Care of the patient with cancer cervix

1. Case scenario
Annie is a 45-year-old divorced mother of four
children ranging in age from 16 to 23.She was
married at age 18 and had several sexual partners
prior to her marriage. She has had three sexual
partners since her marriage ended. Last year she
was treated with cryosurgery for venereal warts. The
Pap smear taken 2 weeks ago showed atypical
cells, and she has come in for a repeat test.

2. Care Of Patient With Cervical
Cancer
Moderator:
Dr. L.Gopichandran
Associate professor
CON,AIIMS
Presenter:
Saumya Prakash
Srivastava
Msc.Nsg 2nd year
CON,AIIMS

3. Objectives:
At the end of this class, students will be able to:
• Define Cervical Cancer
• Explain epidemiology of cervical cancer
• Explain in brief anatomy and physiology of cervix
• Enlist etiology and risk factors of cervical cancer
• Describe pathophysiology of cervical cancer
• Enumerate types of cervical cancer
• List down sign and symptoms of cervical cancer
• Explain diagnostic tests done for cervical cancer
• Explain in brief classification and grading of cervical cancer
• Describe prevention of cervical cancer
• Explain medical and surgical management of cervical cancer
• To enlist the complications of cervical cancer
• Explain nursing management of cervical cancer

4. Cervical cancer
• Cervical cancer is a malignant tumour deriving from cells
of the "cervix uteri", which is the lower part, the "neck" of
the womb, the female reproductive organ.
• Cells change from normal to pre-cancerous (dysplasia)
and then to cancer. Mainly occurs in transitional zone.
• Fortunately, HPV infections get cleared in 1 to 2 years
following exposure
• Persistent infection with oncogenic (HPV), most
frequently contracted through genital skin to skin
contact/vaginal intercourse, is necessary for the
development of cervical cancer and high-grade precursor
lesions.

5. Introduction
• Cervical cancer is the fourth most frequent cancer
in women with an estimated 570,000 new cases in
2018 representing 6.6% of all female
cancers.(WHO)
• It remains a leading cause of cancer-related death
for women in developing countries.
• In the United States, cervical cancer is relatively
uncommon

6. Cont..
• A cancerous tumour of the cervix can grow into
nearby tissue and destroy it. The tumour can also
spread (metastasize) to other parts of the body.
• In India, approximately 90% of invasive cervical
cancer cases are squamous cell carcinoma, while
10–12% is adenocarcinomas
• Most precancerous changes in the cervix do not
progress to cancer.

7. Cont..
• Squamous cell carcinoma is the most common
histologic subtype of cervical cancer, accounting for
approximately 80% of cases.
• The second most common tumor type is cervical
adenocarcinoma, which constitutes about 15% of
cervical cancer cases and develops from a
precursor lesion called adenocarcinoma in situ.
• Adenosquamous and neuroendocrine carcinomas
are rare cervical tumors that account for the
remaining 5% of cases

8. Epidemiology
• The peak age of incidence of cervical cancer is 55–
59 years.
• Specific types of oncogenic HPV-16, 18 have been
identified in patients with cervical cancer.
• Cervical cancer is the commonest cancer cause of
death among women in developing countries.
• 86% of all deaths due to cervical cancer are in
developing, low- and middle-income countries.

9. Facts and figures..
• In India, cervical cancer contributes to
approximately 6–29% of all cancers in women.
• Highest is 23.07/100,000 in Mizoram state and the
lowest is 4.91/100,000 in Dibrugarh district.
• India accounts for 1/4th of global burden of
cervical cancer .
• Cervical cancer is the second most common
cancer among Indian women (As per Globocan
2018).

10. Cont..
• There is a wide variation in the incidence of cervical
cancer across the globe.
• Early detection through regular screening has aided
to significantly control the prevalence of this disease,
thereby.
• The proportion ranged from 15% to 55% of female
cancers from different parts of the country. (ICMR)

11. cont..
One woman dies
of cervical cancer
every 8 minutes
in India
--NCI
New cases of cervical
cancer detected in
India: 96,322 every
year
Deaths due to
cervical cancer in
India: 60,078/year

12. Anatomy of cervix

13. Structure
• The cervix is about 3 to 4 cm
long. It is made up mostly of
connective tissue and
muscle. It is divided into 2
main parts:
• The endocervix is the inner
part of the cervix lining the
canal leading into the uterus.
• The ectocervix (exocervix) is
the outer part of the cervix. It
is rounded and lip-like and
sticks out into the vagina.

15. What the cervix does
• Part of the lining of the cervix contains glands that
make and release mucus.
• Every month, except during pregnancy or
menopause, the lining of the uterus (called the
endometrium) is shed through the cervix into the
vagina, then out of the body. This process is called
menstruation.
• During childbirth, the cervix widens (dilates), allowing
the baby to pass through the birth canal.

16. Etiology
• Cervical carcinogenesis occur in a stepwise fashion
• Persistent infection of Human Papilloma Virus (HPV) is
considered the most significant casual agent for the
development of cancer of uterine cervix.
• 30 HPVs that infect the ano–genital tract, of these15 HPV
types classified as ‘high-risk’ types (HPV types 16, 18, 31,
33, 35, 39, 45, 51, 52, 56, 58,59, 68, 73 and 82)
• High risk HPV types are associated with high grade
cervical cancer precursor lesions and invasive cervical
cancers

17. Etiology
• The prevalence of HPV in cervical intraepithelial
lesion and cancer is > 80% .
• HPV 16/ 18 compiles in about > 90% of the cervical
cancer cases.
• HPV16 was found to be highest in Chennai (88%),
and lowest in Jammu and Kashmir (14.2%) ICMR
national HPV Mapping

18. Cont..
• If I have HPV, does it mean i will get cancer??
NO!
• In most cases HPV goes away
• Only women with persistent HPV (where the virus
does not go away) are at risk for cervical cancer
• How common Is HPV?
• Most men and women who have had sex have been
exposed to HPV
• More than 75% of sexually active women tested
have been exposed to HPV by age 18-22

19. Risk factors
• Multiple sexual partners
• A male partner with multiple previous or current sexual
partners
• Young age at first intercourse
• High parity
• Persistent infection with a high oncogenic risk HPV, e.g.,
HPV 16 or HPV18
• Poor Nutrition
• Immunosuppression
• Certain HLA subtypes
• Use of oral contraceptives
• Use of nicotine
• Daughters of women who took DES may have a higher
risk of developing precancerous changes of the cervix

20. Pathophysiology

22. Progression

24. Types of cervical cancer
• Squamous cell carcinoma
• Most cervical cancers are SCC. This type of cancer starts
in squamous cells that cover the outer surface of the
cervix, called the ectocervix.
• SCC develops most often in the squamo-columnar
junction.
• SCCs can be keratinizing or non-keratinizing
• Rare types of SCC of the cervix include verrucous
carcinoma, papillary SCC, papillary transitional cell
carcinoma, warty carcinoma, basaloid SCC and
lymphoepithelioma-like carcinoma.

25. Cont..
• Adenocarcinoma
• Most of the other cervical cancers are
adenocarcinomas. Adenocarcinoma starts in the
glandular cells that line the inside of the cervix, called
the endocervix.
• Mucinous adenocarcinoma is the most common type
of adenocarcinoma in the cervix.
• Endometrioid adenocarcinoma is a type that looks
similar to the cancer that develops in the lining of the
uterus.
• Clear cell carcinoma may happen in daughters of
women who used diethylstilbestrol (DES) during their
pregnancy.

26. Cont..
• Rare types of adenocarcinomas include papillary
serous adenocarcinoma, villoglandular papillary
adenocarcinoma, mesonephric adenocarcinoma and
microcystic endocervical adenocarcinoma.

27. Cont..
• Adenosquamous carcinoma
• Adenosquamous carcinoma contains a mixture of
both glandular and squamous cells. It can affect
women of any age.
• Glassy cell carcinoma is an aggressive type of
adenosquamous carcinoma.

28. Signs and Symptoms
Early symptoms:
• Cervical cancer may not cause any signs or symptoms
in its early stages.
• Abnormal vaginal bleeding including between periods,
after menopause and after sexual intercourse
• Abnormal or increased amount of vaginal discharge
• Foul-smelling vaginal discharge
• Unusually long or heavy periods
• Bleeding after a pelvic exam or vaginal douching
• Pain during sexual intercourse

29. Cont..
Late symptoms:
• Difficulty urinating
• Difficulty having a bowel movement
• leaking of urine or feaces from the vagina
• Pain in the pelvic area or lower back that may go down
one or both legs
• Leg swelling, often in one leg
• Loss of appetite
• Weight loss
• Shortness of breath
• Coughing up blood
• Chest or bone pain
• Fatigue

30. Research Input
Knowledge, attitude, and practice about cervical cancer
and its screening among community healthcare workers
of Varanasi district, Uttar Pradesh, India
Divya Khanna et al .Published in journal of family medicine
and primary care; may 2019
Aim:
This study aims to assess the knowledge, attitude and practice
(KAP) of cervical cancer and its screening amongst community
health workers of Varanasi district, Uttar Pradesh.
Settings and Design:
Descriptive, cross-sectional study was done to assess the
socio demographic profile and KAP for cervical cancer and its
screening of community health workers. Scoring for awareness
and attitude for cervical cancer screening was done.

31. Research Input
• Results:We observed that despite of good knowledge and
perception less than 10 percent of workers have undergone
screening. Significant association was seen between level of
knowledge and practice of screening.
• Conclusion:It is of utmost importance that narrowing of existing
gap between the perception and practice of cervical cancer
screening should be initiated through introducing more
educational programs for workers and encouraging them to
participate in screening campaigns.

32. Diagnosis
1. Health history :
o symptoms that suggest cervical cancer
o sexual activity
o abnormal PAP tests and treatments
o Smoking
2. Physical examination:
To look for any signs of cervical cancer
o Pap test and a pelvic exam
o Digital rectal exam (DRE) to feel for any abnormal
changes
o feel the lymph nodes in the groin and above the
collarbone to see if they are swollen
o Complete physical and gynecological examination
(Examination Under Anesthesia if required to confirm
the stage)

33. Screening for cervical cancer(WHO)
• screening should be performed at least once for
every woman in the target age group (30-49 years)
when it is most beneficial
• HPV testing, cytology and visual inspection with
acetic acid (VIA) are all recommended screening
tests
• cryotherapy or loop electrosurgical excision
procedure (LEEP) can provide effective and
appropriate treatment for the majority of women who
screen positive for cervical pre-cancer
• “screen-and-treat” and “screen, diagnose and treat”
are both valuable approaches

34. cont..
• Pap test: The test
can find abnormal
changes in cells early,
before cancer
develops.
• A Pap test is used to
screen for cervical
cancer. It is done every
1 to 3 years,
depending on your
province’s or territory’s
screening guidelines
and your health history.

35. PAP test

36. Cont..
• HPV test:
A human papillomavirus (HPV) test is a lab test that
looks for the DNA of only high-risk types of HPV that
have been linked to cervical cancer.

37. Cont..
• Colposcopy:
• A colposcopy uses a
colposcope (a lighted
magnifying instrument) to
examine the vulva, vagina
and cervix.
• A colposcopy is done after an
abnormal Pap test or a
positive HPV test suggests a
precancerous condition of the
cervix or cervical cancer.
• A colposcopy may also be
done if you have symptoms
of cervical cancer.

38. Cont..
• Biopsy: For histopathological confirmation of
malignancy
• Punch biopsy
• Wedge biopsy
• Cone biopsy

39. Cont..
• Blood chemistry tests: Blood chemistry tests are
done to check how well the kidneys and liver are
working as part of the diagnosis process for cervical
cancer.
• Endoscopy:
• Cystoscopy
• Sigmoidoscopy

40. Cont..
• Chest x-ray: A chest x-ray is used to see if cancer has
spread to the lungs.
• Barium enema: It is used to check if cancer has spread
to the colon or rectum.
• CT scan: A CT scan is used to:
• Assess the pelvis, abdomen and lymph nodes
around the cervix
• See if cancer has spread to other organs or tissues
• Guide the needle when doing a biopsy of an area of
suspected metastasis

41. Cont..
• MRI
• Intravenous pyelogram (IVP):It may be used to
see if cancer is blocking the ureters (tubes that
connect the kidneys to the bladder).
• PET scan: A PET scan may be used to find cervical
cancer that has come back or has spread to other
organs or tissues

42. Research Input
Low-Cost Instructional Apparatus to Improve Training
for Cervical Cancer Screening and Prevention
Sonia Parra et al published in Obstetrics Gynecology.
2019 March
Method:
• LUCIA is a low-cost, universal cervical cancer
instructional apparatus that can be used to teach and
practice a variety of essential skills for cervical cancer
screening, diagnosis, and treatment, including: visual
inspection with acetic acid, Pap and human
papillomavirus DNA specimen collection, colposcopy,
endocervical curettage, cervical biopsy, cryotherapy,
and loop electrosurgical excision procedure.

43. Research Input
Experience:
• LUCIA was used to provide hands-on training in six
courses held in Texas (n=3), El Salvador (n=1), and
Mozambique, Africa (n=2). Standardized provider
evaluations were administered at three of these
courses and resulted in mean scores of 4.12/5 for
usefulness, 4.46/5 for skill improvement, and 4.43/5
for ease of skill evaluation.
Conclusion:
• LUCIA provides dynamic, real-time feedback that
allows trainees to learn and practice important skills
related to cervical cancer prevention while
simulating a patient exam

44. TNM classification

45. FIGO Staging(2018)
• For cervical cancer there are 4 stages. Often the stages 1 to 4
are written as the Roman numerals I, II, III and IV.
• Stage 0 is not included in the FIGO system.
Stage 1-The carcinoma is strictly confined to the cervix
(extension to the uterine corpus should be disregarded)
• Stage 1A – Invasive carcinoma that can be diagnosed only by
microscopy, with maximum depth of invasion <5 mm
• IA1-Measured stromal invasion <3 mm in depth
• IA2-Measured stromal invasion ≥3 mm and <5 mm in depth
• Stage IB:Invasive carcinoma with measured deepest invasion
≥5 mm (greater than Stage IA), lesion limited to the cervix uteri

46. Cont..
• IB1Invasive carcinoma ≥5 mm depth of stromal
invasion, and <2 cm in greatest dimension
• IB2Invasive carcinoma ≥2 cm and <4 cm in greatest
dimension
• IB3Invasive carcinoma ≥4 cm in greatest dimension
Stage II:The carcinoma invades beyond the uterus, but
has not extended onto the lower third of the vagina or to
the pelvic wall
• IIA:Involvement limited to the upper two‐thirds of the
vagina without parametrial involvement
 IIA1Invasive carcinoma <4 cm in greatest dimension
 IIA2Invasive carcinoma ≥4 cm in greatest dimension

47. Cont..
• IIB:With parametrial involvement but not up to the
pelvic wall
Stage III:The carcinoma involves the lower third of
the vagina and/or extends to the pelvic wall and/or
causes hydronephrosis or nonfunctioning kidney
and/or involves pelvic and/or para‐aortic lymph nodes
• IIIAThe carcinoma involves the lower third of the
vagina, with no extension to the pelvic wall
• IIIBExtension to the pelvic wall and/or
hydronephrosis or nonfunctioning kidney (unless
known to be due to another cause)
• IIICInvolvement of pelvic and/or para‐aortic lymph
nodes, irrespective of tumor size and extent

48. Cont..
 IIIC1-Pelvic lymph node metastasis only
 IIIC2-Para‐aortic lymph node metastasis
• Stage IV
The carcinoma has extended beyond the true pelvis or has
involved (biopsy proven) the mucosa of the bladder or
rectum. (A bullous edema, as such, does not permit a case
to be allotted to Stage IV)
 IVA-Spread to adjacent pelvic organs
 IVB-Spread to distant organs

50. Grading of cervical cancer
The pathologist gives cervical cancer a grade from 1 to 3. A lower
number means the cancer is a lower grade.
• Low-grade cancers-have cancer cells that are well
differentiated. The cells are abnormal but look a lot like
normal cells and are arranged a lot like normal cells.
Lower-grade cancers tend to grow slowly and are less
likely to spread.
• High-grade cancers have cancer cells that are poorly
differentiated or undifferentiated. The cells don’t look like
normal cells and are arranged very differently. Higher
grade cancers tend to grow more quickly and are more
likely to spread than low-grade cancers.

51. Prevention
As per WHO..
• Community education
• Social mobilization
• Vaccination
• Screening
• Treatment
• Palliative care

52. Prevention
• Avoiding risk factors and increasing protective factors
may help prevent cancer.
 Quit smoking
 Exercising
 Using OCP’s for long time-The risk is 4 times greater
after 10 or more years of use.
 Eating fruits and vegetables , taking certain
medicines, vitamins, minerals, or food supplements.
• Getting an HPV vaccine-
Three types:Gardasil®, Gardasil® 9, and Cervarix®.
All three vaccines prevent infection with HPV types 16
and 18

53. Cont..
HPV vaccine is recommended for young
women through age 26, and young men through
age 21.
HPV vaccines have been shown to provide
protection for five to ten years.
• Using barrier protection during sexual activity

54. Treatment
While planning treatment, healthcare team will
consider:
• Stage of the cancer
• Age
• General health
• Whether or not you want to become pregnant in the
future
• preference or want of the patient

55. Treatment Options
Five types of standard treatment are used:
• Surgery
• Radiation therapy
• Chemotherapy
• Targeted therapy
• Immunotherapy

56. Standard treatment modalities
• Surgery
 Conization
 Total hysterectomy
 Radical hysterectomy
 Modified radical hysterectomy
 Bilateral salpingo-oophorectomy
 Pelvic exenteration
• Radiation therapy
 External RT
 Internal RT(Brachytherapy)

57. Cont..
• Chemotherapy
systemic chemotherapy
Regional chemotherapy
• Targeted therapy
Monoclonal antibody therapy (Bevacizumab)
• Immunotherapy-Pembrolizumab is a type of
immune checkpoint inhibitor used to treat recurrent
cervical cancer.

58. Treatment for CIN-I,II,III
CIN-I
• PAP smear and HPV DNA –if positive= repeat the test
annually ,usually regresses after 2 years.
• If does not regress,= ablative surgeries to be performed
(cryosurgery, laser surgery)
CIN-II,CIN-III
• LLETZ- large loop excision of transformation zone
• LEEP- loop electro excisional procedure
Recurrent CIN ,suspecting adenocarcinoma ,
associated with pelvic pathology
• Hysterectomy

61. Treatment for stage 0 cancer (CIS)
• local ablative or excisional
measures:
o Cryosurgery
o Laser ablation
o Loop excision
• Hysterectomy - This is done only if
the tumor cannot be completely
removed by conization.
• Internal radiation therapy for
women who cannot have surgery.

62. Treatments for stage IA cervical cancer
• Stage IA cervical cancer is separated into stage IA1 and
IA2
• Stage IA1:
• Conization.
• Total hysterectomy with or without bilateral salpingo-
oophorectomy.
Cone
biopsy
• A cone biopsy may be done for stage
IA1 cervical cancer who want the
option to become pregnant.
• A cone biopsy removes a cone-shaped
piece of tissue from the cervix.
• Types: cold-knife conization, LEEP,
Laser surgery

63. Cone
biopsy

64. IA1
• Total hysterectomy
with or without
bilateral salpingo-
oophorectomy.

66. Stage:IA2
Treatment for stage IA2 may include the
following:
• Modified radical hysterectomy and
removal of lymph nodes.
• Radical trachelectomy.
• Internal radiation therapy for women
who cannot have surgery.

67. Cont..
Radical
Hysterectomy
• In a radical hysterectomy, the
uterus, cervix, both ovaries, both
fallopian tubes, and nearby tissue
are removed.
• These procedures are done using
a low transverse incision or a
vertical incision.

69. Cont..
Lymph node
removal
Lymph nodes in the pelvis and back of
the abdomen (called the para-aortic
lymph nodes) may be removed during
surgery for stage 1 cervical cancer.
• A pelvic lymph node dissection
(PLND) is the removal of lymph
nodes from the pelvis.
• A sentinel lymph node biopsy
(SLNB) is the removal of the
sentinel lymph node to see if it
contains cancer.

70. Cont..
Radical
trachelectomy
• A radical trachelectomy
removes the cervix, the
upper part of the vagina,
some of the structures and
tissue around the cervix and
lymph nodes in the pelvis.
• It may be offered for stages
1A2 and small 1B1 cervical
cancer (less than 2 cm) if
patient wants to become
pregnant after treatment.

71. Radical trachelectomy

72. Cont..
• A type of radiation therapy in
which radioactive material
sealed in needles, seeds,
wires, or catheters is placed
directly into or near a tumor.
Also called brachytherapy,
implant radiation therapy, and
radiation brachytherapy.
Internal
Radiation
Therapy

73. Brachytherapy In Ca
Cervix
Radiation source

76. Brachytherapy In Ca Cervix

77. Brachytherapy In Ca Cervix

78. Management of Stages IB and IIA Cervical
Cancer
• Treatment of stage IB and stage IIA cervical cancer
may include the following:
• Radiation therapy with chemotherapy given at the
same time (chemoradiation).
• Radical hysterectomy and removal of pelvic lymph
nodes with or without radiation therapy to the pelvis,
plus chemotherapy.
• Radical trachelectomy.
• Chemotherapy followed by surgery.
• Radiation therapy alone.

79. Cont..
Chemoradiation
• It is often a main treatment for stage 1B2 or higher
cervical cancer.
• This treatment combines chemotherapy with
external radiation therapy.
• Chemotherapy is given during the same time
period as radiation therapy to make the radiation
therapy more effective.
• Cisplatin or cisplatin plus 5-fluorouracil (Adrucil, 5-
FU) is the chemotherapy that is used.

80. cont..
Radiation therapy
• External radiation therapy may be given alone or
with intracavitary brachytherapy (a type of
internal radiation therapy) for stage 1 cervical
cancer.
• Radiation therapy is usually given 5 days a week
for 6 to 7 weeks. Brachytherapy may be given
after external radiation therapy.

83. Treatment for Stages IIB, III, and IVA
Cervical Cancer
• Radiation therapy with chemotherapy given at the
same time.
• Surgery to remove pelvic lymph nodes followed by
radiation therapy with or without chemotherapy.
• Internal radiation therapy.
• A clinical trial of chemotherapy to shrink the tumor
followed by surgery.
• A clinical trial of chemotherapy and radiation therapy
given at the same time, followed by chemotherapy

85. Treatment Of Stage IVB Cervical
Cancer
• Radiation therapy as palliative therapy to relieve
symptoms caused by the cancer and improve
quality of life.
• Chemotherapy and targeted therapy.
• Chemotherapy as palliative therapy to relieve
symptoms caused by the cancer and improve
quality of life.

87. Treatment Options for Recurrent
Cervical Cancer
• Immunotherapy.
• Radiation therapy and chemotherapy.
• Chemotherapy and targeted therapy.
• Chemotherapy as palliative therapy to relieve
symptoms caused by the cancer and improve
quality of life.
• Pelvic exenteration.
• Clinical trials of new anticancer drugs or drug
combinations.

89. Chemotherapy regimen
• Bevacizumab 15 mg/kg IV over 30-90 min on day
1 plus cisplatin 50 mg/m2 IV over 60 min on days
1 or 2 plus paclitaxel 175 or 135 mg/m2 IV over 3
h or 24 h on day 1 every 3 wk

90. Cont..
The most common chemotherapy drug combinations
used to treat cervical cancer are:
• cisplatin and ifosfamide
• cisplatin and paclitaxel
• cisplatin and gemcitabine
• cisplatin and topotecan
• paclitaxel and topotecan

91. Chemotherapy regimen
• Cisplatin 50-75 mg/m2 IV on day 1 plus 5-
fluorouracil (5-FU) 1000 mg/m2 continuous IV
infusion over 24 h on days 1-4 (total dose 4000
mg/m2 each cycle) every 3 wk for a total of three
or four cycles; plus radiation therapy, 1.8-2 Gy
per day for a total for 45 Gy

92. Cont..

93. Supportive care for cervical cancer
• Self-esteem and body image::
 scars
 hair loss
 changes in body weight
 sexual problems
 having an ostomy
 urinary or bowel problems
• Sexuality:
 vaginal dryness caused by cancer treatments such as
radiation therapy or surgery
 vaginal narrowing caused by scarring after radiation
therapy
 treatment-induced menopause

94. Cont..
• Fertility problems:
 Hysterectomy
• Lymphedema:
 Due to build up of lymph fluid in the legs secondary
to removal of excessive number of lymph nodes.
 Exercise,compression stockings and regular
physiotherapy.
• Ostomy care:
 People who have a pelvic exenteration will have the
bladder, rectum or both removed.
 They require Urostomy as well as colostomy

95. Cont..
 Many people can adapt to an ostomy and live normally
with it, although they have to learn new skills and how
to care for it.
 Anaemia: Low hemoglobin level is frequently observed
in these patients because of prolonged vaginal
bleeding, poor nutrition, advanced disease, bone
marrow toxicities during treatment and lack of
supportive care.
 A low hemoglobin level during radiotherapy/ chemo-
radiotherapy reflects lower local control and survival.

96. Clinical nurses’ awareness and caring experiences for patients with
cervical cancer: A qualitative study
Hae Won Kim et al Published in PLOS one May 21, 2019
• Aim:To determine the degree to which nurses are aware of cervical cancer
and to describe nurses' experiences of caring for patients with cervical
cancer.
• Methods: Interviews were conducted with 14 registered nurses. The
interviews were audiotaped, transcribed and analyzed. Content analysis was
performed. Fourteen nurses who had been working at wards and cancer
education centers were recruited in this study.
• Results:Nine key themes emerged from three categories such as nurses’
awareness of cervical cancer, awareness of cervical cancer patient and
caring experience. Nurses expressed fear of cervical cancer and
helplessness in the face of a life-threatening prognosis. Nurses stated that
they might have prejudice about cervical cancer, since it is caused by a
sexually transmitted disease. They also recalled that patients with cervical
cancer were more sensitive and demanding.
• Conclusion:Clinical nurses showed complex emotional reactions to cervical
cancer, and expressed prejudice against the sex life of cervical-cancer
patients. More education is required to ensure that clinical nurses can
provide a nurse-led intervention with patients by managing nurses’ fear,
prejudice, and the care burden

97. Complications of Cervical cancer
• Flank pain
• Hematuria
• Renal failure associated
with bladder
involvement.
• Ureteric obstruction
• Intermenstrual PV bleed
• Vesicovaginal fistula
• Post-menopausal PV
bleed
• Uterine enlargement
• Menorrhagia
• Vaginal dryness and
narrowing
• Lymphedema
• Early menopause

98. Prognosis
• In general, the earlier cervical cancer is diagnosed
and treated, the better the outcome.
• Most early-stage cervical cancers have a good
prognosis with high survival rates.
• If cancer is found after it has spread to other parts of
the body (referred to as an advanced stage), the
prognosis is worse and there is a higher chance of
recurrence

99. Side effects associated with RT
• Vaginal bleeding and pain
• Increased risk of bleeding or
infection
• Bowel irritation
• Bladder problems
• Sexual function and vaginal changes
• Bowel changes
• Bladder changes
• bowel obstruction
• Sexual function and vaginal changes
• fatigue
• Developing a second cancer
Short-
time SE’s
Long-
time SE’s

100. Vaginal bleeding and pain
• A small amount of bleeding or spotting
• Pain, soreness or swelling where the applicator was
located
• Cramping or swelling in the abdomen
• A burning sensation while urinating

101. Increased risk of bleeding or infection:
• Wash your hands often.
• Keep a thermometer at home and take your
temperature regularly, and if you feel unwell.
• Learn how to recognise the signs of infection.
• Limit contact with people who are sick.
• Report these symptoms to the physician :
 Temperature of 38°C or higher
 chills, shivers, sweats or shakes
 a headache or stiff neck
 a sore throat or cough
 uncontrolled diarrhoea
 severe pain in your abdomen

102. Bowel irritation: Characteristics are
 Bowel motions that are more urgent or frequent
 A small amount of bleeding or clear discharge when
passing a motion
 A sore or irritated rectum
 bloating, cramping or pain
• A small amount of bleeding or clear discharge when
passing a motion
• a sore or irritated rectum
• bloating, cramping or pain.
• Take anti-diarrhoea medication as directed by your
doctor.
• Drink plenty of fluids .
• Avoid spicy foods, dairy products, high fibre foods,
and coffee.

103. Bladder problems:
• Patient may have discomfort and burning while
urinating
• Blood in your urine(hematuria).
• There can be Incontinence which may be temporary
or ongoing.
• Increasing fluid intake will relieve from the burning
sensation when passing urine.

104. Sexual function and vaginal changes:
• Patient may get dryness, itching or a burning
sensation in the vagina.This may cause pain or
discomfort during sexual intercourse.
• Using a water-based lubricant may ease some
discomfort.
• To overcome vaginal dryness, patient can use an
internal moisturiser
• Provide information, support,and behavioral skills
regarding effective use of dilators and lubricants.
• Discuss about sexual functioning in non-judgemental
environment

105. Bowel changes:
Patient will have:
• Pain during bowel movements
• Small amount of bleeding or clear discharge when
passing a motion
• Diarrhoea
• Constipation
• Bowel incontinence

106. Bowel changes:
Patient will have:
• Pain during bowel movements
• Small amount of bleeding or clear discharge when
passing a motion
• Diarrhoea
• Constipation
• Bowel incontinence

107. Nursing Care for the patient undergoing
Radiation therapy
• Review treatment procedure (eg, external beam,
intracavitary).
• Review side effects of therapy (eg, to skin, effect on
blood values, vaginal stenosis as indicated).
• Explain mobility restrictions with intracavity, interstitial
radiotherapy as indicated.
• Assess for deep-vein thrombosis.
• Encourage diversional activities to relieve boredom.

108. Nursing Care for the patient undergoing
Radiation therapy
• Emphasize availability of pain relief measures.
• Explore non pharmacologic pain relief measures with
patient.
• Assess concerns related to sexual function (changes
in libido, orgasm, coital frequency, fertility).
• Assess cultural beliefs as they relate to treatment
(blood transfusions, avoidance of drugs, dietary
• restrictions).
• Assess spiritual needs/concerns

109. Side effects are common (occurring in greater than
30%) for patients taking Fluorouracil
• Diarrhea
• Nausea and possible occasional vomiting
• Mouth sores
• Poor appetite
• Watery eyes, sensitivity to light (photophobia)
• Taste changes, metallic taste in mouth during infusion
• Discoloration along vein through which the medication
is given
• Low blood counts

110. Diarrhea:
• Drink plenty of clear fluids (8-10 glasses per day).
• Eat small amounts of soft bland low fiber foods
frequently. Examples: banana, rice, noodles, white
bread.
• Avoid foods such as:
 Greasy, fatty, or fried foods.
 Raw vegetables or fruits.
 Strong spices.
 Whole grains breads and cereals, nuts, and
popcorn.
• Take antidiarrheal Loperamide
• Perform skin care around the anus gently with warm
water

111. Nausea and Vomiting:
• Drink fluids throughout the day like water and juices
• Eat small amounts of food throughout the day
• Eat dry foods such as dry cereal, toast , or crackers
without liquids especially first thing in the morning.
• Avoid heavy, high fat and greasy meals right before
chemotherapy.
• Relax and try to keep your mind off the
chemotherapy.
• Suck on hard candy, popsicles, or ice during
chemotherapy.
• Avoid caffeine and smoking
• Take anti-emetic drugs as prescribed:Aprepitant
,Dolasetron,Granisetron

112. Mouth sores:
• Rinse mouth with water frequently .May add salt or
baking soda (1/2 to 1 teaspoon in 8 ounces of water).
• Use saliva substitute if needed.
• Apply lip moisturizer often (i.e. chap stick).Suck on
hard candies.
• Keep mouth & teeth clean.
• Use soft-bristle toothbrush ,cotton swabs, mouth
swabs to clean teeth after each meal and at bedtime.
• Avoid mouthwash containing alcohol.
• Use topical or local agents such as Orajel, or Zilactin-
B apply generously.
• Take high protein and high calorie foods
• Avoid:Hot, spicy, coarse or rough textured foods.

113. Loss of apetite:
• Try to eat small meals or snacks instead of three
large meals a day.
• Take foods that are high in protein or calories.
• Eat foods that are rich in calories and nutrients.
• Avoid heavy meals, greasy or fried foods, and foods
that cause gas.
• Avoid smells that are obnoxious or bothersome to you
while you are eating.
• Add different seasonings to food in order to stimulate
apetite.
• Keep mouth clean by brushing at least 2 times/day

114. Watery eyes, sensitivity to light (photophobia)
• Using bright light when you are trying to read may
help.
• Wear corrective lenses, such as glasses, to improve
your vision.
• There may be redness, or swelling of the eyelids.
• There may be scratchy, watery or itchy eyes.
• Avoid touching or rubbing your eyes. wash your hands
before and after contact.
• Avoid contact with the substance that may cause
allergic reaction.
• In case of dry eyes,artificial tears, or ointments to help
alleviate dry eye syndrome.
• Wear dark or colored glasses .This will decrease the
amount of light that enters eyes, and make you less
sensitive to light.

115. Taste changes, metallic taste in mouth during infusion
• Maintain good oral hygiene - brush your teeth before and
after each meal.
• Choose and prepare foods that look and smell good to
you.
• Eat small, frequent meals.
• Do not eat 1-2 hours before chemotherapy and up to 3
hours after therapy.
• Use plastic utensils if food tastes like metal.
• Eat mints (or sugar-free mints), chew gum (or sugar-free
gum) or chew ice to mask the bitter or metallic taste.
• Avoid cigarette smoking
• Eat in pleasant surroundings to better manage taste
changes.
• Increase fluid intake

116. Low blood counts:
• Rest between activities.
• Avoid activities that make cause shortness of breath
• Eat a diet with adequate protein and vitamins.
• Drink plenty of non-caffeinated and non-alcoholic
fluids
• Perform frequent hand washing
• Avoid contact with anyone who is sick.
• Do not use rectal suppositories or take your
temperature rectally.
• avoid flossing teeth.
• Use a very soft bristle toothbrush or oral swabs
• Rinse with cold water.If bleeding of gums occurs.

117. Nursing Care For the Patient undergoing
Chemotherapy
• Explain treatment (rationale for chemotherapy, name of
chemotherapy agents, nadir, method of administration,
side effects).
• Assess psychological status of patient.
• Assess for anxiety, depression, changes in body, self-
image.
• Assess effects of treatment on quality of life.
• Assess concerns related to sexual function.
• Assess cultural beliefs as they relate to treatment (blood
transfusions, avoidance of drugs, dietary
• restrictions).
• Assess spiritual needs/concerns.

118. Nursing Management
Nursing Assessment:
• Patient’s history: risk factors, woman’s menstrual
history, abnormal bleeding or spotting between
periods or after menopause, metrorrhagia or
menorrhagia, dysparuenia and postcoital bleeding;
leukorrhea, abdominal or pelvic pain, persistent
vaginal discharge, postcoital pain and bleeding.
• Physical Examination: signs of inflammation,
bleeding, discharge, or local skin or epithelial
changes, examine the size, consistency, shape,
mobility, tenderness, and presence of masses of the
uterus and adnexa.

119. Nursing diagnosis
• Pain (acute) related to post procedure swelling and
nerve damage
• Anxiety
• Ineffective coping
• Ineffective sexuality patterns
• Risk for infection

120. Acute pain related to compression/destruction of nerve
tissue as evidenced by patients verbalization of pain ,
pain scale.
• Assess pain intensity , frequency ,character ,alleviating
and aggravating factors.
• Provide nonpharmacological comfort measures (massage,
repositioning, backrub) and diversional activities (music,
television).
• Encourage use of stress management skills or
complementary therapies (relaxation techniques,
visualization, guided imagery, biofeedback, laughter,
music, aromatherapy, and therapeutic touch).
• Provide cutaneous stimulation (heat or cold, massage).

121. Cont..
• Administer analgesics as indicated: NSAIDs,
opioids, corticosteroids.

122. Anxiety related to disease process as evidenced by
fatigue, pallor, diminished productivity, faintness sleep
disturbance and difficulty in concentration
• Monitor vital signs.
• Encourage patient to share thoughts and feelings
• Provide open environment in which patient feels safe to
discuss feelings or to refrain from talking.
• Explain the recommended treatment, its purpose, and
potential side effects.
• Administer antianxiety medications, e.g., lorazepam
(Ativan), alprazolam (Xanax), as indicated
• Refer to additional resources for counseling/support as
needed.

123. Ineffective coping related to uncertain prognosis, Gender
differences in coping strategies as evidenced by repeated
expressing of concerns related to disease and its prognosis
• Assess for the presence of defining characteristics.
• Assess for the influence of cultural beliefs, norms, and values
on the patient’s perceptions of effective coping.
• Observe for causes of ineffective coping such as poor self-
concept, grief, lack of problem-solving skills, lack of support, or
recent change in life situation.
• Identify specific stressors
• Monitor risk of harming self or others and intervene
appropriately.
• Assist patient set realistic goals and identify personal skills
and knowledge.
• Encourage the patient to recognize his or her own
strengths and abilities.
• Refer for counseling as necessary.

124. Sexual Dysfunction related to altered body structure and
function possibly evidenced by dyspareunia,
verbalization of problems with sexual function
• Obtain sexual history including usual patterns of
functioning and level of desire.
• identify current stressors in individuals situation.
• Avoid making value judgments
• Include partner in discuss if appropriate.
• Establish therapeutic nurse-client relationship.
• Instruct patient to perform Kegel exercises daily.
• Suggest sexual or psychological therapy, if appropriate.

125. Cont..
Risk for infection related to Compromised host defenses
.
• Assess for the presence, existence of, and history of risk
factors.
• Monitor white blood cell (WBC) count
• Assess and monitor nutritional status, weight, history of
weight loss, and serum albumin.
• Assess immunization status and history.
• Monitor the following signs of actual infection:Redness,
swelling, increased pain, purulent discharge from
incisions, injury, and exit sites of tubes (IV tubings),
drains, or catheters, Elevated temperature.
• Wash hands and teach patient
• Encourage intake of protein-rich and calorie-rich foods.
• Limit visitors.

126. Conclusion
• Cervical cancer is preventable,as the vast majority of
cases are caused, in part, by persistent infection with
oncogenic HPVs.
• Cervical cancer is a leading cause of death in
developing countries. the cause may be attributed to
poor socio-economic status, lack of awareness and lack
of accessibility of women in risk group to innovative
methods of screening and prophylactic treatment
modalities.
• Primary prevention efforts have focused on the
development of HPV vaccines to prophylax/prevent
oncogenic HPV infection.
• The role of a nurse is to create awareness regarding
early screening and vaccination against HPV and
promote social mobilization of females in age group 18-
22 yrs to such modalities.

127. References
• Hinkle.L Janice,Cheever H. Kerry.Brunner & Suddarth’s
Textbook Of Medical-Surgical Nursing.13th Edition.U.S:
WoltersKluwerHealth|Lippincott Williams & Wilkins.2014.
• Itano, J. K., & Taoka, K. N. (Eds.). (2005). Core
curriculum for oncology nursing (4th ed.). St. Louis:
Elsevier/Saunders.
• Newton, S., Hickey, M., & Marrs, J. (Eds.). (2009).
Mosby’s oncology nursing advisor: A comprehensive
guide to clinical practice.
• https://www.cancer.gov/types/cervical

128. thankyou