destruction of tissues -Provide diet rich in iron
manifested by -administer iron
supplements as ordered
-Put up n/saline 0.9% as
prescribed
Nsg mx cont…
Monitor vital signs

-put up blood for

transfusion as
prescribed and follow
necessary precautions
Prepare patient
psychologically and
physically for possible
surgical management(
pre-op management)
Nsg mx cont..
Altered comfort pain rt to Evaluate severity of
destruction of nerve pain
endings secondary to Advise and to lessen tension in the
abnormal cell growth demonstrate use of muscles.
manifested by pt relaxation technique
verbalizing etc Present medical
history of pain (symptom
characteristics)
Administer prescribed
analgesics
Nsg mx cont..
Anxiety rt to cancer Assess client’s To understand client's
diagnosis and potential emotional status self concept
loss of life manifested by Assess coping Past methods may be
client withdrawing self, mechanisms useful
client verbalizing etc Allow client time to Promotes understanding
express concerns and of disease and
ask questions and grief treatment, and alleviates
fear
Promotes acceptance
and positive living
Refer to counselor or Some problems may be
beyond GN scope of
support group for
practice
additional information
Nsg dx
Ineffective management Assess factors Promotes patient
regimen rt to disease centered approach
process secondary to that contribute to
Knowledge deficit ineffectiveness
manifested by patient
verbalising
Teach client, partner
and family on how to Prevents skin breakdown
irrigate perineal area and infection
using warm salty water
Apply dry heat using a
heat lamp,emphasise
safety precautions Promotes healing and
comfort
Advise and provide
high protein,iron,andvit c Promote collagen
diet formation and
wound healing
Nsg mx

Other Nsg dx
 Disturbed body image rt to changes caused by treatment
(hysterectomy/radiation) disease process
-Review the side effects of treatment (hair loss,
vomitting,surgical scarring, fatigue, diarrhea to promote a
sense of control( can wear wigs,, take antiemetics)
Identify strengths and resources – facilitates adaptation to
altered self concept
 Sexual dysfunction-provide information rt to alternative
sexual methods, -provide opportunity to express concern rt
to effect of vaginal bleeding on lifestyle and sexual
functioning