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Chapter 8 ---- Cancers of the Female Reproductive Tract

Terms in this set (67)

What significance does cancer play in the death of women?
It is the 2nd leading cause of death for women in the US behind CVD
Who has the highest death rate from CA and CVD?
AA women
What should be included in the Health Hx and Physical Exam?
- Determine current or past factors that increase risk
- Early Menarche
- Late menopause
- STIs
- Use of hormonal agents
- Ask about risky behaviors
- Ask about s/s
What are s/s that may indicate a need for follow up testing for cancer?
- Can be vague and nonspecific, woman may attribute them to another problem
- Abnormal vaginal bleed
- Abnormal discharge
- Vaginal discomfort
- Blood in BM
- Persistent low back ache not r/t standing
- Pain/bleed after sex
Where do most cervical cancers arise?
Squamocolumnar junction of the cervix
What are the most frequent malignancies diagnosed during pregnancy?
- Breast cancer
- Cervical caner
- Hematologic malignancies
- Melanoma
How do some cultures view the sharing of information regarding issues like cancer
Europeans- View sharing as inhumane
Asians- View it as unnecessarily cruel
Chinese- Withhold discussions of serious illness to avoid causing unnecessary anxiety
Clinical Breast Exam
Explanation- Assessment of the breast for abnormal findings; Client may discover lump herself; High risk hx for breast cancer

Indication- Identifies palpable mass, skin change, inverted nipple, or unresolved rash

RN- Educate client to perform self exam and report abnormalities if high risk; Reinforce need for frequent clinical breast exams if risk factors are present
Mammogram
Explanation- Screening for breast cancer or any distortion in the breast tissue

Indications- Detects calcifications, densities, and nonpalpable cancer lesions

RN- Stress importance of annual mammograms for all women after age 40-50 depending on risk/hx
Pap smear
Explanation- Cervical cytology screening to Dx cervical cancers

Indications- Helps detect abnormal cervical cells; Most cervical cancers arise from squamocolumnar junction of cervix

RN- Encourage all sexually active women to get pelvic exam/pap smear to promote early detection if they are high risk; Patient should be in lithotomy position
Transvaginal US
Explanation- Screening for pelvic pathology to assist in dx endometrial cancers

Indications- Allows measurement of endometrial thickness to determine if endometrial biopsy is needed for postmenopausal bleeding *lining greater than 4mm should be biopsied

RN- Review risk factors for endometrial cancer and reason for screening; Assist in prep of client for exam
CA 125
Explanation- Nonspecific blood test used as a tumor marker

Indication- Elevation suggest malignancy but is not specific to ovarian CA; Can be elevated in other types of CA

RN- Review risk factors for ovarian CA and explain test that may be performed to assist in Dx/Tx
Endometrial Cancer (Uterine CA)

- Unopposed means you cant get estrogen alone, you need something to make you bleed

- One of the easiest cancers to cure
- Malignant neoplastic growth of uterine lining
- 4th most common gynecologic malignancy
- 6% off all cancers in women
- Uncommon before 40, then risk increases
- Better prognosis than cervical or ovarian CA
Risk- Women 40>, Nullparity, HTN, Unopposed estrogen, Family Hx,DM,Liver Dz, Endometrial hyperplasia, Hx Uterine fibroids, Tamoxifen use
Screening - Not routinely done - women need to be edu. re s/s
S/S- Abnormal/Painful vaginal bleeding
Dx- Transvaginal US; Endometrial Biopsy
Tx- Total Hysterectomy; Radiation/Chemo
RN- Educate preventive care; Post Sx follow up; Post menopausal bleeding must be assessed; Inform Tx options
What happens when estrogen preparations are given w/o progestin?
Leads to increased risk for endometrial cancer
- Type 1 usually found at early age and results are favorable
- Type 2 associated w/ poorly differentiated cell type; Poor prognosis
What are teaching guidelines for reducing the risk for cancer?
- Risk- Early menarche, Late menopause, STI, Use of hormonal agents, Infertility
- Don't smoke; EtOH in moderation x1 drink/day
- Exercise
- Eat a healthy diet
- Stay current with immunizations
- Use a condom/barrier
- Reach/maintain a healthy weight
- Take preventive medications if needed
- Get recommended screenings
What screenings are recommended for cancer?
- BMI for obesity
- mammogram q1-2 yr at age 40
- PAP smear q1-3 yr if sexually active, btwn age 21-65
- Cholesterol checked annually starting at 45
- BP checked at least q2 yr
- Diabetes test if hypertensive or hypercholesterolemic
- Check for STI's if sexually active
Preventive and follow up measures for endometrial cancer
- Schedule reg. pelvic exams after age 21
- Visit health care provider for early eval of any abnormal bleeding after menopause
- Maintain a low fat diet throughout life
- Manage weight to discourage hyperestrogenic states, which predispose to endometrial cancer
- *Pregnancy serves as a protective factor by reducing estrogen
- Ask your MD about the use of combo estrogen/progestin pills
- Use risk reduction measures w/ combo oral contraceptives
- Be aware of risk factors for endometrial cancer and make modifications as needed
- Report any bleeding or spotting after intercourse, Bleeding that last > 1wk., Reappearance of bleeding after 6 mo. or more of no menses
- After Tx, schedule follow ups for the next few years and communicate concerns with MD
- After Sx, maintain a healthy weight
What is the purpose of a sonohysterogram?
Determine endometrial thickness in a woman w/ postmenopausal bleeding and thick endometrium
- Hysteroscopic biopsy better when 1 or more focal areas of thickness are present
What may be the most important tool available for early detection of endometrial cancer? p.263
Education
When should the client receive routine follow ups?
q 3-4 mo. for first 2 years
What occurs in the stages of endometrial cancer?
Stage 1- Tumor spread to muscle wall of uterus
Stage 2- Tumor spread to cervix, but not outside uterus
Stage 3- Tumor spread regionally to bowel or vagina w/ mets to pelvic lymph nodes
Stage 4- Tumor has invaded the bladder mucosa w/ distant mets to lungs,liver, and bone
What are some modifiable/treatable risk factors for endometrial cancer?
- Obesity
- HTN
- Diabetes
What Tx is indicated to manage endometrial cancer?
- Sx to remove uterus (hysterectomy) and F-tubes/ovaries (Salpingo-oophorectomy)
- Radiation/chemo used adjunct to Sx in advanced CA
- Routine follow up q3-4 mo. for first 2 yr; 85% recurrence in first 3 yr after Dx
Cervical Cancer
- 5 to 8x more common in women w/ HIV and AIDS
- Highest in women 40-49; Usually younger then 50, older than 20
- One of the most treatable cancers when treated at an early stage
Risk- Minorities, HPV , lower socioeconomic status, female offspring of mothers that took diethylstilbestrol (DES), unprotected sex
S/S
Dx- Pap smear/Thin Prep/Colposcopy to ID CA
Tx-cryotherapy, LEEP, LLetz, cold knife cone bx, laser, radiation/chemo Hysterectomy
RN- Primary Prevention
What is the purpose of the PAP test?
Detect cervical cancer and precancerous lesions
What has been developed to improve the sensitivity and specificity of Pap testing
1. Thin Prep - Liquid; Specimen placed in to vial of preservative rather than slide
2. Computer assisted automated Pap - Algorithm ID's slides that should be rescreened
3. HPV-DNA Hybrid - Associates different types of HPV (16,18,33,35,45,51,52,56) and development of cervical CA; ID's high risk HPV and improve detection/mgmt.
4. Computer assisted technology - Detect abnormal cells missed by cytologists
What are the PAP smear guidlines
1. until age 30 - Yearly based on risk profile, using glass slide; Q2 yr using liquid based method
2. Age 30-70 q 2-3 yr if last 3 paps negative
3. After 70 may D/C if past 3 paps normal or no pap smears in last 10 years abnormal
what occurs in the stages of cervical CA
Stage 1- CA is limited to the ovaries
Stage 2- the growth involves one or both ovaries with pelvic extension
Stage 3- CA has spread to the lymph nodes and other organs or structures inside the abd cavity
Stage 4- CA has metastasized to distant sites.
What is a Colposcopy?
*Colposcope
Microscopic exam of lower genital tract using a magnifying instrument; Lithotomy position; Acetic acid makes abnormal cells appear white; Clinic or office setting; Premedicate w/ ibuprofen
Which vaccines are approved to prevent HPV and protect against cervical cancer?
Gardasil and Cervarix
Prevent HPV 6,11,16,18
Effective in preventing HPV, Cervical Ca, Precursor lesions, Vaginal/vulvar ca lesions, and genital warts
- IM admin x3; 2nd and 3rd and 2 and 6 mo after 1st
- Age rec. 9-26
- Protect 6-8 years
What is the recommened ACOG screening for Cervical cancer?
- PAP q2 yr for women age 21-29; q3 yr for women age 30 and older that have had 3 negative cervical cytology and have no high risk pap smear hx
What should the RN know about the patho of cervical cancer?
Starts w/ abnormal changes in cellular lining or surface of the cervix, typically in the squamous columnar junction of the cervix
What is the 5 year surivival rate for all stages of cervical cancer?
72%
- 5-8x more common in women w/ HIV/AIDS
Management of cervical cancer during pregnancy depends on what 5 factors?
1. Stage of the disease (Tumor/Size)
2. Nodal status
3. Histologic subtype of the tumor
4. Term of the pregnancy
5. Whether the client wishes to continue pregnancy
Screening and Dx of cervical cancer
- Presence of CIN determines if further testing is needed
- 3 main factors the influence low grade dysplasia to high grade: Type/duration of viral infection; Host conditions that compromise immunity (Multiparity/Poor nutritional status); Environmental factors (Smoking,OC's, Vitamin deficiencies)
What Tx options are available to treat cervical cancer?

- Cryo not done too often these days, more wait/watch w/ vinegar use
- Wait to PAP until 21 so cervix is not compromised
- Cryotherapy freeze and destroy; Healing up to 6 wk; Profuse watery vaginal DC for 3-4 wk
- Cone biopsy/Conization removes cone shaped section of cervical tissue in ectocervix; Tx also, can remove precancers/early cancers via 2 method: LEEP/LLETZ to remove cervical tissue with heated wire/electric current; Local anesthetic used; 10 min; Mild cramping/bleeding may ensue for weeks after
- Cold knife cone biopsy under general anesthesia; Sx scalpel/laser use instead of heated wire; Done in hospital; Cramping/bleeding may persist for weeks
- Laser Therapy via ultra light beams to destroy tissue/varporize/burn; Watery brown discharge; Very effective for precancers/progression
- Hysterectomy Sx to remove uterus and cervix
- Radiation Therapy
- Chemoradiation Weekly cisplatin Tx concurrent w/ radiation
Prevention for cervical cancer

- 12k Yearly diagnosed 1/3 will die
Primary
- ID risk behavior
- Take steps to prevent STI's
- Avoid early sexual activity
- Barrier methods
- Avoid smoking/ EtOH
- HPV Vaccine
- Annual PAP smear to screen cervical cancer

Secondary
- Focused on reducing or limiting the area of cervical dysplasia

Tertiary
- Focuses on minimizing disability or the spread of cervical cancer

- Encourage rest for 1mo post cervical Tx
What strategies should bee used to optimize PAP smear results?
- Schedule Pap 2 wk (10-18 days) after first day of last menses to increase chance of getting best cervical cells w/o menses
- Refrain from intercourse for 48 hours prior to prevent washing away abnormal cells
- Don't use tampons/jellies, vaginal creams/meds for 72 hours prior
- Cancel appt if vaginal bleed occurs because of interference w/ visual eval
Risk factors for Reproductive Cancer
early menarche
late menopause
STI's
use of hormonal agents
infertility
family history of cancer
lifestyle behaviors
Warning signs of Reproductive Tract Cancer
-blood in a bowel movement
-unusual vaginal discharge or chronic vulvar itching
-persistent abdominal bloating or constipation
-irregular vaginal bleeding
-persistent low backache not related to standing
-elevated or discolored vulvar lesions
-bleeding after menopause
-pain or bleeding after intercourse
Ovarian Cancer

malignant neoplastic growth of ovary
S/S: pelvic and abdominal pain, urinary frequency and urgency, increased abdominal size, difficulty eating (feeling full)
malignant neoplastic growth of ovary
S/S: pelvic and abdominal pain, urinary frequency and urgency, increased abdominal size, difficulty eating (feeling full)
Ovarian Cancer
-9th most common cancer among women
-most common between 55-75
-extent of disease: most important variable for prognosis
-patho: most cells originating from ovarian epithelium
-screening/diagnosis: no adequate screening test, typically not diagnosed until stage III or IV
True/False:
Most women ignore the early warning signs of ovarian cancer.
true - ovarian cancers typically develop slowly and remain silent without symptoms until the cancer is advanced
Ovarian Cancer: Therapeutic Management
depends on stage and severity of disease; laparoscopy for diagnosis and staging; total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal biopsies, omentectomy, pelvic para-aortic lymph node sampling; chemo recommended for all stages, possible radiation
Ovarian Cancer: Nursing Assessment
-vague complaints
-early symptoms (bloating, early satiety, fatigue, vague abdominal pain, urinary frequency, diarrhea, constipation, unexplained weigh loss or gain)
-late symptoms (anorexia, dyspepsia, ascites, palpable mass, pelvic pain, back pain)
-risk factors
-physical exam
Ovarian Cancer: Nursing Management
-promoting early detection, emphasis on not dismissing innocuous symptoms as "just a part of aging", bimanual pelvic exams and transvaginal ultrasound
-educating the client: risk reduction and health promotion; treatment modalities, tests, follow-up if diagnosed
-supporting client and family
Common Metastatic Sites for Ovarian Cancer
diaphragm, liver, serosal bowel, colon, nodes, pleura, omentum, stomach
Endometrial Cancer
malignant neoplastic growth of the uterine lining; 4th most common gynecologic malignancy
Endometrial Cancer: Pathophysiology
Type 1 (most common): endometrial hyperplasia leads to carcinoma
Type II: spontaneously appears
Endometrial Cancer: Screening and Diagnosis
screening not routine; endometrial biopsy as procedure of choice for diagnosis, ultrasound
Endometrial Cancer: Therapeutic Management
-surgery (hysterectomy and salpingo-oophorectomy)
-adjunct therapy with radiation and chemo for advanced disease
-removal of tubes and ovaries
Endometrial Cancer: Nursing Assessment
-history: major initial symptom is abnormal painless vaginal bleeding
-risk factors
-physical exam, pelvic exam
-transvaginal ultrasound
True/False:
Women are encouraged to obtain routine screening for endometrial cancer.
False - Screening for endometrial cancer is not routinely done because it is not practical or cost-effective
Endometrial Cancer: Nursing Management
supportive listening, follow-up visits, education about prevention and follow-up care, risk reduction
Cervical Cancer: Pathophysiology
changes in cellular lining at squamous-columnar junction; linked to HPV; cervical dysplasia is a precursor; incidence and mortality decreased due to PAP test (could show a false negative result)
Cervical Cancer: Therapeutic Management
colposcopy; management depends on severity and woman's health history
Cervical Cancer: Nursing Assessment
-Risk factors: abnormal vaginal bleeding after sexual intercourse
-physical exam: pelvic exam and PAP test, possible further diagnostic testing
Cervical Cancer: Nursing Management
-primary prevention: education and HPV vaccine, PAP test
-secondary and tertiary prevention
-emotional support
-referrals
Vaginal Cancer: Patho
-majority metastatic from the cervix
-squamous cell (most common) usually in women over 50
-adenocarcinomas
Vaginal Cancer: Therapeutic Management
-radiation, laser surgery, or both
-possible radical surgery in addition to radiation if cancer is extensive
Vaginal Cancer: Therapeutic Management
-radiation, laser surgery, or both
-possible radical surgery in addition to radiation if cancer is extensive
Vaginal Cancer: Nursing Assessment
-risk factors
-S/S, usually asymptomatic
-physical exam with biopsy of suspicious lesions
Vaginal Cancer: Nursing Management
-emphasis on sexuality counseling
-referrals to support groups
Vulvar Cancer
-patho: primarily squamous cell carcinomas
-4th most common gynecologic cancer
-most common in older women (mid-60s to 70s)
Vulvar Cancer: Screening/Diagnosis
-annual vulvar exams
-biopsy of suspicious lesion (usually on labia majora)
Vulvar Cancer: Therapeutic Management
laser surgery, cryosurgery, or electrosurgical incision; radical vulvectomy
Vulvar Cancer: Nursing Assessment/Management
-Risk factors
-persistent vulvar itching
-education - healthy lifestyle behaviors, preventive measures
-communication, information, and support
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