CERVICAL_CANCER_PRESENTndjATION_rsm.pptx

How to manage it

1. CERVICAL CANCER Mumba sama rodrick

2. Overview Introduction Epidemiology Risk factor Staging/diagnosis Treatment Prevention Nursing care / Complications

3. INTRODUCTION Cervical cancer is a cancer affecting the cervix. The cervix is the lower part of the uterus that opens into the vagina. Cancer occurs when the abnormal cells of the cervix grow out of control. In the development of cancer, cells change from normal to pre-cancer (dysplasia) and then to cancer. Cervical cancer mainly occurs in the transitional zone.

4. EPIDEMIOLOGY Worldwide, cervical cancer is the second leading cause of cancer death in women. Cervical cancer affects 16 per 100,000 women and kills about 9 per 100,000 in the world. They are about 500,000 new cases each year in the world and of these 75% occurs in developing countries. Cytology testing has reduced the incidence of cervical cancer by 70% in countries where it is easily available.

5. EPIDEMIOLOGY- Cont In Zambia cervical cancer is the cancer with the highest incidence Cervical cancer made up 32% of all cancer recorded in 2013 at CDH. 665 New cervical cancer patients were recorded in 2013 at CDH.

6. TOP 10 CANCERS IN ZAMBIA- 2013 cervical cancer (32%) has always been on top of CDH disease chart, then followed by breast cancer (9%). Cancers # of Pts % Cervical 665 32 Breast 188 9 Kaposi's sarcoma 151 7 Prostate 102 5 Lymphomas 100 5 esophagus 51 2.5 Colerectal 39 2 keloids 30 1.5 Hepatocellular 18 1 Eye 15 1

7. CERVICAL CANCER AND HPV Human papilloma virus (HPV) is central to cervical carcinogenesis Worldwide the prevalence of HPV in cervical tumours 99.7% High risk HPV types in 16, 18, 31, 33, 41 & 45 50% of cervical cancers are caused by HPV type i6 & 18 High risk HPV infection is necessary but not sufficient for development of cervical cancer.

8. CERVICAL CANCER AND HPV-cont HPV causes the production of two proteins known as E6 & E7 When these proteins are produced, they turn off some tumour suppressor genes These will result in the cervical lining cells to grow uncontrollably and may lead to cancer formation.

9. Additional Risk factors Early onset of sexual activities Multiple sexual partners/ multiple pregnancies/oral contraceptives Immunosuppression History of STI’s Low social-economical status Previous history of vulva, vaginal or cervical squamous dysplasia Smoking

10. SIGNS AND SYMPTOMS Early stage Late stage Often no symptoms -pelvic/lower back pain Vaginal discharge - Sciatica Abnormal vaginal bleeding - Weight loss -Post coital bleeding - Bowel or bladder fistula -Abnormal menses -Post menopausal bleeding -Dysparunia

11. TYPES OF CERVICAL CANCER They are two main types of cervical cancer, squamous cell carcinoma and adenocarcinoma Squamous cell carcinoma accounts for 80 to 90% of all cervical cancers Adenocarcinoma account for 10 to 20% Others account for less than 1% -Adenosquamous cell, glassy cell, carcinoid tumour, neuroendocrine tumour, small cell tumour, undifferentiated

12. PATTERN OF SPREAD Local invasion Lymphatic spread Risk related to depth of invasion -Pelvic nodes before par aortic or supraclavical nodes Haematogenous spread -Common in adenocarcinoma, neuroendocrine or small cell carcinoma Intraperitoneal spread -Unknown prevalence but associated with poor prognosis

13. STAGING Staging is the assessment of cervical cancer to decide how far the disease has progressed Cervical cancer is staged by the International Federation of Gynaecology and Obstetrics (FIGO) staging system The stages runs from stage O to stage 4. Stage O represents early cancer and stage 4 means the cancer has spread to significant parts of the body Stage o is easily cured whilst stage 4 is incurable

14. STAGING FIGO staging is based on clinical examination. It allows only the following diagnostic tests to be used, -Palpation - Proctoscopy -Inspection - Intravenous urography (IVU) -Colposcopy -Cervical colonisation - Endocervical currettege –X ray -Hysteroscopy - Cystoscopy

15. Staging STAGE O –carcinoma in situ STAGE 1 –limited to the cervix. 1A – done by microscopy; no visible lesions. 1A1-stromal invasion <3mm by < 7mm 1A2 – stromal invasion 5mm by 7mm . 1B –visible microscopic lesion <5mmby <7mm. 1B1 –visible lesion 4cm or > great dimension. 1B2- visible lesion more than 4cm.

16. Staging cont. STAGE 2 –invades beyond the cervix. 2A- No parametrial invasion, upper 2/3 of vagina. 2B –with parametrial invasion. STAGE 3 –extends to the pelvic walls 3A –involves lower third of the vagina 3B –extends to the pelvic wall, affects kidneys

17. Staging cont 4A –invades mucosa of bladder or rectum and/or extends beyond true pelvis 4B –distant metastasis can go to as far as to the lungs.

18. DIAGNOSIS Confirmation of cervical cancer requires a biopsy SCREENING The primary screening test for cervical cancer is the pap smear Pap smear is relatively accurate, effective and economical screening technique to detect cervical changes An Ayres spatula spatula and endocervical brush are used to collect squemous and endocervical cells . Sample is smeared on a slide and a fixative is sprayed on the sample

19. DIAGNOSIS -Cont LIQUID-BASED MONOLAYER CYTOLOGY In the UK, a new liquid based cytology method has been introduced. When using this technique, the cellular collection is not smeared on a slide but is transferred onto a vial containing a liquid . HPV TESTING HPV infection is a cause of nearly all the cases of cervical cancer. The English National Health Services now includes HPV testing on all the screening showing cervical changes

20. DIAGNOSIS-Cont TESTING IN RESOURSE-POOR AREAS Many resource-poor countries can not provide regular screening and must rely on infrequent screening The Bill and Melinda Gates has funded an 8 year study for HPV DNA. They have designed a low cost test with results available in a few hours. The test involves a woman taking a swab by themselves at home.

21. DIAGNOSIS-Cont VISUAL INSPECTION WITH ACETIC ACID (VIA) In areas where pap smear is not available or affordable, other methods have been evaluated Visual inspection of the cervix, using acetic acid (white vinegar) or Lugol’s iodine solution is used to highlight precancerous lesions so that they can be viewed with the naked eyes A range of medical personnel – doctors , nurses, or midwives can perform the procedure provided the receive adequate training and supervision

22. Cervical cytology

23. TREATMENT The treatment of cervical cancer varies worldwide, largely due to large variances in disease burden in developed and developing nations, access to surgeons skills in radical pelvic surgery emergence of fertility sparing therapy in developed nations Treatment for surgery and/or radiotherapy and chemotherapy

24. TREATMENT –Cont- SURGERY Surgery may be used to remove some or all of the uterus  For cervical cancer that has not spread beyond the cervix, these procedures are often used Conisation - A cone biopsy may be used to remove micro invasive cancer LEEP - A loop electrical excision procedure uses an electrical current which passes through a thin wire hook. The hook removes the tumour

25. TREATMENT –Cont- Cryotherapy -  is the local or general use of low temperatures in medical therapy

26. TREATMENT –Cont- Other surgical procedures include: Radical trachelectomy- The cervix, surrounding tissue and the upper part of the vagina are removed but the uterus is left in place Hysterectomy - The cervix and the uterus are removed Pelvic exenteration- This is a major operation in which the cervix, vagina, uterus, urinary bladder, ovaries, fallopian tubes and the rectum are removed

27. TREATMENT –Cont- RADIOTHERAPY Radiation may be used on its own or in combination with surgery for early stage cancer or in combination with chemotherapy for advanced cancer of the cervix Radiation can be used to control bleeding and pain- Hemostatic brachytherapy They are generally two ways in which RT can be delivered ; External beam RT and Brachytherapy (internally)

28. TREATMENT –Cont- CHEMOTHERAPY It is the treatment of cancer using anti cancer drugs It can be combined RT to try and cure cervical cancer or it can be used as a sole treatment for advanced cancer to slow its progression and relieve symptoms

29. CHEMO PROTOCALS CRT Stages I - IIIB Cisplantin 40mg/m2 iv once wkly plus RT 1.8-2Gy per fraction OR Cisplatin 80mg/m2. 3wkly Radio-Sensitizer Palliative For stage IVB/Recurrent Dz Pacltaxel 135mg/m2 iv over 2 hrs on day 1 & Cisplantin 50mg/m2 iv every 3wks. OR Bevacizumab 15mg/kg iv over 30-90 min plus Cisplatin 50mg/m2 iv ON plus paclitaxel 135mg/m2 iv 3 wkly Paclitaxel & Carboplatin

30. Role of radiotherapy Curative role Adjuvant role Palliative role

31. PREVENTION Prevention is a key strategy for eradication of cervical cancer Divided into primary and secondary prevention Counselling adolescents and women of all ages regarding STI’s infection Use of barrier type of contraceptives Limiting number of sexual partners Strategies to prevent or discourage tobacco use should be recommended Adolescents should be targeted because they are more likely to be sexually active

32. PREVENTION-Cont- VACCINATION They are two vaccines for cervical cancer Gardasil and Cervirix They reduce the risk of cancerous and pre cancerous changes of the cervix and perineum by about 93% and 62% respectively HPV vaccines are typically given to women age 9-26 as the vaccine is only effective before infection occurs Cost of the vaccines remains a challenge to developing countries .

33. Complications Cancer Related Renal failure from hydronepnrosis Anemia VVF/RVF Treatment Related Vaginal stenosis Ovarian ablation (Radiotherapy induced) - infertility/early menopause in young women

34. Conclusion Cervical cancer presents nurses with many challenges along the continuum of prevention, early detection and treatment. Nurses must have many skills and knowledge on cervical cancer.

35. References American Cancer Society, 2014. Chemotherapy Administration. Gates R.A. 2008. Oncology Nursing Secrets . 3 rd ed. Mosby Elsevier  Langhorne, M. E., Fulton, J. S., Otto, S. E. 2011. Oncology Nursing. 5 th ed. Mosby: Elsevier. Yarbroetal. 2014. Cancer Nursing Principles and Practice . 6 th Ed, London. Jones and Batlet .

36. THANK YOU ANY QUESTIONS