Cervical Cancer: Prevention and Treatment

By Mary Alice Tinari, RN, AOCN, MSN

Nursing made Incredibly Easy!

November/December 2008 2.5 ANCC/AACN contact hours Online: www.nursingcenter.com

© 2008 by Lippincott Williams & Wilkins. All world rights reserved.

Two Main Types

 Squamous cell carcinoma—responsible for the majority of cervical cancers; typically occurs in the transformation zone of the cervix  Adenocarcinoma—responsible for 20% of cervical cancers; arises from the mucus producing gland cells of the endocervix  Mixed adenosquamous carcinoma is also possible

Picturing Cervical Cancer

Two Grading Systems

 Cervical intraepithelial neoplasia (CIN) grading system    CIN I describes mild dysplasia CIN II describes moderate dysplasia CIN III describes severe dysplasia or a lesion that involves the full thickness of the epithelium  National Cancer Institute’s (NCI) Bethesda system provides further details about the quality of Pap test results

Risk Factors

 Exposure to human papillomavirus (HPV)   Present in 99% of cervical cancers One-third of American women infected with HPV by age 24  Sexual activity  Multiple sex partners    Early age at first intercourse Sex with a promiscuous partner History of sexually transmitted diseases  Family history of cervical cancer  Low socioeconomic status  Smoking and exposure to secondhand smoke  Multiple pregnancies or early childbearing  Long-term contraceptive use

HPV

 Over 100 different types of HPV; types 6 and 11 responsible for genital warts  Affinity for epithelial cells  HPV proteins bind with p53 tumor suppressor, interfering with normal cell growth  Most individuals are unaware of contracting HPV because symptoms may not develop for years

Signs & Symptoms

 Bleeding between menstrual periods or after intercourse, douching, or pelvic exam  Increased vaginal discharge  Pelvic pain or pain after intercourse  Locally advanced disease may cause pain in the legs, back, or pelvis; bleeding from the rectum; or blood in the urine  Cancer spread outside the pelvis can cause bone pain, fractures, or lung problems

Diagnostic Testing

 Pap test—microscopic exam of cells from the cervix  Results fall into six major categories  After cervical cancer is diagnosed, it’s staged using the International Federation of Gynecology and Obstetrics (FIGO) system or the TNM (tumor, node, metastasis) system

Pap Test Categories

 Normal—most frequent result; 90% to 95% of the time 

Atypical squamous cells of undetermined

significance (ASC-US)—60% of women are HPV-negative; 40%, HPV-positive 

Atypical glandular cells of undetermined

significance (AGC-US)—50% of women will have normal histology; high-grade lesions may be found in 20% to 50% of women with this result

Pap Test Categories



Low-grade squamous intraepithelial lesions

(LSIL)—typically an HPV infection result in 75% women age 35 and younger; in older women, due to declining estrogen  High-grade squamous epithelial lesions— 90% of women will show cell changes due to HPV  Cancer—either squamous cell carcinoma or adenocarcinoma

Pap Results and Care

 For ASC-US:     Standard of care is to repeat the PAP test in 4 to 6 months If HPV testing is positive, colposcopy is indicated If HPV-negative, the PAP test is repeated in 1 year Post-menopausal women may have estrogen therapy for 3 months and then repeat the PAP test  For AGC-US:  Requires colposcopy and endometrial biopsy for women over age 35 with bleeding

Pap Results and Care

 For LSIL in sexually active adolescents:  Colposcopy indicated  For LSIL in post-menopausal women:    Treated with 3 months of estrogen therapy, if not contraindicated The Pap test is then repeated 1 week after estrogen therapy is stopped If vaginal atrophy is absent, the woman is treated as if the Pap result was ASC-US

The FIGO Staging System

Treatment Options

 Women with CIN 1 or LSIL have the option of no treatment because 50% to 70% of these lesions spontaneously resolve; a PAP test is required every 6 months  If lesions progress and don’t resolve within 2 years, treatment includes:     Cryotherapy—freezing used to treat CIN 1 lesions Loop electrosurgical excision—uses a thin wire loop through which an electric current is passed, turning the loop into an effective cutting tool Laser ablation—indicated for lesions that extend into the cervical canal Cold-knife conization—uses a scalpel to remove the portion of the cervix that contains the abnormal cells

Other Treatments Options

 If invasive cancer is found, a total hysterectomy is performed  For more advanced cancers, a radical hysterectomy is performed  Chemotherapy/radiation is used when margins of normal tissue are difficult to obtain or if cervical cancer relapses  Fertility-sparing surgery may be an option for early-stage cervical cancer

Picturing Total Hysterectomy

Follow-Up Care

 PAP test every 3 months for the first year following successful treatment  PAP test every 4 months for the second year  PAP test every 6 months for the third year  Annually thereafter

Patient Teaching and Prevention

 Explain testing  Offer emotional support  Reinforce the need for regular monitoring after an abnormal PAP test result  Screening by Pap test should be started when a woman becomes sexually active or by age 21, regardless of sexual activity  Quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine for young women ages 9 to 26, given I.M. in three doses over 6 months; 99% effective in preventing precancerous cervical changes