Gynecological Cancers

The different types of GYN cancers

Cervical- About 12,990 women will receive a new diagnosis this year in the
US
It is estimated that 4,120 women will die from cervical cancer.
Ovarian- The American Cancer Society estimates for ovarian cancer in the
United States for 2016 are:
About 22,280 women will receive a new diagnosis of ovarian cancer.
About 14,240 women will die from ovarian cancer.
Uterine- It is estimated that 10,470 deaths from this disease will occur this
year
It isestimated 60,050 women in the
United States will be diagnosed
with uterine endometrial cancer
and
Vaginal & Vulvar
(which will not be covered
in this presentation)

Nursing Interventions:

Teach women the importance of having routine screenings for

cancer of the reproductive system. (pap smear, and pelvic exam)

Teach women about hormone replacement therapy and the side

effects.

Manage client's pain related to chemotherapy

Monitor for infection

Teach client to prevent DVTs after surgery, i.e. frequent changes in

positions, leg exercises to promote circulation.

Offer encouragement and allow the patient to discuss her fears

regarding ovarian cancer.

Nursing Interventions Cont.

Provide additional education and help

the patient find a support group.
Explain the need for increased intake of
fruits, vegetables, and whole grains.
Also, a decreased fat intake of <30% of
calories.
Assess patient for body image changes
as a result of disfiguring treatment.

Cervical Cancer
What is cervical cancer?
There are few different types of cervical cancer.
Most up to 9 out 10, are squamous cell carcinomas ( these cells form in
the exocervix, most often beginning in the transformation zone where
the exocervix joins the endocervix.)
The rest are classified as adenocarcinomas (cancer that develop from
gland cells), or rarely, mixed with adenosquamous carcinomas.
The adenocarcinomas begin in the mucus glands and are often due to
HPV, which can be prevented by the Human Papilloma Virus Vaccine;
which is now offered as early as 12 years old.

Risk Factors
Sexual activity - With multiple partners/partners that have been
exposed to HPV
Early childbearing
Family history of cervical cancer
Smoking and exposure to second hand smoke
Over-weight or nutritional deficiencies such as folate, betacarotene and vitamin c

Clinical Manifestations
Early stages of cervical cancer rarely produces symptoms.
If they are present, they may go unnoticed as thin, watery
vaginal discharge often noticed after sexual intercourse
When symptoms such as discharge, irregular bleeding or pain
and bleeding after intercourse occur the disease may be
advanced.
The bleeding which occurs at irregular intervals (metrorrhagia)
may be slight and occurs after mild trauma or pressure
(douching, sexual intercourse or bearing down during
defecation)

Clinical Manifestations cont.

In advanced cervical cancer discharge gradually increases and becomes
watery than finally dark and foul smelling, from necrosis and infection.
Leg pain, dysuria, rectal bleeding and edema of the extremities signal
advanced disease. As the cancer advances it may invade the tissues
outside the cervix including the lymph glands anterior to the sacrum
In 1/3 of patients with invasive cancer the disease involves the fundus
(uterus), which may lead to infertility and or removal of the uterus. Also,
the nerves in the region may be affected producing excruciating back and
leg pain.
If the disease progresses it often produces extreme emaciation and anemia,
accompanied by fever (secondary to infection) and abscesses in ulcerating
mass/formulating fistula.

Assessment & Diagnostic

Findings
In its very early stages cervical cancer is found microscopically by PAP
smear
Diagnosis may be made on the basis of abnormal PAP smear results,
followed by biopsy results identifying severe dysplasia.
Screenings should begin within 3 years of the initiation of sexual
intercourse or at the age of 21.
In later stages pelvic examination may reveal a large, reddish growth or
deep ulcerating lesion; with this the patient may report spotting/bloody
discharge.
When the patient has been diagnosed with invasive cervical cancer,

Treatment Options
Many treatment options are available depending on severity of the cancer,
the following slides will discuss treatment options by stage.
Precursor or Preinvasive Lesions
When precursor lesions such as low grade squamous intraepithelial lesions
are found by colposcopy and biopsy careful monitoring by frequent pap
smears or conservative treatment is possible
Conservative methods consist of:

Frequent monitoring
Cyrotherapy- freezing with liquid nitrogen
Laser therapy- Also known as LEEP, loop electro-cautery excision procedure
An outpatient procedure usually performed in a GYN office which involves a
thin wire loop with a laser is used to cut away a thin layer of cervical tissue.
Conization: a cone shaped portion is removed to biopsy in search of CIN III or
HGSIL (severe dysplasia & carcinomia in situ)

Preinvasive cervical cancer (carcinoma in situ) occurs when a woman has

completed child bearing, ( a simple hysterectomy) is usually recommended. If a
woman is pregnant or wishes to have children, and invasion is less than 1mm,
Conization may be sufficient. Frequent follow up examinations are necessary to
monitor for recurrence.

Conization

Cryotherapy

LEEP

Treatment Options cont.

Invasive Cancer- treatment for invasive cancer depends on the stage of
the lesion, the patients age and general health, also the judgment and
experience of the provider.
Surgery and radiation treatment (intracavity and external) are most often
used.
Surgical procedures consist of:
Total hysterectomy: removal of uterus, cervix and ovaries.
Radical hysterectomy: removal of uterus, ovaries, fallopian tubes, proximal vagina, and
bilaterial lymph nodes through an abdominal incision.
Radical vaginal hysterectomy: vaginal removal of the uterus, ovaries, fallopian tubes and
proximal vagina.
Bilateral pelvic lymphadenectomy: removal of the common iliac, external iliac, hypogastric,
and obturator lymphatic vessels and nodes.
Pelvic exenteration: removal of pelvic organs, including the bladder or rectum and pelvic lymph
nodes and construction of diversional conduit, colostomy and vagina.
Radial trachelectomy: removal of the cervix and selected nodes to preserve child bearing

Treatment Options cont.

Radiation which is often part of treatment to reduce recurrent disease may be delivered via
external beam or by Brachytherapy.
Brachytherapy is a method of radiation in a sealed source near the affected area
(tumor).
To treat cervical cancer who a woman who has previously had a hysterectomy a cylinder of radioactive
material is placed in the vagina, for women who still have a uterus a tandem (which is a small metal tube)
is inserted in the uterus along with small round metal holders called ovoids placed near the cervix, this is
known as tandem and ovoid treatment, also available in tandem and ring treatment, for this a round
holder like a disc is placed close to the uterus.
Selection for treatment depends on what type of brachytherapy is planned.

Low dose brachytherapy treatment: is completed in a few days, during which the
patient is on bed-rest in the hospital with instruments such as the ovoids in place holding
the radioactive material.
High dose brachytherapy treatment: is done outpatient over several treatments (often
at least 1 week apart). For each high dose treatment the material is inserted for a few
minutes and then removed, the advantage of this treatment is not having to remain still for
prolonged periods.
The benefit of brachytherapy is that the radiation only travels a short distance; the main
affects are on the cervix and vaginal walls. The most common side effect is irritation of the
vagina, though brachytherapy can cause many of the same side effects as external beam
radiation. Often brachytherapy is given right after external beam (before the side effects

Are you smarter than the

NCLEX?
Which patient is at highest risk for cervical cancer?*

A. A 21 year old who reports first sexual partner at the age of 14

and that she has had at least 10 sex partners.
B. A 60 year old with a history of syphilis and cigarette smoking.
C. A 32 year old in a monogamous relationship who declined the
HPV vaccine.
D. None of the patients are at risk for cervical cancer.

Answer
A. A 21 year old who reports first sexual partner at
the age of 14 and that she has had at least 10 sex
partners.
Due to the patient's young age of a first sexual
encounter (any age before 17 is significant) and
multiple sex partners, drastically increases a person
risk of cervical cancer.

Everyones favorite kind of

question!
The nurse is giving instructions to a patient who is
undergoing brachytherapy for cervical cancer. What
information does the nurse include? Select all that
apply
A. Limit interactions with others between
treatment for their protection
B. You are not radioactive between treatments
C. Report any blood in the urine or severe
diarrhea immediately
D. Expect heavy vaginal bleeding during this time
E. You will be on bed-rest during the treatment

Answer
B-You are not radioactive between treatments
C- Report any blood in the urine or severe diarrhea
immediately
E-You will be on bed-rest during the treatment session

Yes, another one. Youre

probably all so excited!
A client is being admitted to the hospital for a radiation implant for
cervical cancer. The nurse teaches the client that:
A.It is fine for the client's school age children to visit as long as they
limit the visit to less than one hour.
B. The client will be radioactive for one month after the radiation
implant is removed.
C.Visitors should be limited. Small children and pregnant women
should not visit.
D.The client's urine and stool will be not be radioactive while the
implant is in place.

Answer
C. Visitors should be limited. Small children and pregnant
women should not visit.

Uterine Cancer
Endometrial cancerdevelops in the lining of the uterus, called the endometrium.
This is the most common type of uterine cancer, accounting for more than 95 percent
of cases.
Uterine sarcomais a more rare type of uterine cancer, and forms in the muscles or
other tissues of the uterus.
3 types
Type 1
Most common (80%)
Estrogen related
Occurs in women who are younger, obese, and perimenopausal
Low grade with a good prognosis

Type 2
10% cases
High grade
Serous cell of clear cell
Older and African American women at higher risk

Type 3
10% cases
Hereditary and genetic

Uterine Cancer
Staging
Uterine cancer is staged using the American Joint Committee on Cancer TNM
system:
Tumor (T) describes the size of the original tumor.
Lymph Node (N) indicates whether the cancer is present in the lymph
nodes.
Metastasis (M) refers to whether cancer has spread to other parts of
the body, usually the liver, bones or brain.
Stage 0
Pre-cancerous lesion
carcinoma in-situ
cancer cells on surface of endometrium
Stage 1
cancer cells growing in uterine body but not spread to lymph nodes
Stage 2
cancer has spread from the uterine body and into the supporting
connective tissue of the cervix
Has not spread outside of uterus
Stage 3
cancer has spread outside of the uterus or into nearby tissues in the
pelvic area.
Stage 4
cancer has spread to the inner surface of the urinary bladder or the
rectum to lymph nodes in the groin, and/or to distant organs (bones,
omentum or lungs)

 Age > 50 years

Risk Factors

Cumulative exposure to estrogen

Early menarche (before 12 years old)
Late menopause (after age 52)
Nulliparity (not baring offspring)
Anovulation (ovaries dont release oocyte)
Obesity which leads to increased estrogen levels from conversion
of androstenedione to estrogen in body fat which exposes uterus
to unopposed estrogen
Unopposed estrogen therapy (estrogen used without
progesterone)
Use of tamoxifen (Estrogen modulator to treat breast cancer) can
cause proliferation of uterus
Infertility
Diabetes

Signs & Symptoms

Abnormal bleeding
bleeding between periods
prolonged periods
bleeding after intercourse or after menopause
Watery or bloody discharge
Pain during intercourse or at other times

Assessment & Diagnostics

Pelvic exam

Endometrial aspiration or biopsy to rule out hyperplasia (a precursor to

endometrial cancer)

-Not painful
Transvaginal ultrasound to measure thickness of endometrium
Post-menopausal women should have a thin endometrium due to low levels
of estrogen

CT Scan
Dilation & Curettage
Dilate with cervix and scrape the lining of the uterus
Under general anesthesia

Hysteroscopy
lighted microscope

MRI
Lab tests
Genomic tumor assessment to identify mutations
Tumor molecular profiling to identify proteins, enzymes, and genes

Sentinel lymph node biopsy

Used to diagnose and stage cancer
Radioactive substance or dye is injected at the tumor site and the first lymph
node to absorb it is where the cancer first spread

Treatment Options
Therapy based on:
Stage
Type
Differentiation
Degree of invasion
Node involvement
Surgical staging:
Total or radical hysterectomy (uterus and cervix are
removed)
Bilateral salpingo-oophorectomy (remove uterus,
cervix, ovaries and fallopian tubes)
Lymphadenectomy
Cancer antigen 125 (CA-125) levels should be monitored
because elevation means extrauterine disease or
metastasis

Treatment Options cont.

Radiation:
External beam
lower the risk of gastrointestinal and sexual function side
effects
A fast, painless outpatient procedure
Once a day for 5 days in a row
Up to 2-10 weeks

Brachytherapy
catheter placed inside close to the tumor and radioactive
pellets inserted
controls the location and intensity for maximum dose
Less sessions required for complete treatment

Whole pelvis radiotherapy if it is spread beyond uterus

Side effects of radiation:
Fatigue, nausea, vomiting, diarrhea, bladder or rectal irritation, anemia,
leukopenia,
Vaginal dryness or stenosis, lymphedema, weaken bones

Treatment options cont.

Chemotherapy
Useful for cancer that has spread beyond endometrium
Side effects:

Nausea and vomiting, Loss of appetite

Mouth and vaginal sores
Hair loss
Leukopenia
Anemia
Thrombocytopenia

Hormonal therapy

Progestins

medroxyprogesterone acetate (Provera)

megestrol acetate (Megace)
intrauterine device that contains levonorgestre (Mirena)
Side effects:
hot flashes, night sweats, weight gain (from fluid retention and an increased appetite),
and worsening of depression
Hyperglycemia in women with diabetes

Luteinizing hormone-releasing hormone agonists

For women who still have functioning ovaries

Question 1:
In staging and grading neoplasm TNM system
is used. TNM stands for:
A) Time, neoplasm, mode of growth
B) Tumor, node, metastasis
C) Tumor, neoplasm, mode of growth
D) Time, node, metastasis

Answer

B) Tumor, node, metastasis

Question 2:
A client had undergone radiation therapy
(external). An expected side effect is:
A) Fatigue
B) Ulceration of oral mucous membranes
C) Constipation
D) Headache

Answer

A) Fatigue

Question 3:

What are the signs and symptoms of

uterine cancer, select all that apply:

A) Abnormal bleeding
B) Watery or bloody discharge
C) Vaginal itching
D) Pain during intercourse

Answer
A) Abnormal bleeding
B) Watery or bloody discharge
D) Pain during intercourse

Ovarian Cancer

Ovarian cancer is the leading cause of GYN cancer deaths in the United States
Difficult to detect despite careful physical examination because they are usually deep in the
pelvis
For now there isnt any early screening mechanism to detect it

The cancer begins in the ovaries (produces eggs for reproduction, main source of the female
hormones estrogen and progesterone)
Three types
Germ cell tumors - start from the cells that produce the eggs (ova).
Epithelial cell - start from the cells that cover the outer surface of the ovary. Most
ovarian tumors are epithelial cell tumors.
Stromal tumors - start from structural tissue cells that hold the ovary together and
produce the female hormones estrogen and progesterone.
Most of these tumors are benign (non-cancerous) and never spread beyond the ovary. Benign
tumors can be treated by removing either the ovary or the part of the ovary that contains the
tumor.

Risk Factors
Family history
First degree relative mother, daughter, or sister
5-10% are family cancer syndrome
If have had breast cancer = high risk for ovarian cancer
The risk of ovarian cancer after breast cancer is highest in those
women with a family history of breast cancer
Increases after age of 40, but most common after the age of 60 yr
Reproductive history
first full term pregnancy after the age of 35
never carried a pregnancy to term
Estrogen and hormone therapy
Estrogen after menopause = high risk
Highest in industrialized countries
Affects more Caucasian women than African American women
Late menopause
Obesity
However, most woman that develop ovarian cancer have no known risk
factors

Prevention Methods
Using oral contraceptives (birth control pills) decreases the
risk of developing ovarian cancer, especially among women
who use them for several years
Hormone therapy - Estrogen and progesterone both = less risk
Gynecologic surgery - Both tubal ligation and hysterectomy
may reduce the chance of developing ovarian cancer,
Regular women's health exams

Wait, before we move on

Question time:

A client with ovarian cancer asks the nurse, What is

the cause of this cancer? The most accurate
response by the nurse is:

A. Use of oral contraceptives increases the risk of

ovarian cancer.
B. Women who have had at least two live births are
protected from ovarian cancer
C. There is less chance of developing ovarian cancer
when one lives in an industrialized country.
D. the risk of developing ovarian cancer is related to
environmental, endocrine, and genetic factors.

Answer:

D. the risk of developing ovarian cancer is

related to environmental, endocrine, and
genetic factors.

A definitive cause of the ovary is unknown.

The highest incidence is in industrialized
Western countries. Use of oral contraceptives
does not increase risk of developing ovarian
cancer, but its protective. Endocrine risk
factors include women who are nulliparous.

Clinical Manifestations

Increased abdominal girth

Pelvic pressure
Bloating
Back pain
Constipation
Abdominal pain
Urinary urgency
Indigestion
Flatulence
Increased weight size
Leg pain
Pelvic pain

Symptoms are so vague that we often tend to ignore

Ovarian cancer is silent but enlargement of the abdomen from an
accumulation of fluid is a common sign
Vague, undiagnosed, persistent gastrointestinal symptoms should get
evaluated for potential ovarian cancer
Palpable ovary for a woman who already passed menopause should
be checked immediately because after menopause ovaries should be
smaller and less palpable

Assessment & Diagnostics

Any enlarged ovary must be investigated.
Pelvic examination does not detect early ovarian cancer and
Pelvic imaging techniques are not always definitive
By time of dx most ovarian cancers are advanced
Dx:
MRI scan
Transvaginal
Pelvic ultrasound
Chest x-rays
Blood test for CA-125 - protein in the blood. In many
women with ovarian cancer, levels of CA-125 are high
To rule of metastasis abdominal CT scan

Question time
What is the primary factor for the low survival rates
for patients who are diagnosed with ovarian cancer?
a. Ovarian Cancer develops in patients with
underlying immunosuppression and poor health.
b. Ovarian cancer does not respond well to
conventional radiation and chemotherapy
treatments.
c. Symptoms are mild and vague, therefore, the
cancer is often not detected until its late stage.
d. There are no specific diagnostic tests that can
confirm or rule out ovarian cancer.

Answer:

C. Symptoms are mild and vague,

therefore the cancer is often not
decided until its late stage.

Whomps another question

When teaching a client about ovarian cancer, the

nurse should include information about which of
the following? Select all that apply.

A. details about the prognosis.

B. staging and grading of ovarian cancer.
C. need for routine colonoscopy beginning at age
30.
D. procedure for diagnosis if there is a pelvic mass.
E. symptoms occurring early in the disease
process.

Answers:

B. staging and grading of ovarian

cancer.
D. procedure for diagnosis if there is a
pelvic mass.

Client teaching emphasizes the

importance of regular gynecologic
examinations.

Treatment Options

Medical Management:

Surgical removal treatment of choice stages the tumor by TNM

system that is performed to guide treatment
Likely treatment total abdominal hysterectomy
Removal of fallopian tubes and ovaries

Pharmacological therapy
Chemotherapy
Paclitaxel
Carboplatin
Lipsomal therapy
Delivery of chemotherapy in a liposome
Allows the highest possible dose of chemotherapy to the
tumor target with a reduction in adverse effects
Combination IV and intraperitoneal chemotherapy
symptoms:
Pain, fatigue, and hematologic, gastrointestinal, metabolic,

Treatment Options cont.

Radiation therapy for ovarian cancer
Radiation therapy uses high energy x-rays or particles to kill cancer cells. These x-rays may be
given in a procedure that is much like having a regular (diagnostic) x-ray. In the past radiation
was used more often for ovarian cancer, at this time radiation therapy is only rarely used in this
country as the main treatment for this cancer. It can be useful in treating areas of cancer spread.

External beam radiation therapy

In this procedure, radiation from a machine outside the body is focused on the cancer. This is the
main type of radiation therapy used to treat ovarian cancer. Treatments are given 5 days a week
for several weeks. Each treatment lasts only a few minutes and is similar to having a regular xray. As with a regular x-ray, the radiation passes through the skin and other tissues before it
reaches the tumor. The actual time you are exposed to the radiation is very short, and most of the
visit is spent getting precisely positioned so that the radiation is aimed accurately at the cancer.

Brachytherapy
Radiation therapy also may be given as an implant of radioactive materials, calledbrachytherapy,
placed near the cancer. This is rarely done for ovarian cancer.

Radioactive phosphorus
Radioactive phosphorus was used in the past, but is no longer part of the standard treatment for
ovarian cancer. For this treatment, a solution of radioactive phosphorus is instilled into the
abdomen. The solution gets into cancer cells lining the surface of the abdomen and kills them. It
has few immediate side effects but can cause scarring of the intestine and lead to digestive
problems, including bowel blockage.

Last Question:
A patient who had total abdominal hysterectomy is
anxious to resume her activities because she has young
children at home. What post procedure information does
the nurse provide to patient? ( Select all that apply.)
a.
b.
c.
d.
e.

Climb stairs to build strength and endurance.

Avoid sitting for prolong periods.
Do not lit anything heavier than 5 to 10 lbs.
Walk or jog at least 1-2 miles everyday.
When sitting, do not cross legs.

Answers:

B. avoid sitting for prolong period of

time.
C. do not lift anything heavier than 5 to
10 lbs.
E. When sitting, do not cross legs.

Thank you

References

Cervical

http
://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-trea
tingradiation
http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancerwhat-is-cervicalcancer
Oncology chapter from Brunner & Suddarth vol. 2

Uterine:

http://www.cancercenter.com/uterine-cancer/

http
://www.cancer.org/cancer/endometrialcancer/detailedguide/endometrial
-uterine-cancer-what-is-endometrialcancer
http://www.webmd.com/cancer/tc/endometrial-cancer-treatmentoverview
http://www.cancer.net/cancer-types/uterine-cancer/statistics

Ovarian: