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02.12 Cervical Cancer

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Overview

  1. Direct link to Human Papillomavirus (HPV)
    1. Preventable, sexually transmitted infection
    2. Vaccination available
    3. Suggested for all women and men 26 and younger
  2. Incidence much higher worldwide than in US
    1. Treatable, cure dependent on extent of disease spread
    2. 60-80% 5-year survival rate if caught stage 1 or 2
    3. Less than 50% stage 3 or 4

Nursing Points

General

  1. Higher incidence worldwide vs. US due to well known screening guidelines
    1. Screening every 3 years starting with onset of sexual activity or at age 21, whichever comes first
    2. Gardasil vaccination available to prevent HPV
      1. Both men and women eligible for vaccination
  2. Risk factors
    1. Known HPV infection
    2. Obesity
    3. HIV infection
    4. Multiple sexual partners
    5. Smoking
    6. Using birth control pills for a long time (five or more years).
    7. Having given birth to three or more children.
  3. Prevention
    1. Gardasil-9 vaccination
    2. Protects against 9 strains of HPV known to cause cervical cancer
    3. 3 shot series available to men and women up to age 26

Assessment

  1. Signs & symptoms
    1. Vaginal bleeding
      1. Not related to period
      2. Abnormal in amount or substance
      3. Post-menopausal
    2. Vaginal pain
    3. Foul smelling discharge
    4. Pain with urination
    5. Pain with intercourse
  2. Routine monitoring
    1. Pap smear every 3 years at onset of sexual activity until age 30
    2. HPV screening every 3-5 years until age 65
    3. Recommendations constantly changing

Therapeutic Management

  1. Dependent on staging at time of diagnosis
    1. Early phase may only require surgery
      1. Cryosurgery
      2. Ablation
      3. Conical excision of affected area
    2. Otherwise, combination of surgery, chemotherapy, and radiation
      1. Surgery: Partial or Radical Hysterectomy
        1. Advanced Stage: Pelvic Exoneration
      2. Radiation
        1. Internal Radiation (Brachytherapy) – radioactive device inserted into vaginal canal to directly radiate the cervix
        2. Traditional Radiation
      3. Chemotherapy
    3. May not be treating for cure
      1. Any therapy can be palliative
  2. Fertility
    1. Encourage referral to oncofertility prior to intervention
    2. Hysterectomy is common

Nursing Concepts

  1. Health Promotion
    1. Preventing HPV infection is key to preventing cervical cancer
    2. Encourage adherence to routine screening
  2. Infection Prevention
    1. Prevent HPV infection
    2. Encourage vaccination
  3. Reproduction
    1. Encourage oncofertility consult for women of childbearing age
    2. Hysterectomy is common even in early stage disease

Patient Education

  1. HPV Prevention
    1. Gardasil vaccine
    2. Safe sex practice
    3. Routine screening
  2. Fertility Impact
    1. Hysterectomy and pelvic radiation is common
    2. Encourage consult to oncofertility
  3. Treatment specific education
    1. Chemotherapy precautions
    2. Post-surgical recovery expectations
    3. Radiation side effects

Reference Links

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Video Transcript

Hi guys. Today, we’re going to be talking about cervical cancer and before we get into the cancer, we’re going to talk about a brief anatomy review. So what are the female reproductive organs? We see this picture a lot, right? Female power. So we have ovaries, the vagina, the cervix, and the uterus, right? So we’re talking about the cervix right here, cervical cancer.

All right.

Now cervical cancer is pretty unique in that it is directly linked to a virus, human papillomavirus, or HPV has a direct link to cervical cancer, which has significantly decreased the amount of cervical cancer. We see because we have a vaccine available for this. So what is human papillomavirus? It’s a sexually transmitted infection, so safe sex practices can prevent cervical cancer from forming. But also we do have the vaccine available. There is no cure for HPV, but there is a way to prevent it. And that again is safe, sex practice using protection and then recommending the vaccine. So the vaccine is suggested for all women and men younger than 26. It is given as a series of shots. It’s either two shots if you’re less than 14 or a series of three shots if you’re older than 14. And honestly, sometimes it’s even given to patients that are older than 26 years old that they think it will be beneficial for. Okay. So some facts about cervical cancer. It is a treatable cancer but the cure does depend on the extent of disease like with all cancers, right? But it does have a pretty high survival rate it is 60 to 80%, five-year survival if it’s caught in stage one, but it is less than 15%. If it’s caught in stage three and four. Incidence is much higher worldwide than in the United States because we have done significant things to prevent this in the United States. We do screening,

and we do the HPV vaccine, and we also do early treatment. So if we find abnormal cells on this screening, we’re going to treat them right away. And we’re going to talk about that screening. So the whole reason we get pap smears is to look for cervical cancer. I mean, also STDs and stuff are detected when we do vaginal exams, right? Pap smears are looking for cellular changes to the cervical tissue. Okay. So, girls, I know you’ve been through plenty of pap smears before, but for the gentlemen that have not, I’ll just review it quickly. So a speculum is inserted into the vagina and cells are scraped off the cervix to analyze for abnormalities. And it is as uncomfortable as it sounds that scraping is not comfortable, but the cells are then, um, assessed to see if there are any abnormalities. If there are abnormal cells, they’ll do additional testing. That’s done with actually a vinegar wash and then the cells are visualized and that’s called a colposcopy.

And that’s done through the vagina also with a vinegar wash to look at the cells. And then they’ll also take a biopsy if needed. Okay. So we do our pap smears, right. Recommendations for when we should get the vaccine kind of change over time. But right now we’re saying every three years, get your pap smear ladies up to age 65. HPV screening is another great thing we do here, it’s done the same way during the pap smear usually. This, we recommend doing every three to five years to assess for HPV. And as I said, recommendations do change over time. So just make sure you’re up to date. So you can educate your patients on what they need to do. Symptoms of vaginal cancer are related to the cancer, attacking the cervix. Right? I said, vaginal cancer, I’m sorry. I meant cervical cancer. Right? So the cancer is attacking the cervix. So of course we’re going to have bleeding and pain and discharge. Those symptoms all make sense, right? So this bleeding can even be post-menopausal. It can be not related to your period, after intercourse, and the pain also can be related to intercourse or any kind of pain you didn’t have before. There shouldn’t be any pain, so what’s going on, right? If you notice that then you need to get checked out. Then discharge can be purulent or foul-smelling. So just any changes, right? Get checked out. If you notice any changes, late symptoms are related to tumor growth. If the tumor is getting bigger and spreading into that pelvic area. So they might have radiating pain sometimes it’s to the left flank, or they could have pelvic pressure or urinary changes like blood in the urine, even as the cancer is spreading and damaging other organs. Treatment. We have several options for treatments here. Surgery, as you kind of saw briefly in the next slide, We’re going to be talking about many different surgical options and then radiation, and chemotherapy is done in conjunction often with this surgery. Radiation has two options. It can be internal or external beam radiation. The internal beam is preferable since there are so many abdominal organs around there. Chemotherapy can be done before or after surgery. And then remember all of these treatments can be palliative. Even if we know there’s not a cure, pursuing treatments can improve a patient’s comfort and quality of life. So we need to make sure we’re always having those conversations with our patients. What do they want to do? What are their goals for treatment? Okay, so surgical procedures, we do cryosurgery and ablation. We do these to treat precancerous cells. So if we see that there are some cellular changes on that pap smear, we can do cryosurgery, which freezes the cells or laser ablation. So this just destroys those precancerous cells so they don’t develop into cancer. And then we have some other options to remove the cancer. A conical incision, a cone biopsy is when we take out a cone-shaped section of the cervix and we remove those cells, this can actually be done for precancerous cells or cancerous cells too. And then a trachelectomy or a hysterectomy is done. A trachelectomy is done to preserve fertility. It removes the cervix and part of the vagina. So it removes the cervix and part of the vagina, but the uterus is left intact, and that’s how it preserves fertility and a hysterectomy takes out the uterus also, so they can not have children. So we’ll refer them to a fertility specialist. Pelvic exoneration or exoneration is extreme. This is taking out all the organs in the pelvic cavity. So this blue line we’re taking out all of these organs, the vagina, the bladder, the uterus, the ovaries, the cervix, the bowel, and the anus. So obviously this is also gonna come with some reconstructive surgery, a colostomy somehow to reroute the passage of stool and urine. And this is life-changing, right? It takes a long time to recover from something like that and to adjust to your new normal, right? So patient education with cervical cancer. We need to talk about the fertility impact, recommend that they talk to a fertility specialist if they want to bank their eggs, right. Treatment, specific education. If they’re going through surgery if they’re going through chemo or radiation, what is that going to look like? And then HPV prevention, right. So important. With that is getting screening appropriately. Nursing concepts, health promotion, we want our patients to make sure they get their routine screening. Infection prevention, we’re checking for that HPV infection- vaccinate to prevent it, and then reproduction oftentimes these are women of childbearing age. And we want to refer them for banking or to an onco fertility specialist. So some key points here with cervical cancer, HPV a million times, I can say this HPV prevention, this is huge, huge, huge, early detection and treatment with our screening. And then we have multiple treatment options for this cancer. All right, guys, that’s all I have about cervical cancer. Go out and be your best selves today. And as always happy nursing.

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